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KAP KEYS Based on TIP 18
The Tuberculosis Epidemic: Legal and
Ethical Issues for Alcohol and Other Drug
Abuse Treatment Providers

        CSATs
Knowledge Application Program

KAP Keys
For Clinicians

Based on TIP 18
The Tuberculosis Epidemic:
Legal and Ethical Issues for
Alcohol and
Other Drug 
Abuse Treatment
Providers

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov

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KAP KEYS Based on TIP 18
The Tuberculosis Epidemic

These KAP Keys were developed to accompany the Treatment
Improvement Protocol (TIP) Series published by the Center for
Substance Abuse Treatment (CSAT), Substance Abuse and
Mental Health Services Administration. These KAP Keys are
based entirely on TIP 18 and are designed to meet the needs
of the busy clinician for concise, easily accessed "how-to" infor
mation.

For more information on the topics in these KAP Keys, readers
are referred to TIP 18.
Introduction

TIP 6, Screening Instruments for Infectious Diseases Among
Substance Abusers (1993) BKD131
Other Treatment Improvement Protocols (TIPs)
that are relevant to these KAP Keys:

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1
Recommendations for Typical
Scenarios Regarding TB

KAP KEYS Based on TIP 18
The Tuberculosis Epidemic

Applicants for substance abuse treatment will present a variety
of symptoms and histories, so risk assessments must be made
on a case-by-case basis. The following scenarios may be repre
sentative:

 Condition: Positive PPD, no symptoms, recent negative chest
x-ray. 
 Recommendation: Evaluate for preventive therapy.  Begin
substance abuse treatment.
 Condition: No history of TB, two months of fever, 15 percent
weight loss. 
 Recommendation: Perform PPD. If positive, report to health
department (if required by State law, and without violating
Federal confidentiality law). Arrange for complete medical
assessment to rule out infectiousness.
 Condition: TB six months ago, on medication, no symptoms.
 Recommendation: Consult public health officials, since
patient may still be under case management by them.
Consider bacteriologic examination of sputum. Monitor for
adherence to TB treatment. Proceed with substance abuse
therapy.
 Condition: TB six months ago, did not complete course of
treatment. 
 Recommendation: Consult public health officials.  Provide
full medical evaluation for infectiousness. Provide for follow-
up. Do not admit without a medical determination of non
infectiousness.

TB Cause and Transmission 
TB is caused by an organism called Mycobacterium tuberculo
sis or M. tuberculosis. (M. tuberculosis organisms are some
times called tubercle bacilli.) The condition is spread primarily
by tiny airborne particles (droplet nuclei) expelled into the air
by someone with infectious pulmonary or laryngeal TB disease,
typically through coughing or sneezing. Depending on ventila
tion and other factors, these droplets can remain suspended in
the air for several hours. Should another person inhale them,
he or she may become infected with TB.  TB infection and TB
disease (or active TB) are not the same. Infection by M. tuber
culosis does not necessarily lead to active TB disease or conta
giousness. Persons who are TB-infected but who do not have
TB disease do not pose a danger of transmitting TB to others,
while persons with active disease do.

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Facts Regarding TB-related
Discrimination

These answers are intended as general guidance: For
providers to make decisions consistent with these laws, they
should consider the circumstances involved in their particular
situations. The statements expressed herein do not reflect the
official position of the U.S. Department of Health and Human
Services (DHHS), do not constitute legal advice, and are not
binding on DHHS.

Q: Is it legal for a substance abuse treatment program to ask a
substance abuse treatment services applicant whether he or she:
1) Is currently infected with TB?
2) Has an infectious TB disease?
3) Has a history of TB infection or infectious disease?
4) Is currently being treated for TB infection (prophylaxis) or 
infectious TB by a health care provider?
A: Only if obtaining such information is needed to enable the
program to provide services or to ensure its safe operation. As a
general rule, a program subject to the Rehabilitation Act and/or
the ADA may not ask a prospective client whether he or she has
a particular disability simply for the purpose of identifying and
excluding all people with that disability from the program.

Q: Is it legal for a substance abuse treatment program to condi
tion admission upon an applicant's consent to be tested for TB?
A: For manyif not mosttreatment programs, the answer will
be yes.  However, while a substance abuse treatment program
may require a client to submit to a TB test, the program may
not act in a discriminatory manner with respect to the test
results.

