Tuberculosis Control Program

BUMEDINST 6224.8

Chief, Bureau of Medicine and Surgery
February 8, 1993

Tuberculosis Contact Investigation Program and Tuberculosis Patient Management

1. Program Summary. Upon discovery of an active case of tuberculosis disease in the command, do the following:

a. Initiate a Disease Alert Report (MED 6220- 3), as required by reference (b).

b. Locate the patient's close contacts (i. e., spouse or significant others, household, berthing compartment, or workspace).

c. Screen these contacts for evidence of tuberculosis disease or infection and repeat the screening investigation 3 months later. Manage any tuberculin reactors as described in enclosure (2).

d. Maintain records of the summary results of the investigation per enclosure (5).

e. Clinically evaluate possible secondary cases for tuberculosis disease.

2. When to do a Contact Investigation. An investigation must be started upon notification that a present or former (within the past 6 months) member of the command has suspected or confirmed tuberculosis disease. If the person suspected of having tuberculosis is subsequently found not to have the disease, the investigation, which was begun among the contacts, may be stopped.

3. How to do a Contact Investigation

a. Investigation of contacts.

(1) Identify each person who has been a close contact of a known case (whether suspected or confirmed) of infectious tuberculosis disease for evidence of tuberculosis.

(2) Screen each close contact for evidence of tuberculosis infection or disease initially and 3 months later.

(a) Contacts, who are tuberculin nonreactors or who have not been identified as tuberculosis infected, must receive a tuberculin skin test per enclosure (1) with repeat skin tests at 3 months unless testing indicates they are reactors or convertors. If skin test is missed at 3 months, the test still must be done as soon as possible. Any tuberculin reactors or convertors identified during this screening should be managed.

(b) Contacts who are previously- known (old) tuberculin reactors must receive an initial evaluation consisting of a chest radiograph and a clinical examination for evidence of active tuberculosis disease. The clinical evaluation must be repeated at 3 and 6 months, but the chest radiograph only repeated if clinically indicated.

(3) Start and maintain appropriate documentation in the medical treatment record (SF 600)) of each contact. Record the results of the initial and all subsequent evaluations on an SF 600. Take particular care to record all items before the transfer of an involved member from the command.

(4) The command undertaking the tuberculosis contact investigation must maintain a "tickler" file or equivalent system to ensure the timely evaluation of all contacts. If a followup evaluation is missed, conduct the screening at the earliest possible date.

(5) Upon completion of the 3 month followup period, those contacts who remain tuberculin nonreactors will return to the routine tuberculosis screening program per enclosure (1).

(6) Contacts separating from the service must be counseled, with documentation on a SF 600, regarding the need for appropriate medical evaluation.

b. Special Situations

(1) Active Tuberculosis Disease Aboard Ship

(a) When a case of active tuberculosis disease is discovered aboard ship, crewmembers who share the same berthing compartment or workspace on a regular basis with the suspect case are close contacts. In addition, any very close friends of the case should be considered close contacts. Also, consider as close contacts any crewmembers whose berthing compartments or workspaces are served by the same ventilation system as the suspect case.

(b) All or most of the crew may be close contacts in some situations. On smaller ships, it may be easier to screen the entire crew, than to decide on who is a "close" contact. When a patient is highly infectious (e. g., the patient has cavitary pulmonary disease or has sputum which is strongly positive for tubercle bacilli), more crewmembers are at risk of tuberculosis infection. Also, if the patient is highly infectious, and duties took him or her many places on the ship or put them in regular contact with many crewmembers, more crewmembers should be considered close contacts. Consult the area NAVENPVNTMEDU for advice in specific instances where question exists.

(c) The percent of close contacts who are tuberculin reactors or convertors is a good indicator of the case's infectivity. If a large percentage of close contacts are newly-identified reactors, the case was "infectious." It may be necessary to expand the definition of "close" contacts and screen a larger group of crewmembers. If less than 2.5 percent of close contacts are newly- identified reactors, the patient was probably not very "infectious."

(2) Active Tuberculosis Disease at a Shore Facility. The cognizant MDR and local preventive medicine professionals determine the close contacts of an active case of tuberculosis disease at a shore facility. Contacts include any dependents with whom the patient resides, any person who shares the same berthing facility (room, open bay barracks, apartment, etc.), close work contacts during duty hours, and frequent liberty and social companions. Commands or activities with exceptionally close living conditions, such as Antarctic units, must follow the guidelines listed for ships. Consult the area NAVENPVNTMEDU for advice in specific instances where any question exists.

