TB Diagnosis and Treatment (For Clinicians)

State and local public health departments are responsible for ensuring that adequate and appropriate TB diagnostic and treatment services are accessed. They monitor the results of therapy and provide consultation, education, and care management for persons with suspect or active TB disease and latent TB infection (LTBI).

In collaboration with the medical provider, public health departments provide the following services for all persons with suspect or active TB disease and LTBI:

• Facilitation of comprehensive TB patient evaluation, testing, and treatment
• Assistance with sputum collection for submission to the Wisconsin State Lab of Hygiene (WSLH) for diagnosis and monitoring treatment response
• Provision of antituberculosis medications; there is no charge for TB-related medications through the Wisconsin TB Dispensary for uninsured or underinsured persons
• Management of care, from diagnosis to cure
• Provision of directly observed therapy (DOT) for all clients with TB disease and clients with LTBI on a case-by-case basis
• Education on TB for patients and families
• Monitoring of medication side-effects and adherence
• Management of clients with complex social and economic needs affecting adherence to the TB treatment plan

In addition, the public health department provides the following services for individuals with TB disease:

• Facilitation of respiratory isolation for persons with infectious TB
• Identification and monitoring of contacts, including TB testing (IGRA or TST) when necessary.

Persons being evaluated for TB disease or LTBI should be screened for risks of infection, risks for disease progression, and symptoms.

People who had close contact with someone with infectious TB or who were born, lived, or traveled extensively in a TB endemic country are at highest risk for TB.

Wisconsin TB Risk Assessment Questionnaire and Symptom Evaluation form, F-02314b (PDF)

TB disease

Persons should be screened and tested for TB disease if they have a persistent cough lasting three or more weeks and one or more of the following symptoms:

• Unexplained weight loss
• Fever
• Night sweats
• Fatigue
• Hemoptysis
• Laboratory tests or radiographic evidence consistent with TB

Latent TB infection

Persons with latent TB infection will not have any of the symptoms listed above and instead should be tested based on:

• Epidemiologic risk of infection
• Regulatory requirements of their occupation
• Risk of progression to TB disease

Testing for TB infection usually means performing a skin test (TST) or IGRA (QuantiFERON® or T.Spot.®TB) blood test. IGRAs are preferred, especially for persons born outside the U.S. due to higher test specificity. Testing for LTBI in low risk individuals is not recommended because of increased likelihood of false positive results (see CDC 2016 Testing and Diagnosis guidelines). Before being diagnosed with LTBI, low-risk individuals who test positive by either IGRA or TST should have a second, confirmatory test.

Persons who are suspected of having active TB disease may have false negative IGRA or TST results. Additional methods of evaluation are needed to diagnose TB disease (see radiography and microbiological test sections below).

Any testing should be considered together with the person’s risk of infection. Risk for TB is very low in Wisconsin. The majority of persons with TB acquire the infection outside of Wisconsin. Clinicians should be aware of populations at risk for TB in their area to help guide testing and evaluation decisions. Contact the Wisconsin TB Program for additional information.

All patients with a newly confirmed positive IGRA or TST test should be evaluated with a chest radiograph (chest x-ray or chest CT). Chest x-rays (CXRs) are reasonably sensitive for pulmonary TB disease, and the vast majority of patients with newly positive TB tests can be cleared (active TB disease ruled out) based on a normal CXR and negative symptom evaluation alone. A single posterior-anterior (PA) view is usually adequate to rule out active TB disease in asymptomatic adults without TB risk factors.

Adding a lateral view to the PA CXR may improve sensitivity for detecting active TB in immune-compromised persons, who are more likely to have atypical radiographic presentations of active TB (Meyer 2003; Eisenberg 2009). Additional imaging to rule out active TB disease may be indicated based on clinical assessment or discussion with the radiologist. A lateral view is also recommended for children under 10 years of age.

Note that CXRs are likely to be normal in patients with extrapulmonary TB disease, so the absence of lung disease on CXR does not indicate absence of infectiousness. Oropharyngeal and laryngeal TB are highly infectious, but disease cannot be detected by plain radiograph.

Persons who are suspected to have pulmonary TB disease, either because of abnormal chest radiograph or TB symptom evaluation, should have sputum specimens collected and sent to the laboratory for smear, culture, and molecular testing (PCR), if indicated. A series of three specimens, at least eight hours apart with at least one being an early morning specimen, are collected to diagnose pulmonary TB, determine infectiousness and release from airborne isolation, and monitor response to treatment. Persons unable to spontaneously produce sputum, P-02380 (PDF) may benefit from nebulized induction, P-02381. (PDF) Persons for whom bronchoscopy is performed should attempt to give sputum samples after the procedure, given the increased sensitivity of post-bronchoscopy specimens (CDC 2017 Diagnostic Guidelines). (PDF)

Persons who are suspected to have extrapulmonary TB disease should have other appropriate specimen samples, such as lymph node aspirates, collected and sent to the laboratory for smear and culture. All patients with confirmed extrapulmonary TB should have sputum specimens submitted for smear and culture to help rule out pulmonary TB disease.

All persons with suspected active TB disease, both pulmonary and extrapulmonary, should be reported to the patient's local health department. Clinicians are encouraged to send specimens to the Wisconsin State Laboratory of Hygiene (WSLH) where rapid full-service mycobacteriology and fee exempt TB PCR testing are available. Local health departments may be able to assist with collecting sputum from high-risk persons with suspected TB. Specimen collection kits and fee-exempt specimen transport are available by calling the WSLH customer service line at 1-800-862-1013.

