DRAFT (7/02/07)

**Department of State**

**Office of Medical Services**

**TUBERCULOSIS CONTROL POLICY**

# I. Background

Currently one-third of the world's population is infected with *M.
tuberculosis* (M.tb), typically resulting in *latent M. tuberculosis
infection* *(LTBI)* Although most persons infected with LTBI remain
asymptomatic for years, 5-10% of persons with LTBI eventually progress
to active tuberculosis (TB) disease becoming sick or infectious during
their lifetime. In most developing countries, tuberculosis is much more
common than in the United States, and it is an increasingly serious
global public health problem. The World Health Organization estimated
that the incidence of active TB disease TB in the world was 8,810,000
and that 1,747,000 people (including those co-infected with HIV) died
from TB in 2003. The highest incidence of tuberculosis disease per
capita occurs in sub-Saharan Africa. The increasing global TB problem is
complicated by persons infected with the HIV virus being much more
susceptible to developing active TB disease after LTBI. Multidrug
Resistant TB and Extended Drug Resistant TB outbreaks threaten to
further complicate management and control of TB (Ref 21)

TB is spread from person to person via airborne transmission. Patients
with chronic cough and cavitary pulmonary lesions with numerous *M.
tuberculosis* organisms (or tubercle bacilli) in sputum secretions are
the most efficient at transmitting TB. Close contacts of these who
breathe from the same airspace, such as in the household or in the
workplace are at risk of LTBI. CDC's Yellow Book and Travax recommends
that travelers to countries with high TB prevalence (i.e. most
developing countries) be screened for LTBI before and after travel since
they are at higher risk than the US general population of acquiring TB
infection; the cutoff for PPD positive is 10mm induration for
international travelers and foreign-born persons (however patients who
are immunocompromised or part of a TB outbreak investigation or have
fibrotic changes on chest radiograph consisted with prior TB have 5mm
cutoff, as per Travax).

The CDC strategy to prevent TB in the US involves 1) prompt detection
and reporting of persons with TB; b) protection of close contacts of
patients with contagious TB from contracting TB infection and disease;
c) taking concerted action to prevent TB disease among the substantial
population of U.S. residents with LTBI; TB screening programs in MED
provide medical care for individual employees and family members, and
provide information that facilitates detection of *M. tub*erculosis
transmission. The MED screening program consists of four major
components: 1) baseline testing for *M. tuberculosis* infection, 2)
serial testing for *M. tuberculosis* infection, 3) serial screening for
symptoms or signs of TBdisease, and 4) TB training and education. The
MED policies support the CDC TB control strategy through a TB screening
program, emphasizing "Force Health Protection" and clinical care of the
Diplomatic and Foreign Service Corps and their families that are higher
than average risk of LTBI or TB disease acquisition because of their
travel and living overseas. A special epidemiological study by Dr Joe
Bryan from July 2001-June 2002 revealed 307 persons reported to MED with
LTBI, and three persons with active TB disease (one lab confirmed, 2
suspect.) Of the 307 persons with LTBI, 54% were foreign-born. MED
providers are involved in several TB outbreak investigations annually at
overseas posts, typically involving FSN or LES workers working within
posts. In 2005, the CDC reported 4.8 TB cases per 100,000 population..
Assuming the MED covered population is 45,000, then the MED TB rate is
6.6/100000, higher than the general USA population. Without MED's
aggressive LTBI detection and treatment program, MED would expect to see
more active TB cases per year among FS staff and family members.

Each year, several FSN and LES staff develop active TB, prompting an
investigation to determine whether transmission occurred among those in
close contact with these, and some may regularly come into close contact
with DOS and FS staff who are within ICASS and MED scope of care. The
screening of FSN staff for TB disease is complicated for FSN and LES,
since many MED HU's will not typically be in a position to provide
longitudinal and comprehensive healthcare services for these. For these
persons and HU's, the primary goal is to promptly detect contagious
pulmonary TB, and to ensure that these people are promptly treated with
medications consistent with best practices in that country, and to
reduce risk of TB transmission to others within the DOS and FS
community. Familiarity with local Ministry of Health and WHO policies
may be necessary. There may be reluctance in some areas to screen with
PPD testing, and reluctance to detect or provide INH therapy for LTBI.
In some locations screening chest radiograph results may be more
important than skin testing (Reference 18, 22). Guidance is available to
perform contact investigations for TB outbreaks in reference 10.

