In 1991, 26,283 tuberculosis (TB) cases were reported in the United States - an 18 percent increase over the number reported in 1985.
From 1985 through 1991, over 39,000 excess cases of tuberculosis (TB) occurred in this country, compared with the expected decline of 7 percent per year observed from 1981 through 1984.
Increases in TB have occurred in blacks and Hispanics and in the 25-44 year-old age group.
They have been noted in the geographic areas of the country with the largest numbers of cases of Acquired Immunodeficiency Syndrome (AIDS).
Evidence for the association between HIV and TB comes from several sources which include: the matching of both the AIDS and TB Case Registries; HIV seroprevalence surveys in several cities, including Boston, and data on coinfection among injection drug users (IDU) in New York and New Jersey.
In a New York City cohort of 480 methadone patients, 15 percent of HIV seropositives with documented prior TB infection developed TB over a 2 year period compared to none of the TB-infected HIV seronegative patients.
With additional years of follow-up, the proportion of HIV-positive IDUs developing TB is expected to rise considerably.
Therefore persons with both TB and HIV infection are at extremely high risk of developing clinically active TB.
Alcoholics and drug addicts are at increased risk for TB because of the environments where many live and because of their elevated risk for HIV infection.
Crowded conditions in shelters and at meal programs, where 40-50 percent of the guests and participants abuse alcohol and other drugs, contribute to the transmission of respiratory infections, including TB.
Similar exposure risks are found in jails and prisons (75-85 percent of inmates have histories of alcohol or other drug abuse) and addiction treatment programs.
In addition, HIV infection is prevalent among individuals enrolled in residential, detoxification, and methadone treatment programs.
Injection drug use is now the leading risk behavior for new cases of AIDS in Massachusetts and is the third most prevalent risk factor associated with tuberculosis in the state.
An analysis of the 1991 TB morbidity indicates that at least 14 percent of all TB cases reported during that period had a history of drug use.
Data from two surveys conducted at the Boston City Hospital TB Clinic during that period had a history of drug use.
Data from two surveys conducted at the Boston City Hospital TB Clinic during 1990 confirm that injection drug use and HIV infection are closely associated with tuberculosis infection or disease.
The rationale for providing TB screening and preventive therapy in substance abuse treatment programs include:
Approximately 90 percent of the new TB cases which occur each year arise from the reservoir of dormant TB infection among some 10 to 12 million individuals in the population.
A major public health goal is to identify infected individuals at highest risk of developing clinical TB, e.g., who are at risk for or have HIV infection and prevent disease in these people.
TB is one of the few contagious respiratory diseases that occur in patients with HIV and AIDS, and it is treatable, curable and preventable.
Clients with a positive tuberculin skin test are at increased risk of active TB, even in the absence of HIV infection, and are at high risk of active TB when HIV is present.
TB skin testing of persons with, or at risk for, HIV infection and also at risk for TB should be conducted in the setting where individuals at risk for both conditions are routinely seen, e.g., substance abuse treatment centers.
Men and women in treatment have better control over their addictive behavior and, therefore, are more likely to follow TB control recommendations.
An effective TB screening and preventive therapy program will significantly reduce the risk of TB disease among clients and reduce the risk of transmission of TB infection from clients to treatment program staff and other clients.
If taken as prescribed, INH preventive therapy has been shown to reduce the risk of developing disease by up to 90 percent among persons without HIV infection.
Based on the good response of HIV-infected persons with active TB (disease) to standard TB drug therapy, INH preventive therapy also should be effective in this population.
Because many treatment programs require frequent (often daily) contact with clients for extended time periods (weeks/months), there is a unique opportunity for the treatment program staff to promote adherence by providing supervised preventive drug therapy (daily or on a twice weekly basis) for the recommended course of treatment (6-12 months).
Such supervision can be facilitated by the simultaneous administration of INH and methadone.
A referral network of 30 TB clinics statewide currently provides free diagnosis and treatment services for tuberculosis. (See attached list)
Because of the environmental and behavioral risk factors for TB found among individuals who abuse alcohol and other drugs, it is critical that addiction treatment programs have aggressive programs for TB screening, referral for TB services, and support for TB medication protocols.