Both LTBI and active TB disease are treatable. Many regimens are available, depending on the person's medical history and the drug (antibiotic) susceptibility patterns, if known.

Latent TB infection

See below or view common LTBI treatment regimens, P-01181 (PDF) See the Wisconsin TB Program publication, P-01181 (PDF) and the CDC website for more detailed information.

Active TB disease

Shown below are the preferred regimens for drug-susceptible, uncomplicated pulmonary TB disease in Wisconsin. Treatment completion is measured by number of doses completed by directly observed therapy (DOT). See current CDC treatment guidelines for more detailed information.

• Self-Study Modules: A series of educational modules designed to provide information about TB in a self-study format.
• 2017 Diagnosis of TB guidelines
• 2016 Treatment of Drug Susceptible TB guidelines
• Other CDC guidelines: List of guidelines, covering topics from managing MDR to HIV co-infection
• 3HP, 3HR, and 4R Medication Trackers and Patient Information Sheets from CDC (including translations)

• Mayo Clinic Center for Tuberculosis (MCCT): The designated COE for Wisconsin that provides education and support for the management of TB and LTBI.
• Curry International Tuberculosis Center: Contains clinical products available for download and ordering; contains link to Drug Resistant TB: A Survival Guide for Clinicians (third ed.),
• Southeastern National Tuberculosis Center: A COE that provides educational webinars and support for the management of TB and LTBI.
• Clinical Algorithms and Short Clinical Guides, Heartland National TB Center: An assortment of clinical resources and references from a CDC-designated Center of Excellence for TB.
• Rutgers Global TB Center: Contains an assortment of training guides and archived webinars on TB.
• Skin Test Calipers and Rulers, Southeastern National TB Center: You can order tools for reading TB skin tests here.

• Statement on four-month HPMZ Regimen for TB Disease, P-03422: Wisconsin TB Program Statement on the four-month HPMZ Regimen for TB Disease.
• "2023 TB/LTBI Training for New Staff" (March, 30th 2023): A webinar by the Wisconsin TB Program introducing TB/LTBI concepts, reporting, and case management for clinicians.
• "TB 101" (August 24, 2021): A webinar by the Wisconsin TB Program introducing general TB/LTBI concepts for clinicians. View the recording of this webinar.
• "TB case management and evaluation for TB disease" (September 28, 2021): A webinar presented by the Wisconsin TB Program about nurse care management for active TB disease, geared towards public health clinicians. View the recording of this webinar.
• "The TB laboratory" (PDF) (Oct. 12, 2021, Simon, reproduced with permission): A webinar presented by the Wisconsin State Laboratory of Hygiene about collecting specimens and interpreting testing for TB. Geared towards clinicians, View the recording of this webinar.
• TB Risk Assessment Questionnaire, F-02314 (also in Spanish): A worksheet to determine a person's risk for TB infection and disease.
• Positive TST-What's next? P-02288 (PDF): A fact sheet outlining steps to take after a positive skin test result.
• Positive IGRA-What's next? P-01182 (PDF): A fact sheet outlining steps to take after a positive IGRA result.
• Nurse Case Management Checklist and Timeline, P-00467 (PDF): A guide for case management activities to be completed by nurses at local health departments.
• Latent Tuberculosis Infection (LTBI) Treatments, P-01181 (PDF): See this fact sheet for information on recommended treatment for LTBI.
• LTBI FAQ Sheet, P-02429: (PDF) Frequently asked questions about LTBI.
• Documenting LTBI in WEDSS P-02426 (PDF): A manual on how to document LTBI in WEDSS.
• TB Disease Initial Request for Medication, F-44000 (PDF): Fill out this form to request medication for active TB disease from the TB program
• TB Infection Initial Request for Medication, F-00905 (Word): Fill out this form to request medication for latent TB infection (LTBI) from the TB program
• Medication Refill Request, F-44126 (PDF): Fill out this form to request a refill on medication for active TB disease from the TB program
• See Financial Resources webpage for ways to support your patient during treatment
• Local Public Health in Wisconsin: A link to local public health departments in Wisconsin.
• Sputum Collection: Spontaneously Produced, P-02380 (PDF): A fact sheet for nursing staff on how to collect sputum specimens.
• Sputum Collection: Nebulized Induction, P-02381 (PDF): A fact sheet for nursing staff on how to collect sputum specimens.

• TB Suspect Case Data form, F-42001 (PDF): A form for reporting suspected active cases of TB.
• Latent Tuberculosis Infection (LTBI) Confidential Case Report form, F-02265 (PDF): Use this form to report cases of LTBI to your local health department.
• Latent Tuberculosis Infection (LTBI) Follow-up form, F-44125 (PDF): Use this form to communicate and document follow-up at the end of LTBI treatment.
• Interjurisdictional Tuberculosis Notification, F-42010 (PDF): Use this form to transfer cases to another jurisdiction in Wisconsin.
• Interjurisdictional TB Notification Follow-up, F-42011 (PDF): Use this form to follow up with cases who transferred to another jurisdiction in Wisconsin during treatment.
• See Reporting and Surveillance page for more information on reporting TB in Wisconsin.