Recent Changes:

The diagnosis, treatment, and prevention of TB and LTBI is complex, and
there have been some changes in best practices over the last ten years
as documented in the CDC Guidelines listed in the references (1-10).
Healthcare workers have special responsibilities to protect themselves
and their patients from healthcare facility associated TB outbreaks, and
MED personnel should be aware of the guidelines and standards that also
may apply to TB and to other airborne transmitted pathogens such as SARS
and pandemic influenza (Ref 14). . CDC now considers the FDA-approved
Quantiferon-G to be of equivalent value to PPD in screening for LTBI and
in contact investigations (Ref 1,16) The Quantiferon test might be
useful to resolve borderline PPD results that might indicate false
positive or cross-reactions rather than actual LTBI, but it expensive
and not available in most places. . Sputum examination is indicated for
persons with a positive TST or QFT result and either an abnormal chest
radiograph or the presence of respiratory symptoms (even when the chest
radiograph is normal). Prolonged use of immunosuppressive agents such as
TNF-α antagonists such as infliximab increases risk of progression from
LTBI to TB disease. Baseline and laboratory monitoring (AST, ALT, and
bilirubin) are needed only for HIV-infected persons, pregnant or
postpartum women, and persons who have chronic liver disease or who
regularly use alcohol.

Follow-up lab tests only indicated if baseline tests are abnormal, with
Emphasis on clinical monitoring at least monthly for signs of possible
adverse drug reactions.

If PPD's for screening are to be performed repeatedly, as they are
expected to be done for most FS workers and their families, the two-step
"boosting" procedure should help to rule out false positive conversions
upon retesting. The requirement for boosting can be met by having a
documented PPD result within one year of beginning serial screening; for
example an applicant for initial overseas screening can have a PPD
placed from their private provider or local health department, and then
the PPD can be placed at the MED Washington screening HU. Neither PPD's
nor Quantiferon tests should not be repeated after initially determined
to be positive and/or the person was treated for LTBI. The criteria for
positive PPD such as millimeters of induration varies by clinical
situation and health status of the person being tested. CDC considers
the decision to test by PPD to be equivalent to the decision to treat,
so that PPD testing is not indicated unless treatment for LTBI or TB
will be offered. CDC and MED discourage the use of BCG for US citizens,
relying instead on periodic PPD screening for detection of LTBI.

Concise TB references and training.

TB resources are available from CDC at
<http://www.cdc.gov/tb/default.htm> and from WHO at
<http://www.who.int/tb/en/index.html>. A concise CDC Guide for Primary
Health Care Providers: Targeted Tuberculin Testing and Treatment of
Latent Tuberculosis Infection, 2005 is available at URL:
<http://www.cdc.gov/tb/pubs/LTBI/default.htm> CDC's discussion of the
screening and care of prison populations in 2006 has the most
comprehensive discussion of the many issues related to TB control that
is applicable to many DOS settings overseas. A guideline for TB control
in healthcare facilities is applicable to control of airborne pathogens
also discusses two-step initial PPD screening in detail. Continuing
education is available for both of these is online from CDC at
<http://www.who.int/tb/en/index.html>. There have been periodic updates
to CDC's Core Curriculum on TB from 2000 (Ref 5.) Travax provides a
superficial discussion of screening for LTBI including use of PPD and
Quantiferon-G.