Programs should be targeted to both clients and staff.
During the client orientation session the importance of testing for tuberculosis will be emphasized in a non-threatening manner.
All staff must be educated, supportive and committed to the need for this testing.
Confidentiality measures for all patient medical information should be discussed and maintained.
The orientation session should also include individual HIV risk reduction counseling (with follow-up counseling as needed) done by trained individuals, and on-site voluntary HIV testing or referral options for such testing.
Every client will have a brief history taken which will include questions about previous TB exposure, skin test results, past treatment for TB and current symptoms which may be suggestive of tuberculosis (cough, fever, night sweats, etc.) If the client has documentation of successful completion of past treatment for TB (at least 6 months of therapy) and has no symptoms, then no further follow-up is necessary.
If the client has symptoms, then he should be referred to the TB clinic for evaluation as soon as possible.
All clients with no documentation of a past positive skin test should receive a skin test for tuberculosis.
The intradermal Mantoux technique (with 5 tuberculin units PPD) is the only acceptable test.
The test results should be recorded in millimeters of induration (swelling).
The skin test should be preceded by an explanation of the reasons for the test and the need for follow-up and preventive therapy if the skin test is positive.
For most clients, a positive skin test is one that measures 10 mm induration.
However, there are some individuals for whom 5 mm would be considered positive.
These clients include: those persons who are known to be HIV infected; persons who are injecting drug users, and persons who have had close contact to someone with active tuberculosis.
All individuals with a positive skin test will be counseled about the significance of the positive result and referred to the local TB Clinic to be evaluated for clinical TB and appropriate treatment.
Persons currently having symptoms suggestive of TB will be referred for evaluation as soon as possible - regardless of the size of the skin test reaction,.
Persons with a negative (0 mm) skin test reaction who are HIV infected or at risk of HIV infection (such as injecting drug users) should be evaluated for anergy by performing anergy testing using at least two control antigens (mumps, candida or tetanus) (see appended anergy testing guidelines).
If the client is not anergic (e.g. there is some response to the anergy tests), and has no symptoms, then no further TB follow-up is required.
If anergic (e.g. no skin test reaction), the client should be referred to the TB clinic for further evaluation.
For clients who can provide documentation of a past previous positive Mantoux skin test and no history of successful completion of TB therapy, a referral to the TB clinic should be made in order to rule out the possibility of active disease, and to evaluate the client for preventive therapy.
NOTE: At methadone treatment sites, skin testing and follow-up for persons who test positive, who have symptoms of TB, or who are anergic, should occur prior to the initial methadone dose if possible.
This serves as an adherence tool as well as to assure that there are no clients entering treatment who have TB disease who could put other clients or staff at risk of tuberculosis.
Whenever possible, all clients who need follow-up for a positive skin test, symptoms or anergy, should be referred to a TB Clinic where expertise in chest x-ray interpretation and tuberculosis treatment and care is available.
If this is not possible, at a minimum, chest x-rays should be read by someone familiar with the varying radiologic presentations of TB.
Follow-up is possible at the treatment site rather than the clinic, if adequate medical/nursing patient supervision is available.
Communications need to be developed with local TB Clinic staff to ensure that: a) scheduling is accomplished smoothly and efficiently for the client (it may be helpful to provide clients with a scheduled TB clinic appointment at the time that their skin test is read at the addiction treatment program); b) the TB clinician is aware of the client's HIV status, if known (client's consent required); and c) referred clients are promptly followed if they fail to keep a scheduled appointment.
If the client fails to keep the first clinic appointment, a second appointment should be scheduled.
Failure to keep the second appointment should result in a concerted effort to encourage and facilitate compliance.
Clients who have been referred who are infected, but do not have current TB disease, will be strongly encouraged to receive Isoniazid (INH) preventive therapy at the substance abuse treatment site.
This will include all persons with a positive skin test and persons who are anergic with an abnormal chest x-ray.
Administration of INH will be directly observed and provided on site daily or twice a week.
Isoniazid may be given at the time that the methadone is dispensed.
Some programs may wish to use a client "contract" as an adherence tool for completion of therapy.
