Tuberculosis Control Program

BUMEDINST 6224.8

Chief, Bureau of Medicine and Surgery
February 8, 1993

Periodic Patient Evaluations

1. Purpose. A successful tuberculosis control program is dependent on the cognizant MDR. Many units have tuberculosis programs that are thorough in testing and record keeping, only to fail by not referring tuberculin reactors for preventive therapy or by not having periodic followup to ensure compliance. Two types of brief periodic patient evaluations are required.

2. Monthly Evaluations

a. After newly- identified tuberculin reactors (or previously- known (old) reactors who have never before had INH) have been referred for preventive therapy, the cognizant MDR must follow these patients monthly until preventive therapy is complete (usually 6 to 12 months). The purposes of these visits are:

(1) To ensure patient compliance with taking INH.

(2) To review with the patient the signs and symptoms of INH- induced liver toxicity.

(3) To review with the patient the signs and symptoms of tuberculosis disease, which can develop even while taking INH preventive therapy. This is particularly important for tuberculin reactors who could not take INH because of a medical contraindication.

b. A locally- prepared patient questionnaire can assist the MDR in this brief evaluation before dispensing another month of INH preventive therapy (see example on page 3 of this enclosure). If any question of liver toxicity or active tuberculosis disease emerges from this evaluation, refer the patient to a medical officer as soon as possible (within 72 hours, if possible). If liver toxicity is suspected, discontinue INH until the medical officer evaluation. Make an appropriate entry in the health record (SF 600) for all monthly evaluations.

3. Annual Evaluations

a. All tuberculin reactors who have completed a course of preventive therapy and monthly evaluations, as well as all previously- known reactors (whether or not they have completed a course of INH) must receive a brief clinical evaluation by the cognizant MDR annually. The purpose of this visit is to review the signs and symptoms of tuberculosis disease with the patient.

b. If any question of tuberculosis disease emerges from this evaluation, refer the patient to a medical officer as soon as possible.

c. Make an appropriate entry in the health record (SF 600) for all annual evaluations. A locally- prepared patient question-naire can assist the MDR in this evaluation and documentation (see example on page 4 of this enclosure). A routine chest radiograph is not indicated and is not required.

Sample Monthly Patient Questionnaire
Patients on INH Preventive Therapy

Please check each of the following that apply to you:

1. It has been 2 or more months since I have seen a physician concerning my medication.

Yes __ No __

2. I have missed taking my medication since my last evaluation.

Yes __ No __

If Yes, specify number of days missed: _____

3. Since my last evaluation I have had:

Unexplained fever lasting more than 3 days. Yes __ No __

Nausea, vomiting, or diarrhea lasting more than 3 days. Yes __ No __

"Yellow Jaundice." Yes __ No __

"Yellow Eyes." Yes __ No __

Dark urine. Yes __ No __

Unexplained muscle or joint aches lasting more than 3 days. Yes __ No __

I have felt rundown since my last visit. Yes __ No __

I have felt a burning sensation in my hands or feet. Yes __ No __

Sample Annual Patient Questionnaire *

PATIENTS WHO HAVE COMPLETED INH PREVENTIVE THERAPY

Please check each of the following that apply to you:

1. I presently smoke cigarettes, cigars, or a pipe. Yes __ No __

If Yes, what type: _________________; how many per day: ____

2. I have the following symptoms:

Persistent cough. Yes __ No __

Coughing up blood. Yes __ No __

Unexplained fever. Yes __ No __

Unexplained weight loss. Yes __ No __

If yes, about how many pounds: ______

Night sweats. Yes __ No __

3. I have felt run down since my last visit. Yes __ No __

4. I have sought care in the past year for chest symptoms. Yes __ No __

If yes, specify when and the symptoms below: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

* Also use these questions for the monthly evaluation of newly- identified tuberculin reactors who cannot take INH preventive therapy.