**II. American Employees and Eligible Family Members**

**A. Pre-employment Tuberculosis Screening of FS and Sponsored Family
Members Overseas**

At the time of their entry into the Foreign Service, all American
employees and their eligible family members are screened for LTBI and
active TB disease with PPD skin testing and a chest x-ray and a
questionnaire for symptoms. The symptom questionnaire should ask for a
history of TB disease, prior treatment for LTBI or TB disease, medical
record review, and symptoms that may suggest active tuberculosis disease
including presence of a cough, evidence or history of significant weight
loss, chronic cough lasting \>3 weeks, hemoptysis, or chest pain, fever,
chills, night sweats, easy fatigability, loss of appetite. Persons with
a positive PPD skin test result must be evaluated by chest radiograph
and sputum examination is indicated for persons with a positive TST or
QFT result and either an abnormal chest radiograph or the presence of
respiratory symptoms (even when the chest radiograph is normal,
Reference 1).

> Persons with symptoms suggestive of TB disease or with a history of
> inadequate treatment for TB disease should be immediately placed in a
> respiratory isolation room until they have undergone a thorough
> medical evaluation, per reference 14. A chest radiograph should be
> obtained to help determine if active pulmonary TB is present (Ref 22).
> If deemed infectious, such persons should remain in isolation until
> treatment has rendered them noninfectious. Facilities without an
> on-site isolation room should have a written plan for referring
> patients with suspected or confirmed TB to a facility that is equipped
> to isolate, evaluate, and treat TB patients. Persons with positive
> smears for Acid Fast bacilli (AFB) are the most infectious, and
> airborne precautions must be taken for those exposed to these(Ref 14).
> There is typically minimal risk to TB transmission when outdoors in
> the sunlight, and a room with a screened window open to ventilation
> with the outdoors may be the best available place to evaluate and
> manage patients with active pulmonary TB until more suitable
> facilities are available.
>
> Symptom screening alone is an only partially effective screening
> mechanism for TB, . The use of symptom screening alone may fail to
> detect pulmonary TB. Positive PPD skin test findings or abnormal chest
> x-rays must be evaluated before the person receives medical clearance
> for overseas assignment. The "two-step method" is recommended at the
> time of initial testing for individuals who will be tested
> periodically as outlined in Ref 14 ) and in Travax. If the first test
> result in the two-step baseline testing is positive, consider that the
> person has LTBI and evaluate and treat the person accordingly. If the
> first test result is negative, the second step of the two-step
> baseline testing should be repeated in 1--3 weeks. The cutoff for
> interpretation of positive results is according to current CDC
> guidelines (1,2). For non-US born persons from countries with high
> rates of TB disease, 10mm is the cutoff for positive. Most
> non-immunocompromized US-born persons will have 15mm induration as the
> cutoff for positive PPD on the boosted PPD upon initial screening.
> Family members traveling overseas will be screened beginning at age
> one year. It is optional to use the expensive Quantiferon-Gold blood
> test using lithium heparin tubes as an alternative to PPD for
> selective persons with borderline, clinically unexpected PPD
> results(3) This procedure might serve to rule out cross reactions from
> atypical mycobacteria in some cases. The rate of indeterminate
> Quantiferon results was reportedly about 2% in Navy recruits with this
> test, which may offer an improvement and assistance in reactions that
> are thought to be false positive PPD tests.

**B. Tuberculosis Screening while on Assignment Overseas**

> **[1. Persons known to be PPD skin test negative prior to
> screening]{.underline}**
>
> a\. Recommendation - All persons older than one year of age who are
> known to be tuberculin (PPD) skin test negative at baseline should be
> screened annually or at least every two years with an intradermal PPD
> skin test. A symptom questionnaire should ask for a history of TB
> disease, prior treatment for LTBI or TB disease, medical record
> review, and symptoms that may suggest active tuberculosis disease
> including presence of a cough, evidence or history of significant
> weight loss, chronic cough lasting \>3 weeks, hemoptysis , or chest
> pain, fever, chills, night sweats, easy fatigability, loss of
> appetite. The Quantiferon-Gold using lithium heparin tubes is an
> alternative test to the PPD and can be selectively used instead of the
> PPD either in screening or in outbreak or contact investigation as
> explained in references 1, 4 and 16. Quantiferon might not be
> available in many Health Units, and is very expensive. Details about
> PPD testing and interpretation of results are available in reference
> 1.

