Tuberculosis Control in Substance Abuse Treatment Centers

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Tuberculosis Control in Substance Abuse Treatment
Centers

• Sue Etkind, RN, MS
• Director
• Division of TB Prevention and Control

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Why is TB an important consideration for
Treatment Centers?

• Active TB is an airborne, infectious disease,
  transmittable to other clients and staff.
• TB disease (including TB in clients who are also
  infected with HIV) is both treatable and curable
  with anti-TB medications.
• Latent TB infection is also treatable reducing
  the risk of developing active TB disease in the
  future by over 90 in infected persons.

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Goals Tuberculosis Control in Substance Abuse
Treatment Centers

• 1. To ensure that there are no clients with
  transmissible active TB admitted to a substance
  abuse treatment center.
• 2. To ensure that there are no new staff with
  transmissible active TB.

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Goals Tuberculosis Control in Substance Abuse
Treatment Centers

• 3. To identify TB high risk clients who are or
  maybe infected with latent TB (LTBI) and to
  assure that treatment for LTBI is initiated and
  completed
• 4. To identify TB high risk staff who are or
  maybe infected with latent TB (LTBI) and to
  provide education and referrals for treatment for
  LTBI.
• A decision to test is a decision to treat

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Current Federal Requirements SAMHSA/CSAT
(condition of federal funding)

• Require the provision of (or arrangements for)
• Counseling the individual about TB
• Testing to determine whether individual is
  infected with TB
• Providing or referring infected individuals for
  appropriate medical evaluation and treatment
• NOTE Treatment Centers are expected to defer to
  state policies for TB Control

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Steps to a TB Policy What do we know about
substance abuse and TB risk?

• TB Disease
• Persons who are substance users who have active
  TB disease can be more infectious
• Why?
• Sputum may be smear positive
• Delays in care seeking leading to more advanced
  disease
• Treatment failures
• Crack cocaine use increased coughing and other
  pulmonary complications
• IMPORTANCE OF SYMPTOM SCREENING

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What do we know about substance abuse and TB
risk?

• TB Infection (LTBI)
• Persons who are substance users can be more at
  risk of acquiring TB if they spend prolonged time
  with an active TB case in areas that are
• enclosed/have limited ventilation/have high
  human traffic, etc.
• Congregate settings correctional facilities,
  shelters, etc.
• However, the epidemiology of TB in MA and case
  contact investigations suggests that this type of
  exposure is infrequent.

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What do we know about substance abuse and TB
risk?

• TB Infection (LTBI)
• Substance abuse can result in immunologic
  impairment and clients once infected with latent
  TB, can be more at risk of progressing to active
  TB disease
• Substance abuse can result in compromised liver
  functionality. This can be exacerbated by TB
  treatment with potentially liver toxic drugs
• IMPORTANCE OF IDENTIFYING THOSE AT HIGHEST RISK
  OF TB INFECTION

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Steps to a TB Policy Goal 1 To ensure that
there are no clients with transmissible active TB
admitted to a substance abuse treatment center.

• 1. Should we screen everyone for signs and
  symptoms of TB and refer them for TB follow up?
• All clients with a prolonged cough? (smokers,
  COPD, etc., etc.)
• NOT feasible

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Steps to a TB Policy

• 2. If not everyone, then who should we target for
  symptom screening?
• Persons who are likely to have TB infection

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Steps to a TB Policy

• 3. How do we identify persons who are likely to
  have TB infection?
• IMPORTANCE OF A TB HISTORY AND TB RISK ASSESSMENT
• 4. Is there a diagnostic test for TB infection?
• Mantoux skin test with PPD (Tuberculin skin test
  or TST)
• TB blood tests

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TB HISTORY CHECKLIST

• 1) Have you ever had a positive skin test for
  TB?
• Do you have the results written down?
• Date ___/___/___ result (in MM) ______
• 2) Have you ever had a positive blood test for
  TB?
• Date___/___/____ result ______
• 3) Do you have a chest x-ray result written
  down
• Date___/___/___
• result normal______ abnormal______
• 4) Did you take medication for your positive
  skin test?
• Have you ever been sick with TB disease?
• If yes, did you take medication for your
  illness?

