U'S' Coast Guard Preventive Medicine Update

1
U.S. Coast Guard Preventive Medicine Update

• Armed Forces Epidemiology Board
• 22 May 2002
• CDR Sharon L. Ludwig, USPHS
• Prev Med and Epi Staff Officer

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Topics

• Tuberculin Outbreak 5 (in 3 years)
• Tuberculosis Control Issues

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Outbreak Report

• Excessive positive Tuberculin Skin Tests (TST),
  Key West, FL
• 25 interpreted as positive of about 250 tested
• 18 evaluated at Navy clinic and most started on
  Latent TB Infection (LTBI) treatment

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Investigation

• Local Coast Guard Health Services Technicians
• CG Atlantic area environmental health personnel
• Monroe County (FL) health dept TB control office

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County Investigation

• County says 10 TST is not excessive (according
  to CDC)
• Found no common exposure11 separate units
  affected
• No active cases
• County avg about 4 incident active TB/year
• All recent immigrants or known exposure long
  ago/far away

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County Investigation

• Did not address question of size of reaction
  considered positive
• Suggested could retest using Tubersol (vs
  Aplisol)

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Early CG Investigation

• Seven of 17 retested w/ Tubersol interpreted as
  positive
• All 18 continued on LTBI treatment

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Staff Assistance Investigation

• Of 25 initial TST interpretations
• Twenty gt 10mm, but lt15mm
• Five gt 15mm
• Of 17 retested with Tubersol
• One still gt 15mm
• One increased from 14 to 15mm
• Of 8 not retested, one gt 15mm

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Staff Assist Investigation

• gt15mm is cutoff for positive (risk-based)
• Total gt 15mm three
• Total tested 268
• Rate for two months 1.1
• Even with 10mm cutoff, rate was 7.5

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Discussion

• Still common perception that 10mm is cutoff
• If risk based screening explained, still
  perception of CG as greater risk

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Discussion

• Perception of increased risk not borne out under
  scrutiny
• Psychological impact of contact with
  immigrants/others
• Historical perceptions (paradigm)

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Investigation Conclusions

• No further investigation indicated
• Concerns
• Individuals and command still worried
• Most health care workers (HCW) inexperienced in
  complexities of TB testing/diagnosis
• Perception military high risk occupation
• Lack of local CG infectious disease, epidemiology
  expertise
• Policy issues

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Policy Issues

• Revising COMDTINST is inadequate for what amounts
  to a paradigm shift