Tuberculosis Control Program

BUMEDINST 6224.8

Chief, Bureau of Medicine and Surgery
February 8, 1993

Tuberculosis Screening Program

1. Screening on Entry into Naval Service

a. All personnel first entering duty in the regular Navy, the Naval Reserve, the Marine Corps, and the Marine Corps Reserve for periods of duty in excess of 30 days, including duty for training, and all persons beginning employment as CIVMARs for the Military Sealift Command must have the result of a tuberculin skin test documented in their medical treatment record.

b. Whenever possible, a person with a history of active disease, a history of a previous reaction to a tuberculin skin test, or a history of INH therapy must provide adequate documentation of any prior tuberculin skin tests, clinical evaluations, hospitalizations, diagnoses, and treatments. Adequate documentation includes copies of pertinent medical records, immunization records, or a physician's statement on letterhead stationary. Transcribe pertinent information into the medical treatment record. If such documentation is not available, apply a 5 TU tuberculin skin test. Interpret and manage any reaction per the guidelines of this instruction.

2. Periodic Screening. Screen personnel according to the following criteria:

a. Annual Screening. Required for personnel in operational units and in units with a high risk for tuberculosis exposure or outbreaks, including:

(1) All shipboard personnel, both active duty and civil service.

(2) All members of deployable Navy and Marine Corps units, except for ready reservists.

(3) All health care workers, including medical and dental treatment facility workers who are not members of the Medical Department.

(4) When recommended by the cognizant NAVENPVNTMEDU (e. g., certain high risk overseas duty stations).

b. Triennial Screening. Required for all other personnel, such as those in low- risk areas (e. g., active duty and Reserve shore- based personnel in the United States), at least every 3 years. Appropriate times for required periodic testing include:

(1) Physical examinations.

(2) Receipt of permanent change of station (PCS) orders.

(3) Review of medical records by the Medical Department representative (MDR).

(4) Reporting for active duty for training (ACDUTRA).

3. Screening Before Separation From Naval Service. All personnel must have a tuberculin skin test (or annual clinical evaluation in the case of a previously- known (old) reactor) documented within the 1- year period before separation from the naval service. 4. Radiograph Requirements

a. Entry into Naval Service. Obtain a chest radiograph only if clinically indicated for the diagnosis or evaluation of suspected tuberculosis, or another medical condition, or if required for programs with special physical qualifications. There is no requirement for a chest radiograph as a routine part of the tuberculosis screening program for entry into the naval service.

b. Separation From Naval Service. Obtain a chest radiograph only if clinically indicated for the evaluation of tuberculosis or another medical condition or if required for programs with special requirements. There is no requirement for a routine chest radiograph as part of the separation physical examination.

c. Other Radiograph Requirements

(1) Chest radiographs are indicated for the following:

(a) All newly- identified tuberculin reactors as part of their evaluation to rule out active disease.

(b) Any time active disease is suspected.

(c) Tuberculin reactors, including previously- known tuberculin reactors, who are contacts of known, potentially-infectious cases of active disease.

(2) Chest radiographs are not indicated for the following:

(a) Previously- known tuberculin reactors (old reactors) as part of their required annual evaluation, if they have remained asymptomatic.

(b) Tuberculin nonreactors.

5. Screening of Dependents. There is no routinely recommended program of tuberculosis screening for dependents, except on the recommendation of the cognizant NAVENPVNTMEDU for dependents living in areas at high risk for acquiring tuberculosis. Screening of dependents who are contacts of a case of active disease is handled on a case- by- case basis. This instruction does not preclude the routine screening of categories of dependents when recommended by appropriate professional organizations, e. g., the American Academy of Pediatrics. In general, tuberculosis screening of dependents follows the procedures and techniques set out in this instruction.

6. Testing Procedures

a. Tuberculin Skin Test Materials

(1) Tuberculin, purified protein derivative (PPD). Per reference (a), the only approved tuberculin skin test material for the routine Mantoux test is the premixed Tween- 80- stabilized intermediate strength PPD (5 TU equivalent) available as NSN 6505- 00- 105- 0102 or NSN 6505- 00- 117- 8783.

(2) Other Tuberculin Preparations. Premixed Tween- 80- stabilized low strength PPD (1 TU equivalent), available as NSN 6505- 00- 117- 8784, is used for low- strength tuberculin skin tests, when indicated.

(3) Multiple- puncture tuberculin tests (e. g., Tine or Monovac tests) produce significant numbers of both false-positive and false- negative test results, and are not to be used except on the specific recommendation of the area NAVENPVNTMEDU. The use of multiple- puncture tuberculin tests in all children and adolescents shall be discontinued.

