Circular 95-09 Appendix A
TUBERCULOSIS INFECTION CONTROL POLICY
TUBERCULOSIS SKIN TESTING PROGRAM
This section (Appendix A) outlines the Indian Health Service (IHS) policy and procedures regarding tuberculin testing and prophylactic treatment for employees working within IHS facilities or programs.
- Health Care Workers (HCWs) Purified Protein Derivative (PPD) Tuberculin Skin Test Screening.
- Employee Surveillance.
All IHS facilities shall have an employee TB screening program in place.
The program will apply to all permanent and temporary, full-time and part-time employees, tribal personnel, volunteers and trainees assigned to IHS facilities who are considered by the facility's employee health physician to be at risk for contracting TB by virtue of exposure in the course of their assigned duties. Consideration should also be given to personnel in tribally operated nursing and other group homes that serve the same patient population.
Screening and prophylactic treatment offered will be in accordance with guidelines published by the IHS, Centers for Disease Control and Prevention (CDC), and the American Thoracic Society (ATS).
- Employee Screening.
Covered employees shall have a tuberculin test at the time of employment. If an employee is known to have had a positive tuberculin test prior to entry on duty, no tuberculin testing will be carried out; instead, the employee will be referred to the employee health physician to establish an individualized program to assure the absence of active TB in the employee. This may include one or more chest x-ray examinations as well as documentation of prior testing and treatment.
The employee health physician shall review all available records and x-rays if an employee is known to have had a positive tuberculin test prior to entry on duty, and shall encourage the employee to accept preventive therapy, unless contraindicated or the employee refuses. When preventive therapy is instituted, it is the responsibility of the locally designated TB control physician to oversee the administration of such therapy.
- Tuberculin Skin Test.
The Mantoux technique tuberculin skin test is the method of choice for TB screening, (i.e. tine testing is not acceptable). The One-tenth milliliter of PPD (Stu) is injected just beneath the surface of the skin of left forearm. A discrete, pale elevation of the skin (i.e. a wheel) that is 6-10 mm in diameter should be produced. (More complete summary may be found in the MMWH, Table: S2-1, P.62.) This technique is preferred for screening persons for TB infection, because it is the most accurate test available. A 2-step procedure should be used initially to minimize the likelihood of misinterpreting a boosted reaction for a recent infection. In the 2-step procedure, an initial tuberculin skin test (Mantoux 5 Stu PPD) is given. If this test result is 0-9 millimeter (mm) of induration, a second test is given at least 1 week and not more than 3 weeks after the first. The result of the second test should be used as the baseline test in determining treatment and follow up of converters/reactors. Skin test results should be recorded in mm of induration and not as "positive" or "negative."
- Interpretation of Results.
Interpretation varies according to the risk factors associated with the group/individual being tested. In general, the recommendations for interpreting skin test results for HCW are equivalent to other members of high or low risk groups. (See Table S2-1, MMWR, Vol. 43/No. RR-13, p62.)
- The prevalence of TB in the facility should be considered when choosing the appropriate cut-point for defining a positive PPD reaction. In facilities where there is essentially no risk for exposure to Mycobacterium tuberculosis (i.e., minimal- or very low-risk facilities), an induration of > 15 mm may be a suitable cut-point for HCWs who have no other risk factors. In facilities where TB patients receive care, the cut-point for health care workers with no other risk factors may be > 10 mm .
- A recent conversion in a HCW should be defined generally as a > 10 mm increase in size of induration within a 2-year period. For HCW who work in facilities where exposure to TB is very unlikely, a increase of > = 15 mm induration may be more appropriate.
- Any employee initially manifesting a positive tuberculin reaction shall have a chest x-ray done.
- Recent converters, as indicated by a PPD increase of 10-mm induration within 2 years for those up to 35 years of age, and a PPD increase of > 15-mm induration for those 35 years old and older.
Any employee initially manifesting a positive tuberculin reaction shall have a chest x-ray done.
- Periodic Repeat Testing.
The required frequency of repeat risk assessment and PPD skin testing is based on the level of risk "minimal," "very low," "low," "intermediate," or "high") assigned by the most recent risk assessment. The frequencies are as follows:
- Annually for "minimal" "very low," or "low risk" areas.