Q: Is it legal for a substance abuse treatment program to
refuse to admit an applicant for substance abuse treatment
services who is:
1) Known to have TB infection?
2) Known to have infectious TB disease?
3) Suspected of having TB infection/infectious disease?
4) Known to have a history of infectious TB disease?
5) Known to have MDR TB or a history of active MDR TB?
6) Suspected of having MDR TB?
A: The answer in each case depends on the answers to two
other key questions. First, would admitting this individual pose
a significant risk to the health or safety of other clients or
staff? If so, are there reasonable modifications the program
can make to its practices, policies or rules that will eliminate or
mitigate the risk? How these questions are answered with
respect to specific TB-related conditions determines your over
all answer:
 TB infection only: No.
 Current active TB disease: Yes, if admitting the patient
Continued on back
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KAP KEYS Based on TIP 18
The Tuberculosis Epidemic

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KAP KEYS Based on TIP 18
The Tuberculosis Epidemic

poses a significant risk, and no reasonable modifications
can be made to mitigate or eliminate that risk.
 MDR TB: Yes, if admitting the patient poses a significant
risk, and no reasonable modifications can be made to miti
gate or eliminate that risk.
 A history of TB infection and/or active TB disease?: No.
 Suspected TB infection or disease, or suspected MDR TB:
No.
Q: Is it legal for substance abuse treatment programs to have
policies that require, as a condition of receiving and/or contin
uing in substance abuse treatment, that an applicant or client
with TB infection undergo preventive TB therapy?
A: No. Individuals generally have the right to make medical
treatment decisions for themselves, and may not be subjected
to medical treatment without their voluntary informed consent
after being apprised of the risks, benefits and possible side
effects of the proposed treatment.

Q: Is it legal for substance abuse treatment programs to have
policies that require, as a condition of admission or continua
tion in substance abuse treatment, that individuals with active
TB disease undergo treatment for their TB?
A: Yes, because individuals with active, untreated TB disease
areor are likely to becomeinfectious to others. 

Q: Is it legal for substance abuse treatment programs to have
policies that require, as a condition of receiving and/or contin
uing in substance abuse treatment, that an applicant or client
with a history of TB disease (and incomplete TB treatment)
undergo TB treatment?
A: Yes, at least for those with active disease.

Q: Is it legal for substance abuse treatment programs to have
policies that require, as a condition of receiving and/or contin
uing in substance abuse treatment, that an applicant or client
with a prior history of TB disease (who completed TB treat
ment) undergo preventive TB therapy?
A: No.

Q: If a client is participating successfully in substance abuse
treatment and is known to have latent TB infection or a history
of prior active disease, is it legal for the substance abuse treat
ment program to require, as a condition of remaining in the
program, that the client undergo periodic examinations to
determine if he/she has progressed to active TB?
A: Yes, if such a monitoring program is carefully designed to
identify those TB-infected patients who are at high risk for
developing active TB, and/or are showing symptoms of redevel
oping active TB.

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The Mantoux Tuberculin Skin Test
(PPD)

The preferred method for detecting TB infectionand the only
way to diagnose TB infection before it progresses to active dis
easeis the Mantoux Tuberculin Skin Test. Please note, howev
er, that all substance abuse treatment programs should obtain
their patients' consent to TB testing beforehand. The Mantoux
Test involves the injection of a small amount of purified protein
derivative (PPD) just beneath the surface of the skin of the
forearm. The result of the PPD test can be read by a trained
health care professional within 48 to 72 hours of the time of
injection. Generally, an immune competent person infected
with TB for more than two to ten weeks will produce an
immune response to the PPD that manifests itself through the
development of an indurationan area of raised, swollen or
hardened skinat the site of the injection. A person not infect
ed with TB will usually produce no induration in response to
the PPD.

Indurations are measured and recorded in millimeters, and a
reaction of 5 mm or more is positive in

 Persons whose chest x-rays suggest previous TB disease 
 Persons who are HIV-positive 
 Persons with risk factors for HIV infection 
 Close contacts of persons with infectious TB
 Injection drug users whose HIV status is unknown 

A reaction of 10 mm or more is positive in  
 Injection drug users who are HIV sero-negative
 Persons with known medical risk factors (other than HIV dis
ease) for developing infectious TB (such as diabetes mellitus)
 Persons from medically underserved or low income popula
tions, including high-risk minority groups such as Asians,
African Americans, Latinos and Native Americans
 Immigrants from countries where TB is common
 Residents of long-term care facilities
 Health care workers in facilities where TB is present
 The homeless 

All others will be considered to have had a positive reaction to
the skin test only if they develop an induration of 15 mm or
more.
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KAP KEYS Based on TIP 18
The Tuberculosis Epidemic

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Ordering Information
           TIP 18
 The Tuberculosis Epidemic: Legal and
Ethical Issues for Alcohol and Other Drug
Abuse Treatment Providers

Easy Ways to Obtain Free Copies 
of All TIP Products

1. Call SAMHSA's National Clearinghouse for Alcohol and
Drug Information (NCADI) at 800-729-6686, 
TDD (hearing impaired) 800-487-4889.
2. Visit CSAT's Website at www.csat.samhsa.gov

Do not reproduce or distribute this publication for a fee with
out specific, written authorization from the Office of
Communications, Substance Abuse and Mental Health
Services Administration, U.S. Department of Health and
Human Services.

DHHS Publication No. (SMA) 01-3572
Printed 2001