Our Services
For Providers
Reports and
Publications
Links
What's ?
April 26, 2011: Hospital discharge guidelines and forms now available. More Information
April 26, 2011: Spring Issue of the TB Tribune newsletter posted. Go to Reports and Publications
Upcoming Events
April 27, 2011: 2011: What do we know about LTBI?
Francis J. Curry National TB Center (in association with CTCA Educational Conference)
One-day training for physicians, nurses, TB program managers, and other licensed medical care providers who manage LTBI patients.
More Information and Registration
April 28-29, 2011: Navigating A Minefield: TB Control in Uncertain Times
45th Annual California TB Controllers Association Educational Conference
May 11, 2011, 9:00 am: TB Control Annual Program Performance Update
Carr Auditorium (SFGH, 22nd and San Bruno streets)
Come learn the TB control facts and figures for San Francisco in 2010, with a glimpse of what the future holds. Director Masae Kawamura, MD and Program Manager/Epidemiologist Jennifer Grinsdale will present.
July 20, 2011: TB? Maybe Not: The Differential Diagnosis of Active Tuberculosis
Francis J. Curry National TB Center Web-based Seminar
A referral form or letter is required to receive testing and evaluation services at the TB Clinic.
If you do not have a referral and need a TB test, please see the list of TB testing sites or see your regular health-care provider.
We do not do school or employment screening.
Clinic Hours
TB Testing
Monday
Tuesday
Wednesday
Thursday
Friday
Weekends
& Holidays
MD Hours
No new patients will be seen during the last hour of clinic. Patients needing a MD visit or x-ray should arrive no later than one hour before clinic closing.
Medication Refill Hours
8:30 a.m. - 12:30 p.m.
No Testing
Closed
1:00 p.m. - 4:30 p.m.
9:00 a.m. - 4:30 p.m.
9:00 a.m. - 11:30 a.m.
10:00 a.m. - 4:30 p.m.
8:30 a.m. - 4:30 p.m.
Program Description
The San Francisco City and County Tuberculosis Control Section of the San Francisco Department of Public Health operates a centrailized TB clinic that specializes in the education, prevention, diagnosis, and treatment of active disease and latent TB infection.
Population Served
We serve all residents of San Francisco regarless of status. Clients must have a provider referral or should call (415) 206-8524 for futher information regarding eligibility for services.
Fees
Services are free of charge. The clinic accepts and bills the following insurance plans: Medi-Cal, Medicare, SF Health Plan, Blue Cross, Healthy Kids, Healthy Families, and private insurance.
Eligibility For Testing
Only persons seeking shelter or program clearance are eligible for TB testing at the TB Clinic. Persons needing clearance must bring a referral from the agency requiring testing. We DO NOT DO school or employment testing. If you need a TB test and are not eligible for TB clinic services, please see the list of TB testing sites for alternative testing locations or call (415) 206-8524 for assistance.
Please note: Only SFUSD bus drivers with proper referral or SFUSD Head Start volunteers with Head Start paperwork will be accepted for TB testing. All other SFUSD employees should seek testing from their primary care provider or at an alternative testing site.
Eligibility for X-ray/MD Evaluation
The TB clinic is a specialty clinic requiring referral from a private or community-based provider. If you need a x-ray or think you are experiencing TB-related symptoms, please see your primary care provider. If appropriate, you will be referred to the TB clinic for further evaluation.
Contact Us
We are located at:
Tuberculosis Control Section
San Francisco General Hospital
2460 22nd Street, TB Clinic
Building 90, 4th Floor
San Francisco, CA 94110
Phone: (415) 206-8524
Fax: (415) 206-4565
Note to Providers: If you wish to request at QFT test for your patient, please call (415) 206-8524 for authorization. DO NOT send your patient to TB clinic or ask your patient to call. They will not be seen unless you receive prior approval from a TB Clinic physician.
San Francisco Tuberculosis Control Guidelines and Policies
San Francisco Tuberculosis Screening, Reporting, Referral and Clinic Infection Control Guidelines for Community Providers
San Francisco Treatment Guidelines for Latent Tuberculosis Infection
San Francisco Guidelines on the Use of QuantiFERON-TB Gold (In Tube Method) for the Diagnosis of Latent TB Infection
San Francisco Tuberculosis Screening Procedures for Homeless Shelter Clients
Provider Guide: Testing for TB Infections & Guidelines for Post-Test Referral
QuantiFERON In-Tube: Use of Quantitative Information, Provider Information and Guidance
GeneXpert MTB/RIF: Provider Information and Guidelines for Interpretation
Guidelines for Discharge of Tuberculosis Patients and Suspects
TB Symptom and Risk Assessment Forms
Adult Patient: Initial TB Symptom and Risk Assessment
Established Adult Patient With No Prior TB Test or Prior Negative Results: Annual/Periodic TB Symptom and Risk Assessment
Established Adult Patient with a Prior Positive TB Test and Incomplete or No Prior Treatment: Annual/Periodic TB Symptom and Risk Assessment
Pediatric Patient: Initial TB Symptom and Risk Assessment
Reports and Publications
Annual Bulletins
Two-page summary of TB incidence in San Francisco
Annual Summaries
A detailed look at TB incidence in San Francisco and Annual Program Activities
Annual Presentations
Annual "TB Update" Presentations
TB Tribune
Read about what's happening in TB Control
Recent Publications
Nahid P, Jarlsberg LG, Rudoy I, de Jong BC, Unger A, Kawamura LM, Osmond DH, Hopewell PC, Daley CL. Factors associated with mortality in patients with drug-susceptible pulmonary tuberculosis. BMC Infect Dis. 2011 Jan 3;11(1):1.