(4) Syringes and Needles. Use a disposable 1 ml tuberculin syringe graduated in 0.1 ml intervals and fitted with a 25- gauge 5/ 8 inch needle, NSN 6515- 00- 982- 4205, for administering the Mantoux test. Do not use the hypodermic jet injector for PPD administration.

b. Tuberculin Skin Test Methods

(1) Personnel authorized to perform the tuberculin test. Only trained Medical Department personnel can perform the tuberculin skin test. The senior MDR must verify in writing that all personnel administering and interpreting the Mantoux test are trained and competent.

(2) Techniques. The technique for the Mantoux method of tuberculin skin testing is depicted in figure 1 and briefly described below.

(a) Prepare a tuberculin syringe with a single dose of 0.1 ml of intermediate strength (5 TU) PPD. Fill the syringe immediately before use, because the solution can be absorbed on the plastic of the syringe.

(b) Make an intradermal injection of 0.1 ml of intermediate strength (5 TU) PPD on the volar aspect of the forearm. The injection site should be clean and dry.

(c) Check for evidence of a good intradermal injection. A properly applied skin test will raise a small, pale, sharply demarcated wheal on the skin, which quickly disappears. If no wheal appears, the PPD has been injected subcutaneously; immediately apply another skin test on the opposite arm.

(d) Use the same method to apply a low strength (1 TU) test. Use 0.1 ml of low strength (1 TU) PPD; do not attempt to dilute or use a reduced dose of 5 TU PPD.

(3) Measuring Results

(a) Examine the tuberculin skin test site 48 to 72 hours after administration. The test must be read by an MDR who is both trained and experienced in reading and interpreting tuberculin skin tests.

(b) Measure the induration (swelling) in millimeters at its widest transverse diameter (across the arm). Redness without induration has no significance; ignore it.

(c) Measure and record any induration. SMALL REACTIONS (LESS THAN 10 MM) ARE IMPORTANT. Measure and record them accurately.

(d) Keep the forearm relaxed and slightly flexed at the elbow. Find the margins of induration by drawing the index or middle finger lightly across the reaction. Use a flexible millimeter ruler to measure the transverse diameter of the induration. If the measurement falls between two millimeter divisions of the scale, use the lower reading.

(e) If it is difficult to locate the margins, look at the reaction in a cross- light while lightly drawing a finger over the reaction. If necessary, the extreme edges of induration may be outlined by drawing onto the skin with a ballpoint pen. From 1 inch beyond any palpable induration, apply the tip of the pen to the skin and draw a line toward the induration. When a distinct change in rolling resistance is felt, remove the pen tip from the skin. That is one edge of the induration. Repeat the steps on the opposite side of the induration. Measure the distance in millimeters between the ends of the two pen marks.

(4) Recording Results

(a) Enter the test technique and result in the medical treatment record. Record the following information on SF 601 under SENSITIVITY TESTS: date, type of tuberculin and its strength (e. g., PPD 5 TU), and the diameter of induration in millimeters. An example of an entry is: "17 Sep 82 PPD (5 TU) 6 mm induration." Enter the information by hand. Do not use rubber stamps or automatic imprinting devices.

(b) Any induration is important, and must be recorded according to its actual measured size, e. g., "3 mm." Induration of less than 5 mm diameter must not be entered as "nonsignifi- cant," "zero," or similar phrase. Enter the complete absence of induration as "zero mm." Results must never be recorded as simply "negative" or "positive."

c. Failure to Return for Test Interpretations

(1) If the person returns more than 72 hours after PPD application and the induration is zero to 14 mm, make an entry of "not read" on the SF 601. Immediately apply a PPD test on the opposite arm.

(2) If the person returns more than 72 hours, (but before or on the 10th day), after PPD application and the induration is 15 mm or greater, the reaction is significant. Enter the indura- tion and the time interval since test application on the SF 601. Manage the person as a tuberculin reactor per enclosure (2). If there is uncertainty as to whether the area of induration is 15 mm or greater, the test should be repeated as in the previous paragraph.

(3) If the person returns more than 10 days after PPD application, make an entry of "not read" on the SF 601 regardless of the size of any induration. Immediately apply a PPD test on the opposite arm.

(4) If the person does not return at all, enter "not read" on the SF 601. Retest the person at the next opportunity.

(5) Do not under any circumstances report a skin test result as "zero mm" if the test was not read by a qualified MDR.

d. Techniques for Screening Large Numbers of Individuals. Within a command, the best opportunities for tuberculin skin are in the medical clinic or in sickbay during medical check- in, during annual record and immunization review and update, and during visits for other medical requirements. A tickler or recall system based on birth month is often useful. Occasionally, a more aggressive program using the "house call" approach may be necessary (e. g., large commands, contact investigations, or screening program catch- up). A qualified MDR goes to the work-space (e. g., division quarters aboard ship) to apply tuberculin skin tests. The MDR returns to the workspace in 48 to 72 hours to read the test. The percentage of tests read may be higher with this method.

