From: Billi Goldberg <bigoldberg@igc.apc.org>
Subject: VA Summary 2/28/92
Note: non-commercial reproduction.
Archive-Number: 5905
Organization: UCLA, Computer Science Department
Date: Sat, 15 Aug 92 08:24:39 PDT

This AIDS Information Newsletter was obtained from the HIV/AIDS Info
BBS (714) 248-2836.  It is the best source of AIDS Info available.
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                   AIDS INFORMATION NEWSLETTER
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     (415) 221-4810 ext 3305
                        February 28, 1992 
                 TUBERCULOSIS AND HIV INFECTION 
                     NOSOCOMIAL TUBERCULOSIS 
      In 1990 Centers for Disease Control (CDC) issued a comprehensive 
Morbidity and Mortality Weekly Report (MMWR) supplement on "Guidelines 
for Preventing the Transmission of Tuberculosis in Healthcare Settings, 
With Special Focus on HIV- Related Issues" (MMWR. 1990;39[no. RR-17]).  
These guidelines were prepared in response to nosocomial outbreaks of 
multidrug-resistant pulmonary tuberculosis among human immunodeficiency 
patients in New York City and Florida hospitals. There also appear to 
have been nosocomial transmissions to healthcare workers.
     The August 30, 1991 issue of MMWR has a condensed, one-page summary 
of the recommendations, which accompanies a report on the tuberculosis 
outbreaks in four hospitals.  These outbreaks appear to have resulted in 
part from late diagnosis of tuberculosis, late recognition of drug 
resistance, and delayed and/or inadequately maintained respiratory 
isolation procedures.
     In at least one of the outbreak hospitals, implementation of CDC 
recommendations was followed by a decrease in cases of drug- resistant 
tuberculosis.  It is unclear, however, whether prompt recognition, 
isolation, and treatment of cases alone would have prevented nosocomial 
transmission, or whether improved environmental controls (negative 
pressure, air filtration, and/or ultraviolet light treatment of air) are 
critical for preventing spread of tuberculosis among hospitalized 
acquired immunodeficiency  syndrome (AIDS) patients.  (Nosocomial 
Tuberculosis. Infection Control and Hospital Epidemiology, 1991 
Oct;12(10):632). 
See also the February issue (Vol. 20, No. 1) of the American Journal of 
Infection Control.  Several articles discuss tuberculosis and HIV 
infection, including commentary from the APIC Guidelines Committee on 
the Centers for Disease Control "Guidelines for Preventing the 
Transmission of Tuberculosis in Health-Care Settings, with Special Focus 
on HIV-Related Issues." 
See also Tuberculosis in Patients with Human Immunodeficiency Virus 
Infection [review article].  The New England Journal of Medicine, 1991 
Jun 6;324(23)1644-50. 

            PUBLICATION OF CDC SURVEILLANCE SUMMARIES 
     Since 1983, CDC has published the CDC Surveillance Summaries under 
separate cover as part of the MMWR Series.  Each report published in the 
CDC Surveillance Summaries focuses on public health surveillance; 
surveillance findings were reported for a broad range of risk factors 
and health conditions.
     A summary of one of the reports published in the most recent 
(December 1991) issue of the CDC Surveillance Summaries is provided 
below.  All subscribers to MMWR receive the CDC Surveillance Summaries, 
as well as the MMWR Recommendations and Reports, as part of their 
subscriptions. 
  Tuberculosis Morbidity in the United States: Final Data, 1990 
Authors: John A Jereb, MD, Gloria D. Kelly, Samuel W. Dooley, Jr., MD, 
George M. Cauthen, ScD, Dixie E. Snider, Jr., MD, MPH, Division of 
Tuberculosis Elimination, National Center for Prevention Services, CDC. 
     The number of tuberculosis cases reported to CDC has been 
increasing since 1988, after a long historic decline. In 1990, 25,701 
cases were reported, an increase of 9.4% over the 1989 figure and the 
largest annual increase since 1953. From 1985 to 1990, reported cases 
increased by 15.8%. Disproportionately greater increases in reported 
cases occurred among Hispanics, non-Hispanic  blacks, and Asians/Pacific 
Islanders. In contrast, decreases were observed among non-Hispanic 
whites and American Indians/Alaskan Natives. By age, the largest 
increase in reported cases occurred in the 25- to 44-year age group; 
this increase may be largely attributable to rising numbers of 
tuberculosis cases among persons with human immunodeficiency virus 
infection or acquired  immunodeficiency syndrome. Notable increases also 
occurred among children. The proportion of cases among foreign-born 
persons has risen steadily, from 21.6% in 1986 to 24.4% in 1990.  
(Reprinted from MMWR, 1992;41(5):85-6). 

       SELECTED REFERENCES -- MMWR REPORTS -- TUBERCULOSIS
                   (Arranged Chronologically) 
Tuberculosis, final data--United States, 1986. MMWR, 36(50-51):817-20, 
1988 Jan 1. 
Use of BCG vaccines in the control of tuberculosis: a joint statement by 
the ACIP and the Advisory Committee for Elimination of Tuberculosis. 