Kato-Maeda M, Kim EY, Flores L, Jarlsberg LG, Osmond D, Hopewell PC. Differences among sublineages of the East-Asian lineage of Mycobacterium tuberculosis in genotypic clustering. Int J Tuberc Lung Dis. 2010 May;14(5):538-44.
Flores L, Jarlsberg LG, Kim EY, Osmond D, Grinsdale J, Kawamura M, Desmond E, Hopewell PC, Kato-Maeda M. Comparison of restriction fragment length polymorphism with the polymorphic guanine-cytosine-rich sequence and spoligotyping for
differentiation of Mycobacterium tuberculosis isolates with five or fewer copies of IS6110. J Clin Microbiol. 2010 Feb;48(2):575-8.
Mohtashemi M, Kawamura LM. Empirical evidence for synchrony in the evolution of TB cases and HIV+ contacts among the San Francisco homeless. PLoS One. 2010 Jan 22;5(1):e8851.
Metcalfe JZ, Cattamanchi A, Vittinghoff E, Ho C, Grinsdale J, Hopewell PC, Kawamura LM, Nahid P. Evaluation of quantitative IFN-gamma response for risk stratification of active tuberculosis suspects. Am J Respir Crit Care Med. 2010
Jan 1;181(1):87-93.
Walter ND, Jasmer RM, Grinsdale J, Kawamura LM, Hopewell PC, Nahid P. Reaching the limits of tuberculosis prevention among foreign-born individuals: a tuberculosis-control program perspective. Clin Infect Dis. 2008 Jan 1;46(1):103-6.
Higgs BW, Mohtashemi M, Grinsdale J, Kawamura LM. Early detection of tuberculosis outbreaks among the San Francisco homeless: trade-offs between spatial resolution and temporal scale. PLoS One. 2007 Dec 12;2(12):e1284.
Dewan PK, Grinsdale J, Kawamura LM. Low sensitivity of a whole-blood interferon-gamma release assay for detection of active tuberculosis. Clin Infect Dis. 2007 Jan 1;44(1):69-73.
Cattamanchi A, Hopewell PC, Gonzalez LC, Osmond DH, Masae Kawamura L, Daley CL, Jasmer RM. A 13-year molecular epidemiological analysis of tuberculosis in San Francisco.
Int J Tuberc Lung Dis. 2006 Mar;10(3):297-304.
Dewan PK, Grinsdale J, Liska S, Wong E, Fallstad R, Kawamura LM.Feasibility, acceptability, and cost of tuberculosis testing by whole-blood interferon-gamma assay. BMC Infect Dis. 2006 Mar 15;6:47.
Dewan PK, Banouvong H, Abernethy N, Hoynes T, Diaz L, Woldemariam M, Ampie T, Grinsdale J, Kawamura LM. A tuberculosis outbreak in a private-home family child care center in San Francisco, 2002 to 2004. Pediatrics. 2006 Mar;117(3):863-9.
Curry International Tuberculosis Center
www.currytbcenter.ucsf.edu
The Curry International Tuberculosis Center (CITC) creates, enhances, and disseminates state-of-the-art resources and models of excellence and performs research to control and eliminate tuberculosis in the United States and internationally.
California Tuberculosis Controllers Association
www.ctca.org
CTCA's mission is the elimination of the threat of tuberculosis form California through leadership and the development of excellence in tuberculosis prevention and treatment.
Centers for Disease Control and Prevention, Division of TB Elimination
www.cdc.gov/tb/
The mission of the Division of Tuberculosis Elimination (DTBE) is to promote health and quality of life by preventing, controlling, and eventually eliminating tuberculosis from the United States, and by collaborating with other countries and international partners in controlling tuberculosis world-wide.
California Department of Public Health, Tuberculosis Control Branch
www.cdph.ca.gov/programs/tb/Pages/default.aspx
To protect and improve the health of all, the California Tuberculosis Control Branch (TBCB) provides leadership and resources to prevent and control tuberculosis (TB). The vision of the Tuberculosis Control Branch is to speed the decline of TB morbidity and mortality.
