Communicable Disease Education, Testing, and Referral Services

Name of Client*

First NameLast Name

TUBERCULOSIS (TB)

Tuberculosis is a disease that usually affects the lungs, but it can attack any part of the body. The TB germ is transmitted from person to person when droplets are expelled through the air by a person active with TB during coughing, sneezing, and talking. Current or anticipated health conditions including HIV infection, organ transplant recipient, treatment with TNF-alpha antagonist (infliximab, etanercept, others), steroids (equivalent dose of Prednisone 15 mg/day for one month or longer), or any other immunosuppressive medications) places an individual at high risk for TB.

Typical symptoms of TB include cough, fatigue, unexplained weight loss, loss of appetite, chills, fever night sweats, and coughing or spitting up blood. If you have TB, there are many medications to treat it. But first, you must find out if you have been infected. The best way to do this is to ask for a tuberculin skin test. The test is easy, does not hurt and may save your life.

HUMAN IMMUNODEFIEINCEY VIRUS (HIV)

Human Immunodeficiency Virtus (HIV) is a sexually transmitted infection (STI). It can also be spread by contact with infected blood or from mother to child during pregnancy, childbirth, or breast-feeding.

· The most common way to contract HIV is to engage in one or more of the behaviors listed below:

o Unprotected sexual activities with persons living with HIV or unknown HIV status, or any individual who has multiple sex partners

o Sharing needles, syringes, or other preparation equipment with persons living with HIV or unknown HIV status

o Persons infected with, or recently treated for viral hepatitis or a STD such as syphilis, gonorrhea, or genital herpes

Some common symptoms of HIV are fever, chills, rash, night sweats, muscle aches, sore throat, fatigue, and swollen lymph nodes. Generally, symptoms would appear after a few weeks and be like the flu. Consequently, there is not a cure for HIV. Although there are anti-retroviral therapies available to slow the progression of the disease. There are several available options for testing including antibody screening, antibody/antigen combination tests, and nuclei acid test. All of the tests check for protein in the body that is made within 2-8 weeks of an HIV infection. Depending on the type of test, results could be obtained within 30 minutes up to a few weeks depending on when the individual became infected.

Pre-exposure Prophylaxis (PrEP) for HIV is an effective biomedical intervention for reducing HIV transmission among populations at high risk for HIV infection and consists of two anti-HIV medications.

HEPATITIS C

Hepatitis C is an inflammatory condition of the liver usually caused by any of various infectious agents or toxins, including alcohol and numerous chemical compounds. Hepatitis C affects your liver the most, but it can cause problems with other body parts, too, including your skin. Bumps, rashes, and itchy spots may be the first signs you notice of this infection. Most people who have been infected with the Hepatitis C virus go for a long time before they know they have it.

Typical symptoms of Hepatitis C include bleeding easily, bruising easily, fatigue, poor appetite, yellow discoloration of the skin and eyes, dark-colored urine, itchy skin, and fluid buildup in your abdomen. However, many individuals do not experience symptoms. If you have Hepatitis C, there are many medications to treat it. But first, you need to be tested to determine if you have been infected. The CDC recommends routine testing for individuals with persistent risk factors including:

· Persons who inject drugs and share needles, syringes, or other drug preparation equipment;

· Persons with selected medical conditions, including persons who ever received maintenance hemodialysis.

There are preventative measures that can be taken to decrease the likelihood of being exposed to Hepatitis C. These measures include receiving the vaccines for Hepatitis A and Hepatitis B, use a condom during sex, don’t share needles to take drugs, practice good personal hygiene, and don’t use an infected person’s personal items.

In most instances, if your HCV antibody test is positive, then you may have been infected at some time. However, if the lab results show a weak positive, the lab will likely retest the sample to ensure that it is a false positive.

VIRAL HEPATITIS

Viral hepatitis is an infection that causes liver inflammation and damage. Hepatitis A and hepatitis E typically spread through contact with food or water that has been contaminated by an infected person’s stool. People may also get hepatitis E by eating undercooked pork, deer, or shellfish. Hepatitis B, hepatitis C, and hepatitis D spread through contact with an infected person’s blood. Hepatitis B and D may also spread through contact with other body fluids. This contact can occur in many ways, including sharing drug needles or having unprotected sex.

Symptoms of viral hepatitis include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-colored stools, joint pain, and jaundice. There are safe and effective prevention methods to decrease the likelihood of contracting the virus including: safe and effective vaccines, standard health care precautions, safe injection practices, and safe sex practices.

To test for viral hepatitis, a doctor would complete a blood sample and send it to the laboratory for testing. The results of a blood test can confirm the type of viral hepatitis, the severity of the infection, whether an infection is active or dormant, and whether a person is currently contagious.

1. Based on the CDC testing guidelines and the recommendation that all individuals aged 13-64 be offered HIV testing and screening, I understand that I am being referred for HIV testing and screening. HIV Testing is offered at the Adagio Mobile Unit, Adagio, Clarion Southwest AIDS Alliance, The Open Door, and Central Outreach (at ARC Manor).