MMWR, 37(43):663-4, 669-75, 1988 Nov 4. 
Tuberculosis and human immunodeficiency virus infection: recommendations 
of the Advisory Committee for the Elimination of Tuberculosis (ACET). 
MMWR, 38(14):236-8, 243-50, 1989 Apr 14.  
Mycobacterium tuberculosis transmission in a health clinic--Florida, 
1988. MMWR, 38(15):256-8, 263-4, 1989 Apr 21.  
Dowdle WR. A strategic plan for the elimination of tuberculosis in the 
United States. MMWR, 38 Suppl 3:1-25, 1989 Apr 21. 
A strategic plan for the elimination of tuberculosis in the United 
States. MMWR, 38(16):269-72, 1989 Apr 28. 
Prevention and control of tuberculosis in correctional institutions: 
recommendations of the Advisory Committee for the Elimination of 
Tuberculosis. MMWR, 38(18):313-20, 325, 1989 May 12. 
Update: tuberculosis elimination--United States. MMWR, 39(10):153-6, 
1990 Mar 16. 
Bovine tuberculosis--Pennsylvania. MMWR, 39(12):201-3, 1990 Mar 30. 
Screening for tuberculosis and tuberculous infection in high-risk 
populations. Recommendations of the Advisory Committee for Elimination 
of Tuberculosis. MMWR, 39 RR 8:1-7, 1990 May 18. 
The use of preventive therapy for tuberculous infection in the United 
States. Recommendations of the Advisory Committee for Elimination of 
Tuberculosis. MMWR, 39 RR 8:9-12, 1990 May 18. 
Outbreak of multidrug-resistant tuberculosis--Texas, California, and 
Pennsylvania. MMWR, 39(22):369-72, 1990 Jun 8. 
Prevention and control of tuberculosis in facilities providing long-term 
care to the elderly. Recommendations of the Advisory Committee for 
Elimination of Tuberculosis. MMWR, 39 RR 10:7-13, 1990 Jul 13. 
Tuberculosis in developing countries. MMWR, 39(33):561, 567-9, 1990 Aug 
24. 
Tuberculin reactions in apparently healthy HIV-seropositive and  HIV-
seronegative women--Uganda. MMWR, 39(37):638-9, 645-6, 1990 Sep 21. 
Nosocomial transmission of multidrug-resistant tuberculosis to health-
care workers and HIV-infected patients in an urban hospital--Florida. 
MMWR, 39(40):718-22, 1990 Oct 12. 
Dooley SW Jr.  Castro KG.  Hutton MD.  Mullan RJ.  Polder JA.  Snider DE 
Jr. Guidelines for preventing the transmission of tuberculosis in 
health-care settings, with special focus on HIV-related issues. MMWR, 39 
RR 17:1-29, 1990 Dec 7. 
Tuberculosis among foreign-born persons entering the United States.  
Recommendations of the Advisory Committee for Elimination of 
Tuberculosis. MMWR, 39 RR 18:1-21, 1990 Dec 28. 
Transmission of multidrug-resistant tuberculosis from an HIV-positive 
client in a residential substance-abuse treatment facility--Michigan. 
MMWR, 40(8):129-31, 1991 Mar 1. 
Tuberculosis outbreak on Standing Rock Sioux Reservation--North Dakota 
and South Dakota, 1987-1990. MMWR, 40(12):204-7, 1991 Mar 29. 
Purified protein derivative (PPD)-tuberculin anergy and HIV infection: 
guidelines for anergy testing and management of anergic persons at risk. 
MMWR, 40 RR 5:27-32, 1991 Apr 26. 
Tuberculosis transmission along the U.S.-Mexican border--1990. MMWR, 
40(22):373-5, 1991 Jun 7. 
Crack cocaine use among persons with tuberculosis--Contra Costa County, 
California, 1987-1990. MMWR, 40(29):485-9, 1991 Jul 26. 
Nosocomial transmission of multidrug-resistant tuberculosis among HIV-
infected persons--Florida and New York, 1988-1991. MMWR, 40(34):585-91, 
1991 Aug 30. 
Tuberculosis outbreak among persons in a residential facility for HIV-
infected persons--San Francisco. MMWR, 40(38):649-52, 1991 Sep 27.  
 VA (DEPARTMENT OF VETERANS AFFAIRS) EMPLOYEE TB (TUBERCULOSIS) TESTING 
PROGRAM   
 1.  PURPOSE:  The purpose of this VHA (Veterans Health Administration) 
directive is to outline guidelines to be utilized in conjunction with VA 
Manual MP-5, part I, chapter 792, change 7.  This directive will not be 
included in the manual.  