Find TB Resources - TB Education and Training Resources
www.findtbresources.org/scripts/index.cfm
The Find TB Resources Website is a service of the Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination (DTBE) to: search for TB education and training materials, find out how to order TB materials, locate TB images, locate TB-related web links, and much more.
Foundation for Innovative New Diagnostics
www.finddiagnostics.org
FIND is a Product Development and Implementation Partnership (PDIP) devoted to developing and implementing diagnostic tools for poverty-related diseases. An independent non-profit foundation based in Geneva with offices in Uganda and India, FIND focuses on a disease portfolio covering tuberculosis, malaria and human African trypanosomiasis. In its commitment to develop technologies that can be used as near as possible to where patients first seek care, FIND has accumulated an impressive pipeline of new diagnostic technologies.
BCG World Atlas
www.bcgatlas.org/index.php
Variations in BCG vaccination practices impact the interpretation of TB diagnostics, such as the widely used Tuberculin Skin Test (TST). The World Atlas of BCG Policies and Practices will help clinicians make better diagnostic decisions concerning TB infection. These data are available for use as a searchable online tool for physicians and researchers alike.
Reporting TB to the Health Department
The San Francisco TB Clinic provides consultation, directly observed therapy, case management and clinical services for patients with TB infection and/or disease. A Disease Control Investigator is assigned to each active TB case to investigate who has been exposed, provide testing and follow-up of contacts, assess the sites of potential transmission, and promote patient adherence. Each active case is assigned a nurse case manager who oversees the care of the patient until completion.
Any confirmed or suspected case of active TB disease is required by law to be reported within one working day to the TB
Control Section by telephone at (415) 206-8524, or by fax at (415) 206-4565.
DO NOT wait for laboratory results to confirm the diagnosis prior to reporting.
All active TB patients being discharged from the hospital or transferred to another healthcare or congregate facility require prior
approval by SF TB Control.
Referral to the San Francisco TB Clinic
To refer patients to the San Francisco TB Clinic please complete the interagency TB47 referral form OR provide complete information of your work up and reason for referral on a SFGH consult form or physician letterhead. Those without a referral will not be seen.
We do not accept referrals for:
-Employment and general TB screening unless seeking shelter or program clearance
-Asymptomatic patients with prior history of completing LTBI treatment unless seeking shelter or program clearance
Referred patients must be residents of the City and County of San Francisco and have one or more of the following criteria for referral:
-TB symptoms and suspected of having active TB (regardless of TB test results)
-An abnormal chest x-ray consistent with old or active TB without prior evaluation or treatment (e.g. chest x-ray with upper lobe
fibrotic infiltrates)
Exclude: isolated granulomas or pleural lesions unless immunosuppressed and TB test negative.
Include: parenchymal infiltrates even if stable over time
-A tuberculin skin test reading ≥ 5 millimeters or positive QFT and any of the following risk factors:
Asymptomatic persons with radiographic evidence of old, healed TB
Contacts to active TB cases
HIV
On immunosuppressive drugs (steroids, cancer chemotherapy, post-transplantation cyclosporine, TNF alpha
antagonists, or immunosuppressive drugs)
-A tuberculin skin test reading ≥ 10 millimeters or positive QFT and any of the conditions or risk factors listed below:
Newcomers to the US (<5 yrs) from TB endemic countries (refer regardless of age)
Foreign born under the age of 35 from TB endemic areas
Individuals with medical risk factors for TB reactivation (refer regardless of age):
-Diabetes mellitus
-Renal failure
-Current and former tobacco smokers who are foreign-born or marginally housed
-Cancer of the head and neck, hematologic and reticuloendothelial disease (e.g., leukemia and Hodgkins disease)
-Low body weight (10% or more below ideal)
-Potential candidate for immunosuppressive therapy
-Silicosis
Documented QFT or TST converters
Patients entering long-term day or residential facilities
Homeless or marginally housed individuals (including SRO hotel residents)
Injection drug users
Pregnant and under 35 years old
Under age 21, regardless of place of birth
Newly positive TB test and prolonged (>1 month) or frequent travel (≥ twice/year) to TB endemic countries
Tuberculosis Screening
Think TB
Think tuberculosis (TB) in patients with: chronic cough (≥ 3 weeks), unexplained weight loss, fever, hemoptysis and/or fatigue.
Active TB rates are highest among:
-foreign-born persons from areas with a high prevalence of TB
-homeless and marginally housed persons
-residents of long-term care facilities (including correctional facilities)
The risk of developing TB disease is significantly increased when co-morbid medical conditions such as diabetes, HIV or other medical conditions that weaken the immune systems (listed below) occur in these same individuals.
Whenever TB symptoms are present, TB disease should always be ruled out with a chest x-ray, sputum smears and culture, and careful clinical evaluation.
If symptoms are absent and active TB is ruled out, preventive treatment should be prioritized for these individuals.