(3) Medical Department Personnel. Military and civilian health care workers who are exposed to patients with tuberculosis disease in the course of their work may be exempted from the contact investigation requirements of this instruction only if they took adequate respiratory precautions before the diagnosis of active tuberculosis disease and if their annual screening is up to date per enclosure (1). This procedure assures followup, yet reduces the administrative burden resulting from multiple exposures to tuberculosis among the same staff members. If such persons are contacts of an active case of tuberculosis disease other than in a patient as described above, they must be included in the contact investigation program. The frequency of hospital staff tuberculin testing must be increased if recommended by the infection control committee of the health care facility or the cognizant NAVENPVNTMEDU.

c. Tuberculin Reactors or Convertors Found During a Contact Investigation. Evaluate these individuals for evidence of tuberculosis disease and INH preventive therapy per enclosure (2). In a close contact of a newly diagnosed infectious tuberculosis case, a tuberculin reaction of > 5 mm induration is indication for INH preventive therapy regardless of the contact's age.

d. Possible Secondary Cases of Tuberculosis Disease Found During a Contact Investigation. If another active case of tuberculosis disease is discovered during the course of a contact study, it is not necessary to begin an entirely new investigation. However, do start contact studies on any persons exposed to the additional cases who were not included as a part of the original investigation.

4. Responsibility for Managing the Contact Investigation. The commanding officer or officer in charge of the duty station to which a person with tuberculosis disease was attached at the time of the diagnosis of his or her disease, is responsible for the tuberculosis contact investigation. However, the actual conduct of the contact investigation is carried out by the appropriate responsible supporting medical department or facility. The commanding officer or officer in charge of any activity is responsible for the successful continuation or completion of contact studies initiated or underway among personnel assigned to or transferred to his or her unit. Any person transferred from the command before contact study is complete must have appropriate documentation on SF 600) in the medical treatment records so the study may continue at the member's subsequent duty station.

5. Management of a Patient with Active Disease. A patient with suspected active disease generally should be referred to a medical treatment facility for inpatient evaluation, diagnosis, and initial treatment.

a. Tuberculosis Referral Centers

(1) The following hospitals are designated to act as contact points for pulmonary medicine or infectious disease consultation and patient transfer if needed: NAVHOSP Oakland, CA; NAVHOSP Portsmouth, VA; NAVHOSP San Diego, CA; and NAVHOSP Bethesda, MD.

(2) These centers: Handle complicated cases of tuberculosis; act as a consulting service for smaller medical and dental treatment facilities with questions on diagnosis, treatment, or disposition of patients; and oversee the reevaluation of tuberculosis cases. At the discretion of the chief of the pulmonary disease or infectious disease service, the reevaluation of any given patient may be performed at another naval medical treatment facility. The results of the reevaluation, including radiographs, must be reviewed at the tuberculosis referral center.

b. All medical treatment facilities: Handle uncomplicated cases of tuberculosis in consultation as appropriate with tuberculosis referral centers; notify the patient's last duty station of the confirmation or revision of the diagnosis of tuberculosis; maintain a patient education program adequate to assure cooperation by the patient during the extended treatment and followup period; maintain records on patients undergoing treatment and followup; perform reevaluation of tuberculosis patients (with guidance provided by the pulmonary medicine or infectious disease service at the nearest tuberculosis referral center); and actively cooperate with CDC, Atlanta, GA in its tuberculosis laboratory quality control program.

6. Decontamination of Spaces Occupied by Persons with Active Tuberculosis Disease. Tuberculosis is transmitted by small airborne droplets or droplet nuclei from person to person in close contact or possibly through ventilation systems, such as on ships. Other dried secretions and fomites in themselves do not pose a significant hazard. Therefore, when a case of active pulmonary tuberculosis disease is discovered, the filters in the ventilation system exhausting the berthing, messing areas, workspaces, and medical spaces must be cleaned per local directives for the maintenance of such filters. No extra (nonroutine) measures need to be taken in cleaning berthing spaces and bedding. If possible, increased circulation of fresh air and exposure of the spaces to natural light (sunlight) will rapidly clear any infectious, airborne droplet nuclei from the spaces. No other sanitation measures are necessary. The area NAVENPVNTMEDU may be consulted for advice in specific instances.