-   Patient age for first PPD testing is 12 months. Persons who have
    received BCG vaccine previously should also be tested.

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-   An FDA-approved reagent containing 5 tuberculin units of PPD should
    be used (i.e. 0.1ml Tubersol or Aplisol)

b\. Interpreting results PPD Results

-   A PPD reaction of 10mm induration or greater is classified as
    positive for international travelers.

-   For especially vulnerable categories of persons (HIV positive
    persons, recent close contacts of a case of active tuberculosis,
    persons with fibrotic changes on chest x-ray consistent with prior
    tuberculosis, persons with organ transplants and those receiving
    immunosuppression equivalent to 15mg of prednisone per day for one
    month or more) a PPD reaction of 5 mm induration or greater is
    classified as positive.

> c\. Actions needed to be taken based upon screening results

-   Persons who become PPD positive will receive a chest x-ray to
    determine whether they have active or latent tuberculosis.

> 1\. Latent tuberculosis

-   Persons with [latent tuberculosis]{.underline} (ppd positive, CXR
    normal) have a 5-10% lifetime risk of developing active
    tuberculosis. Infants and young children (less than age 5 years)
    have up to a 40% likelihood of developing active tuberculosis.

-   These persons should be offered tuberculosis prophylaxis according
    to current Centers for Disease Control (CDC) guidelines (refer to
    reference 1 for clinical details). Presently the preferred treatment
    regimen is isoniazid daily for nine months.

-   HIV positive persons are treated for 12 months. Routine baseline and
    follow-up laboratory monitoring can be eliminated in most persons
    with latent tuberculosis, except for those with HIV infection,
    pregnant women (or those in the immediate post partum period), and
    persons with chronic liver disease or those who use alcohol
    regularly.

-   After an initial clinical evaluation persons receiving isoniazid
    should receive follow-up evaluations at least monthly. This
    evaluation should include questioning about side effects and a brief
    physical assessment checking for signs of hepatitis.

-   Patients should be educated about the side effects associated with
    treatment of latent tuberculosis and advised to stop treatment and
    promptly seek medical evaluation if side effects occur.

> 2\. Suspected Active Tuberculosis A diagnosis of TB disease should be
> considered for any patient who has a persistent cough (i.e., one
> lasting \>3 weeks) or other signs or symptoms compatible with TB
> disease (e.g., hemoptysis, night sweats, weight loss, anorexia, and
> fever). Diagnostic tests for TB include the TST, QFT-G, chest
> radiography, and laboratory examination of sputum samples or other
> body tissues and fluids.

-   Persons with [suspected active tuberculosis]{.underline} (PPD
    positive, chest x-ray consistent with tuberculosis) will receive a
    microscopic examination of three stained sputum smears for acid-fast
    bacilli (AFB) taken on different days and culture and antibiotic
    sensitivity testing to confirm the identification of Mycobacterium
    tuberculosis. If active tuberculosis is confirmed, these persons
    should receive treatment medication according to current CDC
    guidelines (refer to reference 3 for clinical details). Presently a
    four-drug regimen is recommended (isoniazid, rifampin, pyrazinamide
    and ethambutol).

-   *Close contacts of* the person with *active tuberculosis* should be
    evaluated as recommended by the CDC (reference 10).

-   Employees with active tuberculosis can return to work after they
    have completed the first two months of a treatment regimen that
    includes both isoniazid and rifampin (or other medication
    recommended by CDC) and three microscopic sputum smear examinations
    taken on three different days do not show acid-fast bacilli (AFB).
    Additional guidance is discussed in reference 3.