Screening for TB
TB screening is an assessment of:
-TB symptoms
-Risk of exposure and disease progression
-TB infection if symptoms or risks are present
TB screening is not recommended for the general public but should be prioritized and routine for foreign-born populations and those that are marginally housed or reside in congregate settings.
Symptom Review
All patients being screened for TB should be asked if they have the following:
-Cough ≥ 3 weeks
-Unexplained weight loss
-Hemoptysis
-Chronic fever
-Drenching night sweats
Risk Assessment
TB screening is recommended for the following groups:
-Contacts of persons with pulmonary or laryngeal TB disease
-Foreign-born persons born in countries outside of the U.S. (excluding Canada, Western Europe, Australia and Japan)
-Marginally housed or homeless persons
-Persons with prolonged (>1 month) or frequent travel (≥ twice/year) to TB endemic countries
-Employees or residents of congregate settings, such as hospitals, dialysis units, correctional facilities, homeless shelters,
nursing homes, single-room occupancy hotels, or substance abuse treatment centers
-Persons with medical risk factors for TB disease progression, such as:
HIV infection
Diabetes mellitus (prioritize screening foreign-born and homeless)
Prolonged corticosteroid therapy or other immunosuppressive therapy (such as TNF-antagonists, post-transplant
immunosuppressive drugs, cancer chemotherapy, etc.)
Persons with radiographic evidence of previous TB
Current and former tobacco smokers (prioritize screening foreign-born and homeless)
Cancer of the head and neck, hematologic malignancy (e.g., leukemia and Hodgkins disease)
End-stage renal disease
Organ transplant candidates/recipients
Intestinal bypass or gastrectomy, chronic malabsorption syndromes
Low body weight (10% or more below ideal)
Silicosis
Frequency of Screening
In individuals with initial negative tests:
-Annual testing: Individuals living or working in congregate settings
-Periodic testing: Individuals with possible new exposure to TB (contact to a pulmonary/laryngeal TB cases,l
prolonged/frequent travel, or new medical risk factor)
Latent Tuberculosis Infection: Who To Treat
HIGHEST PRIORITY (Regardless of Age)
All household or other close contacts of persons with active pulmonary tuberculosis
-High-risk contacts including children under 5 years and immunocompromised individuals (HIV infection, chronic
corticosteroids, chemotherapy, etc) should receive treatment for LTBI regardless of tuberculin skin test (TST) reaction if the
index case is smear or culture (+) for M. tuberculosis:
-Refer to Contact Investigation Guidelines for other groups
-At 8-10 weeks following exposure, contacts with a negative QFT or TST (<5mm) must be retested. If the non-
immunocompromised contact is still negative (includes children) and the index case is on TB chemotherapy, treatment of
LTBI may be discontinued. Immunocompromised close contacts should complete a full course of treatment regardless of
repeat TST results since test results may be unreliable.
TB test converters
-TST Converter: Increase in the size of the tuberculin reaction by at least 10 mm from less than 10 mm to 10 mm or more
within a 2 year period.
-QFT Converter, Contact: Current positive test with a documented prior negative result within the past two years.
-QFT Converter, non-Contact: Current positive test with a documented prior negative result within the past two years AND a ≥
0.75 IU/ml quantitative increase from prior result.
QFT positive or TST reactors (5 mm or greater) with:
-Abnormal chest x-ray consistent with dormant tuberculosis that have not had adequate prior therapy (it is important to
exclude current disease by bacteriologic evaluation and/or a review of serial x-rays).
-HIV infection or at high risk of HIV infection.
Homosexual/bisexual men and injection drug users are at high risk of HIV infection. Unless the HIV test is known to be
negative and the patient does not belong to other high-risk groups, they should be encouraged to take LTBI treatment.
QFT positive or TST reactors (10 mm or greater) who are:
-Foreign-born newcomers to the U.S. (less than 5 years in U.S.), from areas of the world with a high TB incidence (excludes
Australia, Canada, Japan and countries of Western Europe).
-Injection drug users (HIV testing should be strongly encouraged for all individuals in this group).
-Homeless or have a transient living arrangement and is a TB test converter, contact, or is HIV infected or
immunosuppressed.
Because of increased TB disease susceptibility and probability of TB exposure in group settings, HIV testing should be
strongly encouraged for all homeless tuberculin reactors. These patients should always be placed on DOT.
QFT positive or TST reactors with special medical conditions that increase risk of disease progression. Prioritization of contacts, foreign-born and homeless persons with the following conditions should be made (Note: a 5 mm TST cut point is considered positive for persons who are on immunosuppressive therapy, corticosteroids, or have leukemia or lymphoma. A 10 mm cut point should be used for other medical risk groups.)
-HIV infection
-Current and former tobacco smokers
-Immunosuppressive therapy such as prolonged corticosteriod therapy (>15mg daily of prednisone or equivalent for 2-4
weeks), TNF-antagonists, post-transplant immunosuppressive drugs, and cancer chemotherapy.
