Tuberculosis Control Program

BUMEDINST 6224.8

Chief, Bureau of Medicine and Surgery
February 8, 1993

1. Purpose. To provide guidelines for a tuberculosis control program of screening, preventive therapy, case identification and treatment, and contact investigation to control tuberculosis among members of the Navy, the Marine Corps, and in other medical beneficiaries.

2. Cancellation. NAVMEDCOMINST 6224.1.

3. Background

a. Tuberculosis continues to be a public health problem in the United States and in the U. S. naval forces. Over 20,000 cases of tuberculosis occur annually in the United States, and cases occur regularly among Navy and Marine Corps members, their dependents, retired personnel, and Civil Service Mariners (CIVMARs). The Navy continues to experience local epidemics of the transmission of tuberculous infection onboard ships or in other closed environments. Tuberculosis constitutes an important opportunistic infection among individuals infected with the human immunodeficiency virus (HIV).

b. Morbidity and mortality from tuberculosis can be reduced by the early identification and treatment of persons with tuberculosis disease. In addition, early detection and treatment of persons with tuberculosis disease reduces the potential that infection will be transmitted to others.

c. The tuberculin skin test with purified protein derivative (PPD) administered by the Mantoux method is the most sensitive and specific test available for identifying those who are infected with Mycobacterium tuberculosis, the bacterium that causes tuberculosis. Periodic tuberculin skin testing detects newly infected persons, so that they can receive preventive therapy. An infected person has about a 5 percent lifetime risk of developing tuberculosis disease, if there is no intervention. Preventive therapy with isoniazid (INH) is the most effective measure to prevent the development of tuberculosis disease in a newly infected person. Although preventive treatment reduces the risk of disease, it does not totally eliminate it. Infected persons must be evaluated periodically and kept informed about the symptoms of tuberculosis disease.

4. Tuberculosis Control Program

a. Definitions

(1) Tuberculosis. A disease produced by infection with M. tuberculosis. For purposes of this instruction, persons infected with M. tuberculosis are considered to be in one of the following categories:

(a) Active Disease. The person has symptoms, signs, radiographic, or laboratory evidence of pulmonary, meningeal, miliary, or extrapulmonary tuberculosis. Pulmonary tuberculosis is the most common form of active disease, but not the only one. It causes the most concern because of the potential to transmit the infection to others by the airborne route. In general, such persons require treatment with multiple antibiotics, and will be or should be under the care of a physician.

(b) Tuberculosis Infection. The person has no symptoms, signs, or radiographic evidence of active disease, but does have evidence of infection, as indicated by the presence of a positive tuberculin skin test. For purposes of this program, all individuals who have a positive tuberculin skin test are considered to have a tuberculosis infection. Although such individuals may also have active disease, for purposes of this instruction, tuberculosis infection refers solely to individuals whose only evidence of tuberculosis infection is a positive tuberculin skin test. When the phrase tuberculosis infection is intended to include individuals with active disease, this will be specifically indicated.

(2) Tuberculin Skin Test. Refers to the Mantoux method of skin testing for tuberculosis described in enclosure (1).

(3) Mantoux Method. A tuberculin skin test using a syringe and needle to inject purified protein derivative (PPD) of tuberculin. Intermediate strength is 5 tuberculin units (5 TU) of PPD. Low strength contains one- fifth of the intermediate strength dose (1 TU).

(4) Induration. An area around the site of tuberculin injection that is raised and firm to the touch.

(5) Tuberculin Reactor. A person with an area of induration to a 5 TU tuberculin skin test (or to a 1 TU tuberculin skin test) when read 48 to 72 hours after administration. (The degree of induration which defines a reactor depends upon various risk factors. These are set out in table 1 of enclosure (2).)

(6) Tuberculin Nonreactor. A person with an area of induration of less than 5 mm (usually no reaction or zero mm induration) to a 5 TU tuberculin skin test.

(7) BCG Vaccine. Bacillus Calmette- Guerin (BCG) vaccines made from live attenuated mycobacteria strains are commonly used in some countries in an attempt to prevent vaccinees from becoming infected with tuberculosis.

(8) Health Care Worker. Includes military and civilian medical and dental health care workers.

b. Program Summary. The Tuberculosis Control Program consists of periodic tuberculosis screening, prevention of tuberculosis disease among tuberculin reactors, management of tuberculosis disease, and tuberculosis contact investigations.

(1) Tuberculosis Screening. Detects persons who have tuberculosis infection (including those who have progressed to active disease).

(a) Tuberculin Skin Testing. Enclosure (1) outlines the procedures and frequency for initial and periodic screening.

(b) Chest Radiographs. These are used in the initial evaluation of tuberculin reactors and in the evaluation of any patient who may have symptoms or signs suggestive of active disease. Enclosure (1) describes guidelines for chest radiographs in tuberculosis control programs.

(2) Prevention of Active Disease. Tuberculin reactors will be referred for medical evaluation for preventive therapy to decrease their chance of progression to active disease. Reference (a) and enclosure (2) describe specific aspects of this program.

(3) Management of Active Disease. Persons with active disease must be treated to prevent progression of disease in the individual and to reduce the spread of infection to contacts. A case of tuberculosis shall be reported by Disease Alert Report as required by reference (b). Enclosure (3) describes some aspects of management of a patient with active disease.