My options for HIV Screening and Testing are:*

Adagio, 1097 Oak St., Lower Level, Indiana, PA 15701, 724-349-2022, 814-676-1811 (mobile unit)Clarion Southwest AIDS Alliance, 15870 Route 322, Suite 2, Clarion, PA 16214, 814-454-3811The Open Door, 665 Philadelphia St., Indiana, PA 15701, 724-465-2605 (Must be a client there)Central Outreach Mobile Clinic, ARC Manor, 200 Oak Ave., Kittanning, PA 16201, 724-548-7607I understand that I have been referred for HIV Screening and Testing; however, I am opting out of HIV testing at this time.

2. I would like to be referred for testing for Tuberculosis and/or Hepatitis C. Please select what services you would like referred to below:

TuburculousisType option 3Type option 4

2. I would like referred for testing for:
Tuberculosis Yes No
Hepatitis C Yes No

My options for TB are: (check referral source of choice)*

Armstrong Dept of Health, Armstrong Co State Health Center, 239 Butler Rd, Kittanning, PA 16201, 724-543-2700Indiana Dept of Health, Indiana Co State Health Center, 75 2nd St, Indiana, PA 15701, 724-357-2995, call for additional resourcesClarion Hospital Healthworks, 21159 Paint Blvd, Suite 3, Shippenville, PA 16254, 814-226-1396, sliding fee scale, fee for testIf I cannot afford to pay for a TB test and I have not been in contact with an active TB individual, I can be referred to Case Management Services who can assist me with payment.

My options for Hepatitis C are:*

Adagio, 1097 Oak St., Lower Level, Indiana, PA 15701, 724-349-2022, 814-676-1811 (mobile unit)Clarion Southwest AIDS Alliance, 15870 Route 322, Suite 2, Clarion, PA 16214, 814-454-3811The Open Door, 665 Philadelphia St., Indiana, PA 15701, 724-465-2605 (Must be a client there)Central Outreach Mobile Clinic, ARC Manor, 200 Oak Ave., Kittanning, PA 16201, 724-548-7607I can contact by Primary Care Physician and request testing.

3. I understand that Tuberculosis and Hepatitis C testing is available, and I am considered high risk. However, I am choosing not to be tested.*

I am opting out of testingI accepted a referral for testing

4. I have been tested for Hepatitis C once in my lifetime and do not wish to be retested.*

YesNo

5. I have been tested for tuberculosis within the past three months and do not wish to be retested.*

YesNo

Question 6: Have you ever been an injection drug user?*

YesNo

Question 7: Do you or anyone in your household currently have the following symptoms such as a sustained cough for two or more weeks, coughing up blood, fever/chills, loss of appetite, unexplained weight loss, fatigue, night sweats?*

YesNo

Tuberculosis is a disease that usually affects the lungs, but it can attack any part of the body. The TB germ is transmitted from person to person with droplets are expelled through the air by a person active with TB during coughing, sneezing, and talking.

Typical symptoms of TB include cough, fatigue, unexplained weight loss, loss of appitete, chills, fever, night sweats, and coughing or spitting up blood.

If you have TB, there are many medications to treat it. But first, you must find out if you have been infected. The best way to do this is to ask for a tuberculin skin test. The test is easy, doesn't hurt, and may save your life.

Please review your options for tuberculosis testing listed below and choose one:

Please review your options for tuberculosis testing listed below and choose one:*

I would like to be referred for testing for tuberculosis. I can contact the Department of Health in my county to receive a free TB test ONLY if I meet High Risk criteria (intravenous drug users, individuals exposed to active TB, individuals with HIV). There is a sliding scale fee. The Health Department takes care of medications and follow up for TB positive individuals.I understand that tuberculosis testing is available. However, I am choosing not to be tested.I have recently been tested for tuberculosis and do not wish to be retested.

If you would like referred for testing for tuberculosis, please select from the following options:*

Armstrong Dept of HealthArmstrong Co State Health Center239 Butler RdKittanning, PA 16201724-543-2700Indiana Dept of HealthIndiana Co State Health Center75 2nd StreetIndiana, PA 15701724-357-2995Clarion Hospital Healthworks21159 Paint Blvd, Suite 3Shippenville, PA 16254814-226-1396Sliding fee scale, fee for test.Cowansville Health Center (Armstrong Co residents) I understand there will be a fee for this test. 882 East Brady RdCowansville, PA 16218724-548-5605Referral for Case Management Services for financial assistanceYour own Primary Care PhysicianNot Applicable

If I cannot afford to pay for a TB test and I have not been in contact with an active TB individual, I can be referred to Case Management services who can assist me with payment.

If you were recently tested for TB, please list the date and results:

I accept a copy of this release:*

YesNo

Client Signature*

Date Signed by Client*

Witness Signature*

Witness Name*

First NameLast Name

Date Signed by Witness

I would like to be referred for testing for Tuberculosis: Select Yes or No Yes No*and/or Hepatitis C: blank fields and text.