-Cancer of the head and neck and hematologic malignancies (leukemia or lymphoma)
-End-stage renal disease
-Organ transplant candidates/recipients
-Intestinal bypass or gastrectomy (especially with weight loss)
Less Than 35 Years of Age
Foreign-born QFT positive or TST reactors (10 mm or greater) living in the U.S. greater than 5 years who come from areas of the world with a high TB incidence (includes Central and South America, Asia, Philippines, the former Soviet Union, and Africa).
Post-partum women that are QFT positive or TST reactors (10mm or greater)
-INH is not contraindicated during pregnancy but in general should be delayed until after delivery unless additional risk
factors such as HIV infection, being a close contact or recent TB test conversion exists. Nursing is not a contraindication for
INH.
QFT positive or TST reactors (10mm or greater) for whom the public health consequences of developing tuberculosis disease would be of special importance (i.e. persons who work with small children, such as day care providers, health care providers, teachers, school bus drivers, etc.)
QFT positive or TST reactors (10mm or greater) under 21 years of age, with or without risk factors.
QFT positive or TST reactors (10mm or greater) who are 21-35 years old. As a public health policy, preventive treatment is not routinely administered to this age group without other risk factors present. However, if an individual wishes to take treatment after reviewing risks and benefits, therapy should be given.
For additional information about LTBI treatment regimens, completion and monitoring see the SanFrancisco Treatment Guidelines for Latent Tuberculosis Infection
QuantiFERON TB-Gold (In Tube Method) Frequently Asked Questions
Why the new test?
The new QuantiFERON-TB Gold (QFT In Tube method) allows for greater flexibility in specimen processing. This enables us to offer the test five days a week.
Who should be tested for TB with QFT?
In any situation where the TST is used, the QFT can also be used.
Which test should TB suspects receive?
SFDPH currently recommends that patients suspected of having active TB have both a TST and a QFT. The QFT, like the TST, is a diagnostic aide for the detection of TB infection. Patients with active TB can be either TST negative, QFT negative, or both. Therefore when clinical suspicion of active TB is present, the results of both tests should be interpreted in the context of the clinical, microbiologic and radiographic examinations.
Which test should persons with impaired immune function (including HIV infection) receive?
Like TB suspects, maximum sensitivity for detection of M. tuberculosis infection is preferred in patients with the highest risk of reactivation TB. Because limited data is available to document the sensitivity of the QFT in patients with impaired immune function, SFDPH recommends that both tests be routinely performed. While this is operationally challenging, in this patient population the added sensitivity of both tests is cost effective. Patients with discordant results should be managed as if they are infected with M. tuberculosis, unless some overriding concern exists for false positive TST results (e.g. active non-tuberculous mycobacteria infection).
When can a patient receive both a QFT and TST?
As above, unless they are a TB suspect or have impaired immune function, patients should not routinely receive both QFT and TST. If you already have a test result from either TST or QFT, you should act based on that information.
What if a patient recently received a TST?
In general, patients who recently received a TST should not be getting a TB test again, unless there is some reason to be suspicious of the results. Consult with Tuberculosis Clinic, (415) 206-8524, before requesting the test.
My patient has a negative QFT can they still be a TB suspect, or are they cleared?
Anyone with TB symptoms or TB risk factors and a new abnormal chest radiograph may be a TB suspect, regardless of the QFT or TST result. Like the TST, the QFT is a useful but imperfect diagnostic aide. It should never replace clinical judgment. Patients with a negative TST, as well as patients with a negative QFT, can have active TB. Remember: contacts to active TB cases who are newly infected with TB can take up to 8 weeks to convert their QFT or TST to a positive test.
Can I confirm a positive TST with a QFT?
You can, however there is no gold standard for the diagnosis of LTBI. False negative tests can occur with the QFT. A confirmatory QFT, i.e., QFT after a positive TST is most useful in BCG vaccinated individuals or patients refusing treatment for LTBI. Please note, however, that a TST may cause boosting that may result in a subsequent positive QFT.
The QFT result is indeterminate. What do we tell the patient and what do we do?
Indeterminate results can be caused by high background level of interferon-gamma (failure of the negative control), or lack of response to the mitogen (failure of the positive control). Repeat QFT or TST placement should depend on patient and provider preference. In San Francisco, repeating the QFT will result in a valid result 65-75% of the time.
My patient was QFT-positive OR indeterminate, but he/she never came back for their results. What do I do?
Provide routine follow up per your clinic protocol. For high risk patients, e.g. (HIV positive and QFT positive), assistance can be obtained from Sheila Davis-Jackson at (415) 206-8524.
My patient was QFT-negative, but he/she never came back for their results. What do I do?
If the patient needs to have proof of their result, they can get it anytime. In the future, we may mail out negatives to reduce clinic visits.