7. Significant Reactor Rate. During routine screening after the initial (recruit/ officer accession) screening, the rate of newly-identified tuberculin reactors normally is no more than 1 to 2 percent of personnel tested in most Navy and Marine Corps set-tings. If the rate of newly- identified reactors is greater than 2.5 percent among any group tested, consider searching for an active case of tuberculosis disease in the command. Obtain specific guidance from the cognizant NAVENPVNTMEDU.

8. Special Situations

a. History of Bacillus Calmette- Guerin (BCG) Vaccination

(1) Ignore a person's BCG vaccine status when evaluating them for routine PPD screening, contact investigation screening, or evaluation of suspected active clinical tuberculosis.

(2) Many foreign countries use BCG vaccine for the prevention of tuberculosis, especially among children. Most countries that use BCG vaccine have a significant risk of tuberculosis infection in their population. While the vaccine may be effective in reducing the risk of serious tuberculosis disease (e. g., meningitis) in childhood, its long- term benefit is controversial. It is not used in the United States.

(3) Initially, BCG vaccine causes a reaction to the PPD skin test. The reaction is usually less than 10 mm induration and disappears within 8 years of vaccination. There is no reliable way to distinguish tuberculin reactions caused by BCG from those caused by natural infection. A significant reaction to a 5 TU PPD skin test in a person with a history of BCG vaccine usually means infection with M. tuberculosis. Such a person should be managed per enclosure (2).

b. History of Tuberculosis Disease or Tuberculin Reaction. Persons with a history of tuberculosis disease, a history of a previous reaction to intermediate strength PPD skin test or a history of INH therapy must provide adequate documentation of their prior evaluations, diagnoses and treatments whenever possible. Adequate documentation includes a copy of pertinent medical records, a copy of immunization records, or a physician's statement on letterhead stationery. If documentation is not available, follow the guidelines of this instruction and document in the member's medical treatment record the following: tuberculin skin test result, clinical evaluation (including chest x- ray, if indicated), diagnosis, and appropriate preventive treatment.

c. Use of Low Strength PPD. When a person gives a history of a significant or severe reaction to PPD, but has no documentation of such a reaction, repeat the tuberculin skin test. The best method is to use intermediate strength (5 TU) PPD. This method is standardized and the results are easier to interpret. However, if the person gives a history of a large vesicular reaction, the health care provider may use low strength (1 TU) PPD, which may reduce but not eliminate the risk of another large reaction. A history of a previous erythema nodosum reaction may also be an indication to use low strength PPD. A reaction of 5 mm induration or greater to a 1 TU test is signifi-cant; handle the person like a reactor with a 10 mm induration to a 5 TU test. If the reaction is less than 5 mm induration, apply a 5 TU PPD immediately and read and interpret the test in the normal manner.

d. Periodic Screening and the Booster Phenomenon

(1) Repeated or periodic testing of uninfected persons does not sensitize them to tuberculin (PPD).

(2) A person develops a hypersensitivity to tuberculin protein after being infected with M. tuberculosis or another mycobacteria (including BCG vaccine). (Hypersensitivity does not develop from simple tuberculin skin testing, no matter how often a person undergoes such testing.) The hypersensitivity, as measured by the amount of induration produced by PPD testing, may gradually decrease over the years in some persons. These persons may have no reaction, or only a small amount of induration, to tuberculin when first tested many years (decades) after their initial infection. However, a tuberculin skin test can stimulate or recall the hypersensitivity to its original degree of indura-tion within several days. This effect does not appear in response to the skin test which stimulated it, but produces an increased reaction (a "boosted" response) on the next test. The booster phenomenon is most common in persons over age 55, but can occur at any age.

(3) The booster phenomenon is a concern in a serial or periodic screening program, because it may create the false impression of a new PPD conversion or a new infection. In this situation, the first PPD skin test produces little or no induration, but the boosted reaction, which occurs in response to a test routinely administered a year or more later, is read as a positive skin test response. This positive response is then falsely attributed to a tuberculosis infection newly acquired in the year between the first and the subsequent test. In reality, this "positive" result is simply the boosted response.

(a) Use an initial two- step testing procedure to reduce the likelihood of interpreting a boosted response as evidence of a new infection. If the reaction to a first test is classified as not significant as defined in table 1, apply a second test a week later. Use the results of the second test as the baseline for subsequent testing. If the reaction to the second test is significant, manage the person as infected. If the reaction to the second test is not significant, manage the person as uninfected.

(b) The two- step procedure is most useful in older persons, such as older health care workers entering an MTF screening program. Do not use the two- step procedure for recruit or officer accession screening or other active duty screening programs.