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TB RISK ASSESSMENT CHECK LIST

• 1) Have you lived with or spent time with
  anyone who has been sick with TB in the last 2
  years?
• 2) Have you ever lived or traveled for more than
  a month in Africa, Eastern Europe, Russia,
  Central or South America or the Caribbean?
• 3) Do you have AIDS or HIV infection or other
  immune-compromised condition?
• 4) Do you have (or have you had) other medical
• conditions such as
• Diabetes ?
• Cancer?
• Kidney disease ?
• Rheumatoid arthritis ?
• Stomach or intestinal surgery?

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SYMPTOM SCREENING CHECKLIST Persons with an
identified TB risk

• Have you had a prolonged, unexplained cough
  lasting more than 3 weeks or a recent change in
  a chronic cough
• Have you recently lost weight of 10 pounds or
  more for no apparent reason?
• Have you had a fever of more 100 degrees F for
  over 2 weeks?
• Do you sweat at night?
• Have you felt unusually tired recently?

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Steps to a TB Policy

• 5. Wouldnt it just be easier to test everyone?
• False positives with TST
• Chest x-ray
• Treatment with liver toxic drugs
• Resources needed
• Remember A decision to test is a decision to
  treat

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Minimum Standards Needed to Meet the Goals

1. Obtain TB history and TB risk assessment
2. Perform Symptom Screening for anyone with an
   identified risk
3. Make referral for TB medical evaluation and
   follow up for those at risk
4. Perform repeat screening and testing when
   indicated
5. Provide TB education about symptoms, and need for
   immediate follow-up should symptoms develop

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• CLIENTS

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Procedure for TB Screening and Targeted Testing

• Obtain a TB history and risk assessment before
  admission
• All clients with NO identified TB history or TB
  risk may be admitted. No further evaluation is
  necessary
• Clients WITH an identified TB history or TB risk
  must have a TB symptom screen documented

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TB history or risk identified and Symptomatic
(Goal 1)

• Early identification with active, potentially
  infectious TB is critical to preventing TB
  transmission
• If symptoms suggest a possible case of active TB
• Isolate the client immediately (if possible) and
  have client wear a mask
• Refer client to health care provider, clinic or
  hospital ED for prompt evaluation including an
  x-ray

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Diagnosis of TB Case/Suspect

• Health care provider will report case/suspect
• TB case management will begin in conjunction with
  local health department public health nurse (PHN)
• Before client is re-admitted to Treatment Center,
  the PHN will assure the client is on TB therapy,
  not infectious and is medically cleared.

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Diagnosis of TB Case/Suspect

• The supervision of TB therapy for the client and
  follow-up exam will be the responsibility of the
  health care provider and PHN
• Treatment Center staff may be asked to assist
  with performing directly observed therapy (DOT)
  of client TB medication doses if indicated by the
  provider and if resources are available
• PHN will conduct a contact investigation in
  collaboration with Treatment Center

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Diagnosis of TB Case/Suspect

• All contacts will be tested for TB (if not
  previously positive)
• If the contact tests positive or the contact has
  symptoms consistent with TB
• Treatment Center will need to ensure medical
  treatment to rule out TB disease
• If contacts is prescribed treatment for LTBI,
  assistance with DOT may be suggested, if
  resources are available

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TB Case/Suspect Discharge to the Community

• Upon discharge to the community, all clients on
  treatment for LTBI must be referred to the PHN at
  a local health department where the client will
  reside
• Clients that leave before testing completion
  should be counseled about the importance of the
  TB evaluation process and given TB clinic
  information

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Non-Symptomatic Clients with TB history or risk
Goal 2

• No documented history of TB test
• Admit and assure that a TB test is done on site
  or by referral
• Have documented history of positive TB test (once
  positive always positive)
• Admit to facility, repeat testing is NOT
  indicated
• Provide client with information about TB
  symptoms, the TB fact sheet, and TB/HIV
  connection pamphlet

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Non-Symptomatic Clients with TB history or risk

• Have documented negative TB test
• Admit to facility if tested within 3 months
  (negative TB test no exposure)
• Why lt3 months?
• lt3 months amount of time needed for recent
  exposure to be reflected in the TST, so if
  negative this is a true negative
• gt3months cannot assume no exposure as too much
  time has elapsed. Must do another TB test.