If you have any additional questions regarding the QuantiFERON-TB Gold (In Tube) blood test, please contact:
Dr. Christine Ho, Field Medical Officer, SF TB Control or Dr. Masae Kawamura, Director, SF TB Control, (415) 206-8524
Additonal Information
San Francisco Guidelines on the Use of QuantiFERON-TB Gold (In Tube Method) for the Diagnosis
of Latent TB Infection
QuantiFERON- TB Gold (In Tube Method) Blood Test for TB Infection: Provider Information and
Guidelines for Interpretation
SF DPH QuantiFERON-TB Gold (In Tube Method) Implementation: Frequently Asked Questions
QuantiFERON-TB Gold In Tube Test Processing for the San Francisco DPH Laboratory
Blood based testing for TB infection: A shift in paradigm
IGRAs In San Francisco: Results and Interpretation for Consultants
From the Francis J. Curry National TB Center:
IGRAs: Can They Replace the TST? (Web-based presentation) www.nationaltbcenter.edu/training/arch_igras.cfm
Facility Infection Control
All coughing patients should be asked to wear a surgical mask with instructions to appropriately cover the nose and mouth with both hands while coughing with the mask in place.
Patients with TB symptoms should be seen ASAP by a nurse for triage and have an urgent evaluation by the clinic MD. Consultation with the SF TB Clinic, (415) 206-8524, should occur when referring the patient for evaluation.
When possible, the TB suspect should be removed from common waiting areas and placed in a well-ventilated space, such as a room with an open window, working fan or HEPA filter.
N95 respirators should be used by staff when interviewing, testing or transporting TB suspects. These masks should not be used on coughing patients.
Clinics should have signs at every entryway and in all patient areas instructing all persons to cover their mouth and nose when they cough or sneeze and to wash hands or use waterless hand cleanser, such as Purell, after coughing or sneezing (standard respiratory virus precautions).
Common patient waiting areas should be maintained with adequate airflow, i.e., open windows, running fans and/or HEPA filters that are routinely maintained by industry standards.
Resources
Practical Solutions for TB Infection Control: Infectiousness and Isolation (Web-based Presentation)
http://www.nationaltbcenter.edu/products/product_details.cfm?productID=ONL-13
Tuberculosis Infection Control: A Practical Manual for Preventing TB (CD-ROM)
http://www.nationaltbcenter.edu/products/product_details.cfm?productID=WPT-12CD
Tuberculosis Infection Control: A Practical Manual for Preventing TB (Printed Book)
http://www.nationaltbcenter.edu/products/product_details.cfm?productID=WPT-12
Other Resources:
Shelter Client Screening Guidelines
City Policy
All clients receiving San Francisco shelter services for more than 3 days (cumulative within a 30-day period) are required to complete tuberculosis screening and evaluation within 10 working days of entering the shelter system.
Screening includes a tuberculin skin test (TST) or QuantiFERON-TB blood test (QFT), symptom review and a history of TB treatment and diagnosis. Documentation of prior TST results should be obtained whenever possible.
A baseline chest x-ray (within one month prior to enrollment) is required for all newly enrolled HIV+ clients regardless of prior or current TST results.
Initial Screening for Newly Enrolled Clients
Test: TST or QFT unless documentation of a prior positive result can be provided
Symptom review: chronic cough (>3 weeks), weight loss, night sweats, fever, hemopytsis (coughing up blood)
History: asess prior TB disease and treatment for active or latent TB infection
If the client is TST or QFT positive and asymptomatic, the following are required (may refer to TB Clinic for the following):
-CXR (within 6 months if HIV-, or within 30 days if HIV+)
-Medical evaluation and risk factor assessment (diabetes, end stage renal disease, cancer, chemotherapy or immune
modulating drug intake, HIV, etc.)
See the San Francisco Tuberculosis Screening Procedures for Homeless Shelter Clients (below) for more information.
If the client is symptomatic, with a chronic cough (>3 weeks) or has two or more TB-like symptoms, an urgent medical evaluation and CXR should be obtained.
-Referral to TB Clinic is appropriate, and if necessary, call (415) 206-8524 for assistance.
-All clients should be referred to the TB Clinic with documentation of the most recent TST or QFT result and a detailed symptom
review.
Follow-up Screening
All clients with an initial negative TST or QFT will require a repeat TST or QFT and TB symptom review annually. Certain types of patients will require specific evaluations. See the San Francisco Tuberculosis Screening Procedures for Homeless Shelter Clients (below) for more information.
Initial and Follow-up Screening Documentation
All clients cleared for active TB should have shelter clearance entered into the LCR. If a symptomatic client or TB suspect is lost, enter a clinical alert and contact Sheila Davis-Jackson, TOPS Program Manager, at (415) 206-8524 for assistance.
Additional Resources
Educational Brochures
What is Tuberculosis?
English Spanish Chinese Tagalog Russian Vietnamese
I Have Been Exposed to Tuberculosis (TB)
What Do I Need to Know About Latent Tuberculosis Infection?
What Do I Need to Know About Active TB Disease?