-   A plan must be in place for insuring completion of the full course
    of treatment

> **[2. Persons known to be PPD skin test positive prior to
> screening]{.underline}**
>
> a\. Recommendation - Persons who are known to be PPD skin test
> positive prior to their assignment should be evaluated yearly and
> receive a screening chest x-ray if they have symptoms suggestive of
> active tuberculosis. A symptom questionnaire should ask for a history
> of TB disease, prior treatment for LTBI or TB disease, medical record
> review, and symptoms that may suggest active tuberculosis disease
> including presence of a cough, evidence or history of significant
> weight loss, chronic cough lasting \>3 weeks, hemoptysis , or chest
> pain, fever, chills, night sweats, easy fatigability, loss of
> appetite. Patients with symptoms that may be suggestive of active TB
> should be counseled to seek medical care and evaluation immediately
> and since a positive PPD result is associated with an increased risk
> of active TB disease. They should be evaluated on at least an annual
> basis for whether treatment for LTBI may be indicated, as discussed in
> reference 1 and in light of the fact that INH therapy is now
> considered less side effects than previously believed (Ref 20).

b.  Actions to be taken -- Any person whose chest x-ray is suggestive of
    active tuberculosis will be managed as previously outlined above and
    Reference 3.

    **C. Reporting**

Persons with either latent or active tuberculosis should be reported to
the Office of Medical Services using the Latent or Active Tb Worksheet
and Report and also reported on the Monthly Health Unit report. Copies
of the worksheet can be found on the providers section of the MED
Website (Under Information, SOP, Folders, Reporting) and are attached as
Appendices A and B. Medical officers should comply with local health
reporting of infectious diseases such as TB.

**III. Locally Employed Staff (LE STAFF)**

**A. LE STAFF Pre-employment Tuberculosis Screening**

-   3\. Testing of FSN's or others with high likelihood of having LTBI,
    active TB disease, or positive PPD. Overseas Health Units vary in
    their capacity to deliver healthcare for FSN's. Isoniazid treatment
    of LTBI is not standard practice in many countries public health
    systems. PPD's (or Quantiferon-G if available) screening generally
    is not indicated unless there is the provision of treatment of LTBI
    if the test is positive. It is estimated that approximately 40-60%
    of local employee applicants will be PPD positive on initial skin
    testing. The TB control issues for a high prevalence population are
    discussed in detail in reference 18.

In many cases, Health Units may have the need to screen FSN's for active
TB disease, and the majority of FSN's will likely have LTBI and positive
PPD's.

-   At the time of selection for post employment, all locally employed
    staff (LE STAFF) should be screened with a chest x-ray. A symptom
    questionnaire should ask for a history of TB disease, prior
    treatment for LTBI or TB disease, medical record review, and
    symptoms that may suggest active tuberculosis disease including
    presence of a cough, evidence or history of significant weight loss,
    chronic cough lasting \>3 weeks, hemoptysis , or chest pain, fever,
    chills, night sweats, easy fatigability, loss of appetite. Positive
    skin test findings, if available, or abnormal chest x-rays must be
    appropriately evaluated before the person receives medical clearance
    for post employment. Patients should be counseled to notify the
    Health Unit if they develop symptoms of TB at any time or if they
    are told by their private healthcare provider that they have active
    TB disease. The evaluation of a positive PPD or abnormal chest
    x-ray, or symptoms of TB such as chronic cough is the same as that
    outlined above for American employees. Few countries recommend
    treatment of latent tuberculosis.

-   Any applicant found to have active TB must complete a treatment
    regimen and be found free of active disease before receiving a
    medical clearance for employment. See reference 3 and 19 for CDC and
    WHO treatment guidelines as applicable, and references 10, 15 and 18
    guide contact investigations.

B. LE STAFF (includes drivers and other employees) Tuberculosis
Screening while Employed by Department of State

> **[1. LE STAFF Employees known to be PPD skin test negative prior to
> screening]{.underline}**
>
> a\. Recommendation -- LE Employees overseas should be screened
> annually with symptom screen in the same manner described above for
> American employees. A TB symptom questionnaire should ask for a
> history of TB disease, prior treatment for LTBI or TB disease, medical
> record review, and symptoms that may suggest active tuberculosis
> disease including presence of a cough, evidence or history of
> significant weight loss, chronic cough lasting \>3 weeks, hemoptysis ,
> or chest pain, fever, chills, night sweats, easy fatigability, loss of
> appetite. If INH treatment is available for LE staff, then PPD
> screening can also be included, regardless of prior BCG history, since
> BCG should not typically cause PPD results to be more than 10mm
> induration.

b\. Interpretation of results (See reference 1)

-   In sub-Saharan Africa or other high risk locations (where prevalence
    of disease is equal or greater than 50 cases per 100,000) a PPD
    reaction of 10mm induration or greater is classified as positive.