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Non-Symptomatic Clients with TB history or risk

• If gt 3months, admit and retest or refer for
  testing
• Provide client with TB/HIV fact sheet and copy of
  risk assessment
• NOTE NO retesting is required throughout a
  continuous treatment episode (i.e. transfer
  between facilities/programs)

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Positive TB tests What next?

• On-site TB Testing Report positive TB tests
  to the MA Department of Public Health Office of
  Integrated Surveillance and Informatics Services
  (ISIS) on the LTBI form

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Positive TB tests What next?

• Goal 2 To identify TB high risk clients/staff
  who are or maybe infected with latent TB (LTBI)
  and to assure that treatment for LTBI is
  initiated and completed
• A decision to test is a decision to treat
• Refer the client to a health care provider or TB
  clinic for medical evaluation and treatment
  initiation for LTBI if indicated (prevention)
• Continue TB treatment on-site by DOT if resources
  allow (methadone maintenance/ needle exchange
  program successes)

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Pregnant Clients

• Same admission and follow-up
• What if a pregnant client has active TB disease?
• Can endanger newborn baby at delivery
• Can endanger the pregnancy or complicate the
  pregnancy because of unusual drug reactions
• IMPORTANCE OF SYMPTOM SCREENING

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Pregnant Clients

• Observations
• Only the tuberculin test is recommended for TB
  testing during pregnancy (no blood tests for
  infection)
• TB testing not contraindicated
• Pregnancy has no effect on the performance of the
  TB skin test

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Pregnant Clients

• Shielded chest x-ray can be done any time during
  pregnancy, but may defer to at least 2nd semester
  in asymptomatic and low risk women
• LTBI treatment may be initiated during pregnancy,
  although in many cases it is delayed until soon
  after delivery

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Children and Adolescents

• Children or adolescents who are clients are
  screened following the recommendations for client
  screening
• If a treatment center admits a client with small
  children or adolescents, these non-client
  children or adolescents can be admitted and then
  screened following client screening
  recommendations.

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Children and Adolescents

• Note that for children lt 5 years of age, there is
  an increased risk of acquiring more severe forms
  of TB disease (e.g. meningitis) if infected with
  latent tuberculosis. However, the risk
  assessment form can identify those children who
  are at risk for LTBI who should be tested.
• Children in this age group who have a positive
  tuberculin skin test or blood test may show no
  outward symptoms, and are strongly encouraged to
  have a medical evaluation

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CLIENTS WHO LEAVE BEFORE TESTING COMPLETION

• Clients should be counseled about the
  importance of completing the TB evaluation
  process and given the telephone number of a TB
  clinic to contact for an appointment upon
  discharge. (A list of the current TB Clinics can
  be found on the TB Division website). The client
  will need to be provided with the results of
  testing to date (date of skin test planting,
  etc.).

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REPEAT CLIENT SCREENING

• On-going Educate clients about changing signs
  and symptoms (such as weight loss, new cough or
  change in chronic cough, etc.) which may reflect
  TB disease and the need for medical follow up
  immediately, should such symptoms develop.

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REPEAT CLIENT SCREENING

• Annual evaluation For clients who reside in a
  facility more than a year
• For clients with a documented positive tuberculin
  skin test or TB blood test NO FURTHER TESTING
  is indicated. These clients need to have an
  annual TB risk assessment done and, if a new risk
  has developed (e.g. Diabetes and/or symptoms) the
  client needs to be referred for a medical
  evaluation.

