Tuberculosis Control
Program
Background
Tuberculosis poses a real risk for deployed Sailors and Marines. Foreign travel is
a key risk factor. However, tuberculosis infection can result from exposures in the United
States. In addition, if active tuberculosis occurs in a service member in the
closed-ventilation environment of a ship, the rate of transmission of tuberculosis
infection to shipmates can be high, even up to 25 percent.
Key Points
The Navys Tuberculosis Control Program addresses the risks of
Tuberculosis by providing guidance for the prevention and management of this disease. The
following areas are discussed at length in BUMEDINST 6224.8
-
Annual tuberculin skin test (TST) with purified protein derivative (PPD) to identify
newly infected persons.
-
Provision of preventive treatment with isoniazid
(INH).
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Monitoring those known to be infected for evidence of active disease.
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Early identification and treatment of persons with active tuberculosis to limit
transmission.
-
Contact investigations.
While the GMO is accountable for the program, a preventive medicine technician or
another trained corpsman normally does the routine testing and tracking of reactors that
are being treated with INH. The GMO evaluates suspected reactors, initiates and then
monitors INH treatments. Good entries in the medical records are essential, including;
date and size (in mm) of tuberculin skin test results; INH
start and stop dates; and
compliance.
Tuberculin Skin Test
(TST)
Routine TST programs are administratively challenging, since testing requires two
visits. Be persistent. A corpsman can read tests in a workspace to avoid return visits to
the medical spaces. If a test is not read in 2-3 days, re-administer the PPD. Periodically
check that corpsmen continue to use good intradermal technique. Ensure all tests are read
(induration only, not erythema) and accurately recorded: "not read" if not read;
"zero mm" if no reaction. All other reactions must be measured and recorded in
millimeters. Small reactions (<10mm) are important.
Testing frequency and Criteria for TST Conversion
Service members receive TSTs upon entering the service (and receive INH
if they have a reaction >10mm). Annual TSTs are performed on all personnel stationed on
ships or in deployable billets; all health care workers; and for personnel in certain
high-risk locations overseas. Other personnel receive TSTs at least every 3 years. A TST
reactor is a converter based upon size of induration, active TB exposure history, and age.
A TST reactor is summarized and categorized as follows:
-
If there is a >5mm induration AND the individual is a contact of a known case of
active TB, or they are HIV positive
-
If there is a >10mm induration, under age 35 AND, they were born in a high risk
overseas location or resident of a correctional facility (shipboard due to confined or
restricted ventilation systems) or were a recent PPD convertor.
-
If there is a >15mm induration, under age 35, AND no risk factors.
-
If there is a >15mm induration, over age 35, AND a recent PPD convertor.
More detail is included in BUMEDINST 6224.8.
Key questions in evaluating a TST convertor include:
A convertor receives 6 months of INH
preventive therapy, unless there is a medical
contraindication. Even in an otherwise healthy young patient, baseline liver function
tests (LFTs) are recommended, but not required. Converters and others with reactive TSTs
are not contagious; they may deploy whether or not they received INH.
Convertor managementIf you have a patient with suspected active disease (e.g., suspicious symptoms,
abnormal chest x-ray, or a reactive TST) place them in respiratory isolation and arrange
for referral or medevac. Do not start INH or other drugs because the therapy can
complicate laboratory confirmation. Young patients with tuberculosis, except
severe/miliary/meningitis disease, can tolerate a few more days without treatment. Have
them wear a mask and expectorate into a sealable container during transport. Submit a
Disease Alert Report. Start a contact investigation - TSTs of friends and other close
contacts including others routinely in the same berthing compartment or work space. If
more than 2.5 percent are convertors, expand the contact investigation by testing those in
neighboring work or berthing areas. Contacts need follow up testing in 3 months; a newly
infected person may not convert their TST for 8-12 weeks.
Final Thoughts
Think tuberculosis. It poses a unique risk to the military, especially in a shipboard
environment. Consult pulmonary or infectious disease physicians on the management and
referral of clinical cases. Consult preventive medicine physicians at Navy environmental
and preventive medicine units (see point of contact Introduction to Geographic Medicine
section) on TST interpretation, management of TST reactors, or contact investigations.
Essentials of Tuberculosis Control and Management
-
Properly administer and document TSTs.
-
Keep good medical records.
-
Start convertors on 6-month course of INH, unless medically contraindicated.
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Aggressively investigate cases and contacts.
References
-
BUMEDINST 6224.8 series
-
Tuberculosis Control Program, CDC, Core Curriculum on Tuberculosis, 2nd edition, April
1991.
Revised by LCDR Ann Fallon, MC, USN, Preventive Medicine Officer, Headquarters
USMC, Arlington Annex, Arlington, VA (1998).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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