The use of informed consent for INH prophylaxis is an option for those programs who may feel that this documentation is necessary. (sample appended)
All persons on preventive therapy must be monitored by trained personnel for signs and symptoms of adverse reactions during the entire course of treatment.
Some patients will have underlying liver disease due to previous alcohol or other drug abuse.
Although chronic liver disease is not a contraindication to INH preventive therapy, such patients should be monitored more carefully by symptom review and liver function testing (LFT) (see appended LFT guidelines).
These reviews should be documented on the client's medical record.
A symptom check off list may be useful for this purpose. (sample appended)
Clients who are lost to follow-up before completing at least 6 months of uninterrupted preventive TB therapy, but who are now re-enrolled should be referred to the TB clinic for evaluation for restarting therapy.
When the client is scheduled to leave the treatment site before completing at least 6 months of preventive TB therapy, a well coordinated transition will be arranged to ensure completion of preventive therapy at another health care facility, e.g., a TB Clinic.
Clients found to have TB disease will be placed on appropriate therapy by the local TB Clinic.
Supervision of therapy and follow-up examinations will be the responsibility of the TB Clinic.
Step 1 should be followed, as above, as soon as the client is able to understand the needed education, counseling and medical history instructions.
Due to the nature of this type of service, however, there will not be adequate time for Steps 2 and 3 (referrals and follow-up) before the client is discharged from the facility.
Clients who are symptomatic for TB, however, must be referred as soon as possible to a TB clinic or other health care facility (if tuberculosis-specific clinics are unavailable), for evaluation for active disease (as their continued presence may jeopardize other clients and staff).
Client's skin test results should be recorded in the client's medical record in such a place that allows easy reference when and if, the client returns to that facility.
This system will help to avoid retesting clients who have already tested positive in a previous encounter.
The client should also be given a copy of his skin test result.
For those clients who were skin test positive (or anergic), education should be provided as to the need for follow-up by a TB clinic after discharge, a list of TB clinic addresses and telephone numbers should be part of the discharge information provided, and if possible, an appointment made at a TB clinic for follow-up.
Educational information about the relationship between TB and HIV and the needs for skin testing of designated high risk groups should be made available to the clients attending these sites.
A TB clinic directory and other language specific resource material should be accessible.
Counselors should stress the importance of skin testing as part of their intake procedures.
All clients who are denied admission should be given information relative to available tuberculosis services (TB Clinic list) and the need for testing (sample brochure appended).
All staff should be educated as to the TB/HIV problem, skin testing procedures and interpretation, and the need for follow-up and preventive therapy for their high risk clients.
Because some staff may have prolonged contact with clients who have undiagnosed TB disease, it is recommended that all new employees obtain a skin test upon employment.
Those employees who are skin test positive (10 mm or more reaction), should be referred to the TB clinic for evaluation and possible preventive therapy.
Those employees who are skin test negative, should be retested annually thereafter.
Employees who subsequently "convert" their skin test to positive at the annual screening, should be referred to a TB clinic for evaluation.
If an active case of TB is detected among clients or staff of a substance abuse service site, the local Health Department, in conjunction with the Division of TB Control, will conduct a contact investigation on site.
All persons with prolonged close contact to the case then will be required to be tested (if not previously positive) and followed up as necessary.
As noted, crowded conditions and poor building ventilation predisposes to TB transmission, especially in residential treatment centers when the duration of possible exposure is greater.
Centers with clients at high risk for TB should consider environmental interventions to make TB transmission less likely.
Ventilation should be checked for proper function on a regular basis at least twice yearly, for example, while changing to and from the heating cycle.
Professional engineering advice should be sought, if necessary.
Systems should be balanced if necessary for optimal performance.
Upper room ultraviolet germicidal irradiation may be useful in some settings to reduce TB risk.
The TB Division can offer technical assistance on the use of UVGI and other air disinfection strategies.
TB/HIV in-service education, skin testing training, posters, TB Directories, other educational materials and consultation are available through the Division of Tuberculosis Control (617-522-3700, x 450).
[NOTE: Attachments are not included in this version.CED.]
Site Map
Help
Account
Cart
Home