-   For especially vulnerable categories of persons (HIV positive
    persons, recent close contacts of a case of active tuberculosis,
    persons with fibrotic changes on chest x-ray consistent with prior
    tuberculosis, persons with organ transplants and those receiving
    immunosuppression equivalent to 15mg of prednisone per day for one
    month or more) a PPD reaction of 5 mm induration or greater is
    classified as positive. A close contact is defined as a person who
    had prolonged, frequent, or intense contact with a person with
    tuberculosis while he or she was infectious.

c\. Actions to be taken based on screening results

-   Persons who become PPD positive will receive a chest x-ray and
    symptom questionnaire to determine whether they have active or
    latent tuberculosis.

1\. Latent tuberculosis -

-   Employees with [latent tuberculosis]{.underline} will be managed as
    outlined by host country guidelines. Few countries recommend
    treatment of latent tuberculosis.

2\. Suspected active tuberculosis

-   Employees with suspected [active tuberculosis]{.underline} will be
    referred to a host country tuberculosis consultant for appropriate
    management.

-   LE STAFF may be treated according to World Health Organization (WHO)
    guidelines, which do not require sputum cultures and may have a
    slightly different four-drug treatment regimen than CDC guidelines.
    The differences between WHO and CDC guidelines are outlined in
    reference 3.

> **[2. LE STAFF Employees known to be PPD skin test positive prior to
> screening]{.underline}**
>
> a\. Recommendation --
>
> 1\. Persons in high-risk locations for TB who are known to be PPD skin
> test positive prior to their assignment

-   should be evaluated yearly and receive a screening chest x-ray if
    they have symptoms suggestive of active tuberculosis. These include
    cough for longer than 2-3 weeks unresponsive to standard medical
    treatment, fever, night sweats, and weight loss, hemoptysis or
    pleuritic type chest pain.

> 2\. Persons in average or low risk locations (\<50 cases per 100,000)
> and who are not at risk of contracting or spreading disease based upon
> their occupation

-   Should be evaluated as recommended by the host country standards

b\. Actions to be taken based on screening results - Persons whose chest
x-ray is suggestive of active tuberculosis will be managed as previously
outlined above. (III.B.1.c.2)

**III. [Reporting]{.underline}**

Persons with either latent or active tuberculosis should be reported to
the Office of Medical Services using the Latent or Active Tb Worksheet
and Report and also reported on the Monthly Health Unit report. Copies
of the worksheet can be found on the providers section of the MED
Website (Under Information, SOP, Folders, Reporting) and are attached as
Appendices A and B.

**IV.** **[Exposure to a Person with Active Tuberculosis]{.underline}**

Periodically a member of the Mission staff (American or LE STAFF) will
develop active tuberculosis or be exposed in an outbreak of TB. It is
policy to call MED staff in Washington DC to report these disease events
and to request assistance and consultation if needed from the infectious
disease specialist.

It is important to note that those who are especially susceptible to
tuberculosis disease, such as children under 4 years of age and
immunosuppressed persons, pose special circumstances. Young children and
immunocompromized contacts should be started on isoniazid or other
appropriate treatment regimen empirically after known exposure to an
active case of TB and until PPD testing proves infection did not occur.
(See Ref. 10, 3, and 5 [Core Curriculum on Tuberculosis, U.S. Department
of Health and Human Services, Centers for Disease Control and
Prevention, 2000 p. 55.]{.underline})

**[References]{.underline}**

1\. CDC Guide for Primary Health Care Providers: Targeted Tuberculin
Testing and Treatment of Latent Tuberculosis Infection, 2005 Avilable at
URL: http://www.cdc.gov/tb/pubs/LTBI/default.htm