Posters
San Francisco TB Testing Sites
Please call ahead for eligibility, testing hours, and fees.
Adult Immunization and Travel Clinic
101 Grove Street (Rm 102), (415) 554-2625
*No Appointment Needed, Fee Charged
Castro - Mission Health Center
3850 17th Street, (415) 934-7700
*Current Patients Only
Childrens Health Center at SFGH
1001 Potrero Avenue (Rm 6M5), (415) 206-8376
*Children Under Age 18 Only
Chinatown Public Health Center
1490 Mason Street, (415) 364-7600
*Fee Charged
Curry Senior Center
333 Turk Street, (415) 885-2274
*Seniors Only, By Appointment
Glide Health Services
330 Ellis Street (4th Floor), (415) 674-6140
Haight Ashbury Free Clinic
558 Clayton Street, (415) 746-1950
Lyon Martin Women's Health Service
1748 Market Street, #201, (415) 565-7667
Maxine Hall Health Center
1301 Pierce Street, (415) 292-1300
Mission Neighborhood Health Center
240 Shotwell Street, (415) 552-3870
Mission Neighborhood Resource Center
165 Capp Street, (415) 869-7977
*Homeless Clients Only
Native American Health Center
160 Capp Street, (415) 621-8051
North East Medical Services
1520 Stockton Street, 82 Leland Avenue, 2308 Taraval Street, (415) 391-9686
Ocean - Park Health Center
1351 24th Avenue, (415) 682-1900
Potrero Hill Health Center
1050 Wisconsin Street, (415) 648-3022
St. Anthony's Free Medical Clinic
150 Golden Gate Avenue, (415) 241-8320
San Francisco Free Clinic
4900 California Street, (415) 750-9894
South of Market Health Center
551 Minna Street, (415) 626-2951
Southeast Health Center
2401 Keith Street, (415) 671-7000
Tom Waddell Health Center
50 Lech Walesa Street, (415) 355-7400
The TB Clinic is located at:
San Francisco General Hospital Medical Center
2460 22nd Street
(415) 206-8524
Google Map
Freeway Directions:
Take Highway 101 north or south, exit at Cesar Chavez (Army)/Potrero. Take Potrero Avenue north. Turn right on 22nd Street.
Parking:
3-hour parking is available in front of Building 80 and in hospital pay lot (enter on 24th street). Limited street parking available on Potrero and surrounding residential streets.
Bus Routes:
48-Qunitara, 9-San Bruno, 33-Stanyan MUNI lines; 7b-Sam Trans line
Muni Website
Tuberculosis Testing
If risk factors or symptoms are present, TB testing is strongly advised.
TB Test(s) of Choice
In general, patients should receive a QuantiFERON test (QFT) unless:
-Phlebotomy is refused
-Phlebotomy is impractical (e.g., no veins, very young child)
-The specimens cannot be transported to the SFDPH laboratory before 4:30 PM Monday-Friday and the patient cannot return
for phlebotomy during the specified hours
-QFT test is not routinely available
If patient refuses test:
-Patient may opt for the TB skin test (TST) instead and will need to return to clinic in 48-72 hours following placement for the
skin test reading.
For special circumstances additional tests are needed to maximize the sensitivity of diagnosing LTBI:
-TB suspects (ATS class TB 5) with no prior testing or past negative TB test results:
Use both the TST and QFT to increase sensitivity (may be done on the same day)
Collect 3 sputum for AFB examination and culture
Obtain a chest x-ray if most recent film was taken prior to symptom development or is older than 3 months
-Asymptomatic patients who are TB test negative and on immunosuppressive therapy:
Use QFT or TST as a second test
Obtain a chest x-ray
-Immunosuppressive agents likely to cause false negative results include prednisone, methotrexate, post-transplant
immunosuppressive medications and other cancer chemotherapeutic agents
-The chest x-ray shall serve as a third diagnostic to look for evidence of TB infection (granuloma, hilar calcification, apical
pleural thickening, upper lobe volume loss, fibrotic infiltrate(s), etc.)
TST Positive Criteria
When using the Mantoux method, the skin test should be evaluated within 48-72 hours of administration. Induration (palpable swelling), not erythema (redness) should be measured. The result should be documented and recorded in millimeters of induration and entered into the medical record and electronic database. The skin test is considered positive if the reaction is:
-≥ 10 mm OR
-≥ 5 mm AND the patient is
HIV-infected
Immunocompromised
A close contact to an infectious TB case
A person with radiographic evidence of old, healed TB
Multiple-puncture tests should not be used because the results are less reliable.
The TST and QFT are only diagnostic aids, and a negative result cannot rule out active TB. Persons with active TB disease may have a negative skin test due to overwhelming infection or anergy. Clinical judgment is always needed in relation to symptoms, presentation and risk factors when interpreting results.