(4) Tuberculosis Contact Investigations. These are designed for early detection of infection in persons who probably have been significantly exposed to a person with tuberculosis disease, especially pulmonary tuberculosis. Enclosure (3) outlines the procedures.

5. Action. Each commander, commanding officer, or officer in charge is responsible for the maintenance of an effective Tuberculosis Control Program in his or her command.

a. Active Duty and Reserve Personnel. The Tuberculosis Control Program for active duty and Reserve personnel is outlined in enclosures (1) through (5). The command holding the medical treatment record is responsible for monitoring health records and managing local tuberculosis control programs for affected personnel. Medical treatment records must be reviewed and compliance with the applicable portions of this instruction ascertained at least annually. The activity maintaining medical treatment records is responsible for assuring that tuberculin skin test status is clearly and properly indicated in the sensitivity tests section of the Immunization Record, SF 601, and that periodic patient evaluations of tuberculin reactors are appropriately documented in patient health records on the Chronological Record of Medical Care, SF 600).

b. Dependents and other civilians except for the Military Sealift Command.

(1) Dependents. Commands in high- risk areas, as identified by the cognizant area Navy environmental and preven-tive medicine unit (NAVENPVNTMEDU), must extend the active duty program described to dependents residing in the area. Dependent contacts of cases of active disease must undergo periodic tuberculin skin testing, preventive therapy (if indicated), and followup evaluations. Dependents can be referred to tuberculo-sis referral centers, other military treatment facilities, or civilian sources as warranted by the situation. The local health benefits counselor must advise sponsors on treatment options for patients who are dependent parents or parents- in-law.

(2) Alien Dependents

(a) Foreign- born persons applying for permanent entry into the United States are required to be screened for tuberculosis. Tuberculosis screening and medical followup of aliens must be handled per reference (c).

(b) Before entry of an alien with active disease into the United States may be authorized, the alien must present assurance that medical care in the United States will be provided by a recognized medical facility. The internal medicine services and patient affairs departments of the following naval hospitals (NAVHOSPs) are designated points of contact to offer necessary care for tuberculosis to alien dependents who are currently residing in overseas areas with their Navy or Marine Corps sponsors:

1. NAVHOSP Bremerton, WA

2. NAVHOSP Oakland, CA

3. NAVHOSP San Diego, CA

4. NAVHOSP Bethesda, MD

5. NAVHOSP Charleston, SC

6. NAVHOSP Portsmouth, VA

Upon assurance of appropriate therapy, these dependents will not be denied entry into this country because of active disease when the sponsor is assigned in the United States. Reference (c) provides additional guidelines applicable to the evaluation and management of alien dependents entering the United States.

(3) Civilian Employees. Special programs, such as hospital infection control programs, may require tuberculosis screening for civilian employees. Those found to be tuberculin reactors must be referred for appropriate medical evaluation. If tuberculosis disease is found, the appropriate civilian health agency must be notified. If there is an indication that the infection has resulted from Navy employment, Federal employees should be referred to the Office of Federal Employee Compensation for determination of the availability of treatment under pro-visions of the Federal Employee Compensation Act and reference (d). Nonappropriated fund employees should be referred to an analogous compensation representative for determination of compensability under provisions of the Longshoremen's and Harbor Workers' Compensation Act and reference (d). Contact studies must be done in cooperation with the appropriate civilian health authority using guidelines in enclosure (3). If not covered under provisions of reference (d), the employee must be advised to seek adequate medical care.

(4) HIV Testing of Civilians. All dependents and civilian employees who are tuberculin skin test reactors, as defined in table 1 of enclosure (2), or who have other evidence of tuberculosis must be queried about HIV risk behaviors per reference (e). Individuals with HIV risk factors should be counseled and offered a serological screening test for HIV antibody.

c. Military Sealift Command Personnel. The Tuberculosis Control Program for the Military Sealift Command and its units (to include CIVMARs) is to be equivalent to the program for active duty personnel as outlined in enclosures (l) through (5). HIV testing of such personnel is to be carried out in the same way as for dependents and civilian employees, discussed in paragraph 5b( 4).

6. Specific Problems. Advice on specific problems can be obtained from the cognizant area NAVENPVNTMEDU:

a. NAVENPVNTMEDU TWO, Naval Station, Norfolk, VA 23511- 6288.

b. NAVENPVNTMEDU FIVE, Naval Station, Box 368143, 3035 Albacore Alley, San Diego, CA 92136- 5199.

c. NAVENPVNTMEDU SIX, Box 112, Pearl Harbor, HI 96860- 5040.

d. NAVENPVNTMEDU SEVEN, PSC 810, Box 41, FPO AE 09619- 4299 (Naples, Italy).

7. Record Keeping and Administration. Record keeping and administration requirements for this program are described in enclosure (5).

8. Forms and Report

a. SF 600) (5- 84), Health Record - Chronological Record of Medical Care, NSN 7540- 00- 634- 4176 and SF 601 (10- 75) Health Record - Immunization Record, NSN 7540- 00- 634- 4177, are available from the Federal Supply System through normal supply 10 procurement procedures.

b. The Disease Alert Report, MED 6220- 3, must be initiated as described in enclosures (3) and (5) when required.

D. F. HAGEN

Stocked:

Naval Aviation Supply Office

Physical Distribution Division Code 103

5801 Tabor Ave.

Phila., PA 19120- 5099