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REPEAT CLIENT SCREENING

• Annual evaluation For clients who reside in a
  facility more than a year
• For clients with no documented TB history or risk
  or a documented negative tuberculin skin test or
  TB blood test Conduct an annual TB risk
  assessment and, if a new risk has developed (e.g.
  Diabetes and/or symptoms) the client needs to be
  referred for a tuberculin skin test or TB blood
  test.

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STAFF
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Staff

• Staff must show freedom from active TB disease
  after hire and before working with clients or
  other staff. Proof of freedom from TB disease
  can be obtained by
• TB medical clearance documentation from their
  primary care provider.
• OR
• An on-site TB history and TB risk assessment
  completed (with appropriate follow up as needed)

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Staff

• For staff who have an on-site TB history and TB
  risk assessment completed
• All staff with NO identified TB history or TB
  risk may have client contact. No further
  evaluation is necessary (Flowchart 1).
• Staff with an identified TB history or TB risk
  must have a TB symptom screen documented
  (Flowchart 2).

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Symptomatic Staff with a TB History or Risk

• Early identification of active TB is critical to
  preventing TB transmission
• If the medical evaluation results in active TB
  disease being ruled out then staff may have
  client and staff contact.

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Symptomatic Staff with a TB History or Risk

• If a medical evaluation results in a diagnosis of
  suspected active TB disease, the following will
  occur
• TB case management for the staff member will
  begin in conjunction with the local board of
  health/health department public health nurse
  (PHN) case manager.
• The PHN will assure that the staff member is on
  TB therapy, not infectious, and is medically
  cleared to have client contact.

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Symptomatic Staff with a TB History or RiskRisk

• The supervision of TB therapy for the staff
  member and follow-up examinations will be the
  responsibility of the health care provider and
  the PHN in collaboration with the TB Division.

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Non- Symptomatic Staff with TB History or Risk

• No documented history of a having a TST or TB
  blood test done, or the history is unknown
• Must have a TST or TB blood test completed on
  site or by a private provider and the results
  documented before having client contact.
• Any staff who is newly TST or TB blood test
  positive, should be referred to a TB clinic (or
  to their health care provider) for a medical
  evaluation.
• Report any positive TST or TB blood test
  identified through on-site testing to the
  Department of Public Healths Office of
  Integrated Surveillance and Informatics Services
  (ISIS), on the LTBI reporting form.

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Non- Symptomatic Staff with TB History or Risk

• Documentation of a negative past TST or TB blood
  test
• May have client contact if they have
  documentation of a negative TST or TB blood test
  that was done less than 3 months before hire. No
  further testing is needed at this time.
• May have client contact if the testing was done
  more than 3 months before hire however, the
  individual should make arrangements for a TST or
  TB blood test as soon as possible and follow up
  as needed.

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Non- Symptomatic Staff with TB History or Risk

• Documentation of a history of a past positive
  TST
• May have client contact if they have
  documentation of the past positive TST or TB
  blood test with a follow up normal chest x-ray
  (CXR).

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Repeat Staff Screening

• On-going Educate staff, with a TB history or TB
  risk, about changing signs and symptoms (such as
  weight loss, new cough or change in chronic
  cough, etc.), which may reflect TB disease and
  the need for medical follow up immediately,
  should such symptoms

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Repeat Staff Screening

• Annual Evaluation For staff with a documented
  positive TST or TB blood test NO FURTHER
  TESTING is indicated. These individuals need to
  have an annual TB risk assessment done and, if a
  new risk has developed (e.g. Diabetes and/or
  symptoms), the staff member should be encouraged
  to have a medical evaluation from a TB clinic or
  medical provider.
• For staff with a documented negative TST or TB
  blood test These individuals need to have an
  annual TB risk assessment done (on-site or by a
  medical provider, and, if a new risk has been
  identified (e.g. Diabetes and/or symptoms), the
  staff member should be encouraged to have a
  repeat TST or TB blood test.
• Unless a new TB risk is identified, repeat
  testing is not indicated if staff maintains
  continuous employment within the Agency.

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Questions?