Transmittal Number:92-2
Date: February 12, 1992
To:All Treatment Providers and Local Designated Agencies
Subject:Tuberculosis Update
Since the middle of the 1980's, tuberculosis has re-emerged as a significant public health problem.
After three decades of decline, the number of cases of TB increased for the first time in 1986.
New York City has experienced dramatic increases in cases of tuberculosis, with a 38 percent increase in one year.
Currently, New York City has a TB incidence rate of approximately 50 reported cases per 100,000 persons, approximately five times the national average.
The Division issued a Medical Alert Administrative Bulletin on tuberculosis in 1988 (see Transmittal Number 88-24).
This new bulletin will update you on important developments in this epidemic since 1988 and recommend several actions.
The resurgence of tuberculosis as a major health issue has significant implications for drug treatment programs.
A major factor in this resurgence is the presence of HIV infections among persons who develop clinical tuberculosis.
In one study conducted at the methadone treatment program of Montefiore Medical Center, all eight MMTP patients who developed active TB were also HIV-infected.
Seven of the eight cases involved the reactivation of latent tuberculous infection.
The Centers For Disease Control (CDC) estimate that approximately 90 percent of the new cases of TB occur in persons with latent tuberculous infection, which is reactivated when their immune system, weakened by HIV or other causes, is no longer able to control the TB infection.
The development of drug resistant strains of TB that do not respond to the first line drugs currently used for treatment of tuberculosis is a matter of serious concern.
A recent study of the hospitalized cases of TB in New York City revealed that 34 percent had TB strains that were resistant to one or more of these first line TB medications.
Consequently, MDR-TB must be treated for longer periods of time with drugs that have significantly increased toxicity and require careful patient monitoring.
In immunocompromised patients (e.g., HIV disease), MDR-TB has often been fatal.
In March 1991 the CDC reported on the transmission of a drug resistant strain of TB (resistant to isoniazid, rifampin, and ethambutol) in a residential drug treatment program in Michigan.
The program treated 140 clients in a two-story building with dormitory-style living arrangements.
One client with MDR-TB is known to have infected at least 15, and possibly as many as 31 persons (one staff person).
Non-compliance with the full course of drug treatment for active TB (9-12 months) has been a major factor in the development of MDR-TB.
In New York City, approximately 40 percent of all TB patients are non-compliant with treatment regimens.
The non-compliance rate upstate is approximately 20 percent.
Drug treatment programs are a critical locus for the implementation of measures that can assist patients in the completion of the medication regimen; prevent the reactivation of latent tuberculous infection and reduce the transmission of the TB bacillus through patient education and monitoring.
The Division views these goals as essential to the health and well-being of clients and program staff.
Studies conducted in various settings among persons with HIV infection have noted that HIV infection can suppress tuberculin reactions (i.e., anergy) on the standard test for tuberculous infection even before signs and symptoms of HIV infection develop.
Montefiore's MMTP reported an anergic response in 25 percent of its HIV-infected patients.
The CDC now recommends that persons with HIV infection should be evaluated for anergy in conjunction with tuberculin skin testing.
Anergy testing should also be considered for persons from high risk groups (e.g., injecting drug users) who refuse HIV antibody testing or whose HIV status is unknown (see enclosed MMWR Guidelines for Anergy Testing and Management of Anergic Persons At Risk of TB).
Directly Observed Therapy (DOT) is a patient management tool which has been successfully employed to improve compliance rates among patients with clinical tuberculosis and to prevent the reactivation of latent infection.
Through the use of "sites of opportunity" where TB patients are seen regularly for another service (e.g., drug treatment), the completion of the long medication regimen can be accomplished.
Patients who are no longer infectious at this stage of their illness are observed taking their TB medication when they receive their drug treatment services.
The Division is working with the State Department of Health and Department of Social Services to develop funding streams and protocols which would allow payment to drug treatment programs for provision of directly observed services to their clients.
It is essential that patients with active TB complete their therapy to eliminate the development of MDR-TB and its potential spread to other clients and staff.
To accomplish this, drug treatment programs, hospitals, and public health agencies must improve their communication, define their roles and coordinate their activities in managing the client with TB.
The Division is working with the State and City agencies and the provider community (i.e., COMPA; TCA; State Association; Legal Action Center) to develop ways to improve the continuity of care while safeguarding client rights.
The Division is concerned about the potential exposure of staff to the TB bacillus and recommends that programs perform baseline Mantoux skin tests on all staff, especially direct service staff (see CDC recommendations in "What Drug Treatment Centers Can Do To Prevent Tuberculosis").
Patient education sessions of TB transmission and prevention should also be conducted.
The Division is currently working with the City Department of Health to incorporate TB modules into introductory counseling courses funded by the Division and offered through NDRI.
The Division is also meeting with DOH and DSS to determine what modifications in the physical plant can be readily adopted to minimize the transmission of TB in treatment settings.
The Division endorses the seven recommendations of the Centers For Disease Control for the prevention of TB in drug treatment programs as necessary strategies to be implemented by its programs:
- Routinely provide Mantoux tuberculin skin testing on-site for every person served at the center.
- Refer persons with skin test results of 5 millimeters or greater for TB evaluation.
- Refer persons with TB-like symptoms, regardless of the skin test results, for TB evaluation.
- Provide or refer for HIV counseling and testing: (1) persons with skin test results of 5 millimeters or greater; (2) persons with a part or present history of IV drug use; and (3) the sex partners of persons with a history of IV drug use.
- Follow up on all clients referred for TB evaluation and HIV counseling and testing to make sure they keep appointments.
- Ensure compliance with TB medication by providing on-site (at the drug treatment center) directly observed preventive therapy to persons who have tuberculous infection but no clinical evidence of disease.
This therapy can be provided on a daily or twice-weekly basis and, if possible, it should be provided at the same time the person is seen for drug treatment.
- Provide an ongoing TB screening and prevention program for workers who have regular contact with persons who have or are at risk for TB or HIV infection.
This includes TB skin tests for employees at least once a year.
Drug treatment centers should work closely with their local health department TB program in planning and implementing these screening and preventive therapy recommendations.
Health department TB programs can assist by: (1) training DTC staff to perform tuberculin skin testing and provide TB preventive therapy; (2) assisting with referrals and contact investigation and (3) providing consultation on how to reduce TB transmission in drug treatment centers and medically manage persons with TB infection or disease.
For further information on tuberculosis, contact Rebecca Rosenfeld of the Division's AIDS Resource Unit at (212) 870-8515.
- Marguerite T.
Saunders
- Enclosures
- [NOTE: Enclosures are not included in this version.CED.]
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