TB Test Converter Definitions
QFT-Gold converter:
-Not a TB contact: Current positive test with a documented prior negative result within the past two years AND a ≥ 0.75 IU/ml
quantitative increase from prior result
-Recent contact to known active case: Current positive test with a documented prior negative result within the past two years
TST converter: Recorded negative TST less than two years prior to a positive TST AND an increase of ≥10 millimeters induration from prior result.
Managing Positive Reactions
Symptomatic Patients
If the patient is symptomatic, obtain a chest x-ray immediately.
Consult a TB medical expert to determine if urgent referral to TB Clinic or hospitalization is indicated; SF TB Clinic: (415) 206-8524
TB Test Positive Patients
If the skin test or blood test is positive, a chest x-ray and medical evaluation are indicated (evaluation may be done at the TB Clinic if referral criteria is met.
If the chest x-ray is not suggestive of TB, the patient may be a candidate for preventive therapy. Preventive therapy is indicated for certain risk groups.
If the chest x-ray suggests active disease, the following steps should be followed:
-Collect three sputum for AFB smear and culture, as soon as possible.
-Report the case to SF TB Control within one (1) working day (required by California law) by telephone, (415) 206-8524.
-Start treatment with an appropriate four-drug TB regimen as soon as possible. Do not wait for sputum results.
-Place the patient in home isolation.
-Hospital isolation is advised for individuals who are medically unstable, homeless or living in a congregate setting. SF TB
Control follows the California state TB guidelines regarding release of active TB patients to high-risk housing, work,
correctional settings and inpatient settings.
CDHS/CTCA Joint Guidelines:
Guidelines for the Placement or Return of Tuberculosis Patients into High Risk Housing, Work, Correctional, or In-Patient Settings ( www.ctca.org/guidelines/IIB2highriskplcmt.pdf.)
Discharge of Tuberculosis Patients and Suspects
Gudelines for Discharge of Tuberculosis Patients and Suspects
Treatment and Follow-up Plan
Checklist for Approval of Hospital Discharge and Treatment Plan for
Patients with Confirmed or Suspected Tuberculosis
General Considerations
Many tuberculosis (TB) patients are never hospitalized. The greatest risk of transmission occurs prior to initiation of treatment. Seventy-five percent of all people who are acid fast bacillus (AFB) sputum smear positive will remain so for at least 2 weeks, with the majority remaining positive for 4 to 6 weeks. Therefore, while it is realized that it is generally not practical or necessary to keep all patients hospitalized until 3 consecutive sputum smear are negative, other considerations must be evaluated. These include the likelihood the patient will adhere to treatment and isolation precautions; the likelihood of transmission to others (which includes not only the infectivity of the patient but the number of new contacts): and the likelihood and severity of disease in those who may become infected.
Sputum Smear Positive Pulmonary Tuberculosis and Laryngeal Tuberculosis
Criteria for discharge to home, with no high risk individuals* in the home:
1. The patient has been started on an appropriate** multiple drug regimen.
2. The patient is stable.
3. The patient understands and can comply with home isolation (i.e., will not leave home or have unexposed visitors without
wearing a mask).
4. A plan for ongoing follow up and treatment has been established, and directly observed therapy (DOT) considered.
Criteria for discharge to home, with high risk individuals * in the home:
1. The patient has been on an appropriate ** multiple drug regimen for 1 week, or longer if indicated.
2. The patient is clinically improving.
3. a) If the high risk individuals already have been exposed to the patient, then 3 consecutive sputum AFB smears taken on
different mornings must show a decrease in numbers of AFB.
b) If a previously unexposed high risk individual enters the household while the patient is hospitalized, then 3 consecutive
sputum AFB smears taken on different mornings must be negative.
4. All previously exposed high-risk individuals, including children less than 1 year of age, have been considered for prophylaxis.
5. The patient understands and can comply with home isolation
(i.e., will not leave home or have unexposed visitors without wearing a mask).
6. A plan for ongoing follow up and treatment has been established *** and directly observed therapy (DOT) considered.
Criteria for discharge to a high-risk setting (i.e., prison, jail, hospital, skilled nursing facility, nursing home, HIV communal housing, drug treatment program, homeless shelter, migrant camp, dormitory, or other group setting):
1. The patient has been on an appropriate ** multiple drug regimen for 2 weeks.
3. Preferably, the patient has had 3 consecutive negative sputum AFB smears taken on 3 different mornings, but at a minimum, 3
consecutive smears must show a decrease in numbers of AFB.
4. A plan for ongoing close follow up and treatment has been established *** and DOT considered.
Pulmonary Tuberculosis with Negative Sputum Smears and/or Extra-pulmonary Tuberculosis
Criteria for discharge:
1. The patient has been started on an appropriate ** multiple drug regimen.
3. If the patient has pulmonary TB, he/she has had at least 3 consecutive sputum AFB smears on different days that have been
negative.
4. A plan for ongoing follow up and treatment has been established***
5. If being discharged to a high risk setting, the patient has received at least 4 days of an appropriate ** multiple drug regimen.