- At 6 month intervals for "intermediate risk" areas, and
- At 3 month intervals for "high risk" areas.
(See Appendix B for definitions of "minimal," "very low," "low," "intermediate," and "high" risk).
- For HCWs With Significant Reactions.
Smear and culture examination of at least three sputum specimens collected on different days is the main diagnostic procedure for pulmonary TB. (P.64, MMWR)
During TB screening, it is important to obtain an initial chest radiograph on those persons with significant skin-test reactions, those who convert their skin test, or those who have pulmonary symptoms that may be due to TB.
There is no need to obtain routine chest films of asymptomatic, tuberculin-negative personnel. After initial chest films of persons with significant reactions, repeated chest x-ray examinations have not been found to be of value. Significant reactors, whether or not they complete preventive treatment, do not need repeat chest films unless they have pulmonary symptoms that may be due to TB.
For positive skin test reactions without evidence of disease, the most current recommendations for chemoprophylaxis as published by the IHS, ATS, and CDC should be considered. Any x-ray changes and a variety of underlying diseases must be evaluated on a case by case prior to a final decision on preventive therapy.
- HCWs Exposed to Tuberculosis.
When unprotected employees are exposed to a patient with active TB, the designated TB control person(s) shall immediately make a list of those employees (and patients) who are contacts (i.e. those who have shared air with the patient). Any contacts who have not completed baseline screening should be tested as soon as possible. Skin testing of all exposed tuberculin-negative employees should be completed within 10-12 weeks.
- Any employees whose tuberculin reaction converts from negative to positive shall have a Chest x-ray.
- Such an employee shall be offered appropriate chemoprophylactic therapy. At the discretion of the employee health physician, chest x-ray may be repeated after the completion of the course of chemoprophylaxis.
- Employees who convert their tuberculin test and who decline chemoprophylaxis should be considered for a chest x-ray examination every 3 months for 1 year and every 6 months for the next 2 years, since they are at high risk for developing active disease during that time.
- If the employee health physician determines that any employee has developed TB with active disease, such employee shall receive appropriate chemotherapy. The employee shall be deemed non-infectious before returning to duty. The employee health physician shall also notify the appropriate public health authorities of the case and arrange for such additional contact examination as may be necessary.
- Incidents resulting in the conversion of an employee's skin test to positive or causing active disease should be reported in accordance with the facility's incident reporting program.
A tuberculin test prior to separation Shall be done for all covered employees, unless the employee is known to be tuberculin positive.
All employees records pertaining to TB, including all x-rays, shall be retained with the employee's occupational health record.
The designated employee health specialist (see Indian Health Manual Part 1, Chapter 9) shall review the employee tuberculin testing program on a yearly basis, as a part of the overall employee health program. A copy of the skin testing policy shall be made available to each covered employee. Additionally, TB infection control training shall be provided at the time of assignment to tasks where occupational exposure may occur, and the training shall be repeated periodically.
- Return to Work policy for HCW's with active TB.
- Individuals with evidence of active pulmonary disease are not medically cleared to enter or return to the work site until they have evidence of a definite clinical and bacteriologic response to therapy (i.e., reduction in cough, resolution of fever, and consecutive negative smears for acid fast bacilli. In general, this response occurs after the individual has been on adequate chemotherapy for at least two to three weeks.
- Individuals without evidence of active pulmonary disease are strongly encouraged to follow the medical advice provided (e.g., prophylactic treatment if a new converter or less than (‹) 35 years of age) and are contacted again in a month by the TB control officer to determine their elected course of action. These individuals are medically cleared to enter or return to the work site directly. Compliance with any prescribed prophylactic treatment remains the responsibility of the individual and his/her personal pnysician or the community health clinic. HCWs with without evidence of active pulmonary disease who cannot take or who do not accept or complete a full course of preventive therapy should not be excluded from the workplace. These HCWs shall be counseled about the risk for developing active TB and instructed regularly to seek prompt evaluation if signs or symptoms develop that could be caused by TB.
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