> 2\. CDC. Targeted Tuberculin Testing and Treatment of Latent
> Tuberculosis Infection. MMWR,. June 09, 2000 / 49(RR06);1-54
> <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm>
>
> 3\. Treatment of Tuberculosis. MMWR, vol. 52, U.S. Department of
> Health and Human Services, Centers for Disease Control and Prevention,
> June 20, 2003. <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm>
>
> 4\. Quantiferon Gold
> <http://www.cdc.gov/tb/QuantiferonTBGoldTestNotice.htm>
>
> 5\. CDC. Core Curriculum on Tuberculosis, 2000.
> <http://www.cdc.gov/tb/pubs/corecurr/default.htm>
>
> 6\. CDC. Tuberculosis clinical training resources. web-based courses
> available at <http://www.cdc.gov/tb/pubs/corecurr/index.htm>
>
> 7\. Tuberculosis. World Health Organization Fact Sheet No. 104, April
> 2005
>
> 8\. TB Cases and Deaths Linked to HIV now at Alarming Levels in
> Africa. WHO Web Site, 2005.
>
> 9\. CDC Health Information for International Travel, 2005-2006 (Yellow
> Book) Chapter 4: Tuberculosis. 2006
> <http://wwwn.cdc.gov/travel/yellowBookCh4-TB.aspx>

10\. CDC. TB contact investigations
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm>

<http://www.cdc.gov/tb/pubs/LTBI/AppendixA.htm>

> 11\. Trends in tuberculosis , United States, 2006.
> <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5611a2.htm>
>
> 12\. Appendix C <http://www.cdc.gov/tb/pubs/LTBI/AppendixC.htm>
>
> 13\. Appendix D TST test record and treatment completion letter.
> <http://www.cdc.gov/tb/pubs/LTBI/AppendixD.htm>
>
> 14\. Guidelines for Preventing the Transmission of Mycobacterium
> tuberculosis in Health-Care Settings, 2005 MMWR Vol.54 No. RR-17
> <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm>
>
> 15\. CDC. Guidelines for the Investigation of Contacts of Persons with
> Infectious Tuberculosis MMWR 2005; 54(RR-15):1-48.
> <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm>
>
> 16\. CDC. Guidelines for Using the QuantiFERON®-TB Gold Test for
> Detecting Mycobacterium tuberculosis Infection, United States MMWR
> 2005; 54(RR-15) 49-55.
> <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a4.htm>
>
> 17\. CDC. Controlling tuberculosis in the United States. MMWR 2005;
> 54(12): 1-81. <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm>

18\. CDC Prevention and Control of Tuberculosis in Correctional and
Detention Facilities MMWR 2006: 55(RR9);1-44
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm>

19\. WHO. Treatment of Tuberculosis: Guidelines for National Programmes.
(Geneva.) 2003; 3:1-108 available at URL:
<http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.313_eng.pdf>

[Policy Proposed November 2005]{.underline}

20\. Nolan et.al Heptotoxicity associated with isoniazid preventive
therapy -

A 7-year survey from a public health tuberculosis clinic. JAMA, March

17, 1999, Vol 281, No. 11 pages 1014-1018.

> The symptom questionnaire should ask for a history of TB disease,
> prior treatment for LTBI or TB disease, medical record review,
> presence of a cough, evidence or history of significant weight loss,
> chronic cough lasting \>3 weeks, hemoptysis, or chest pain, fever,
> chills, night sweats, easy fatigability, loss of appetite.

# 21. CDC. Extensively Drug-Resistant Tuberculosis \-\-- United States, 1993\--2006

MMWR Morb Mortal Wkly Rep 2007; 569(11): 250-3

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5611a3.htm?s_cid=mm5611a3_e>

22\. CDC . **Diagnostic Standards / Classification of TB in Adults and
Children\
**Am J Respir Crit Care Med 2000; 161
<http://www.cdc.gov/tb/pubs/mmwr/Maj_guide/Diagnosis.htm>

Drafted Joe Malone, M.D.

Mani Srinivasan, M.D.

Date Mar 21,2007

Revision July 02,2007 jlm.