 2.  BACKGROUND   
   a.  TB continues to be a public health problem in the United States 
with over 20,000 cases reported annually (see par. 5.e.).   
   b.  Substantial increases in TB morbidity are occurring in certain 
areas with a high prevalence in patients with HIV (human 
immunodeficiency virus) infection.  In 1986, after 3 decades of steadily 
decreasing TB morbidity, there is now an increase in annual TB morbidity 
seen in the United States.  The increase occurred mainly in geographic 
areas and demographic groups with  large numbers of AIDS (Acquired 
Immune Deficiency Syndrome) cases, which suggests that the HIV epidemic 
has begun to influence TB morbidity (see par.  5.e.).   
   c.  Outbreaks of MDRTB (multi-drug resistant tuberculosis) were 
reported in 1990-91.  
   (1)  Several factors may have contributed to these outbreaks.  First, 
diagnosis of TB in HIV-infected patients was delayed in many cases 
because of unusual clinical and radiographic characteristics of TB in 
HIV infected patients.  In addition, recognition of drug resistance was 
delayed because of the lengthy time used for laboratory identification, 
confirmation, susceptibility testing and reporting of drug resistance 
patterns (see par. 5.b.).   
   (2)  Ineffective patient isolation may have played a role.  AFB 
(Acid-Fast Bacillus) isolation procedures were delayed and/or not 
maintained; doors to isolation rooms may have been left open; and 
employees and visitors entered rooms wearing no masks or masks that were 
used improperly.  Lastly, AFB isolation rooms often did not have 
negative air pressure with respect to the remainder of the facility (see 
par. 5.b.).   
 3.  POLICY:  Each VA facility will develop a Tuberculosis Testing 
Program in accordance with VA Manual MP-5, part I, chapter 792, change 
7.  The program should include all full- and part-time employees, 
volunteers, trainees, and VA Central Office employees assigned to field 
facilities, who are considered by the Personnel Health Physician to be 
at risk for contracting tuberculosis in the course of their assigned 
duties.  All hospital personnel including  volunteers who may be exposed 
to patients with suspected or known tuberculosis should be educated 
about the medical consequences of becoming infected with TB and should 
follow appropriate precautions for minimizing such exposure.  When 
aerosolized pentamidine is administered, precautions must be taken as 
the HIV infected individual may also be infected with tuberculosis.  
Health care  workers and other persons exposed to patients with 
potential TB for whom appropriate AFB isolation precautions are not in 
place  should be evaluated to determine whether treatment for TB or 
preventive therapy for TB infection is indicated.  All VA facilities, 
especially those where HIV-infected patients receive care, should 
implement the most current published recommendations for prevention of 
TB transmission (see pars. 5.c and b).  Since this is a rapidly evolving 
issue, future guidelines should also be consulted to assure an up-to-
date TB prevention program is in place at each facility.   
 4.  ACTION   
   a.  After the initial screening TB skin test or chest x-ray as 
addressed in the VA Manual MP-5, part I, Chapter 792, Change 7, policies 
for repeat testing should be established at each facility considering 
factors that contribute to the risk that a person will acquire new 
infection.  These factors include the location and prevalence of 
untreated TB in the community, in the institution,  and among personnel.  
For personnel considered to be at risk, repeat skin tests may be 
necessary on a routine basis (for example, every 6 months or yearly). 
This may be of particular relevance in geographic areas of high AIDS 
incidence and in certain specific locations within VA medical centers, 
such as AIDS units and facilities for the delivery of aerosolized 
pentamidine (repeat skin test no greater than every 6 months).  If the 
risk of exposure to TB is documented to negligible, it is not necessary 
to repeat skin tests routinely.  Policy for repeat tuberculin testing 
should be established by the Infection Control Committee at each 
facility based on these individual station characteristics.   
   b.  Employees who have been exposed to the risk of contracting TB 
shall undergo TB testing at their request or that of the Personnel 
Health Physician, and follow-up, if needed, as addressed in the VA 
Manual MP-5, part I, chapter 792, change 7.   
   c.  A tuberculin test prior to separation is recommended for all 
covered employees, unless the employee is known to be tuberculin 
positive.   
 5.  REFERENCES   
   a.  VHA Circular 10-91-084.  Administration of Aerosolized 
Pentamidine to HIV Positive Patients.  August 19, 1991. 
   b.  CDC (Centers for Disease Control).  Nosocomial Transmission of 
Multidrug-Resistant Tuberculosis Among HIV-Infected Persons - Florida 
and New York, 1988-1991.  MMWR 1991;40(34):585-591 
   c.  CDC.  Guidelines for Preventing the Transmission of Tuberculosis 
in Health-Care Settings, with Special Focus on HIV-Related Issues.  MMWR 
1990;39(RR17) 
   d.  CDC.  Guidelines for Infection Control in Hospital Personnel.  
Personnel Health/July 1983 
   e.  Core Curriculum on Tuberculosis.  American Lung Association, June 
1990. 
   f.  CDC.  Screening for Tuberculosis and Tuberculosis Infection in 
High-Risk Populations and The Use of Preventive Therapy for Tuberculosis 
Infection in the United States.  MMWR 1990;39(RR8).  
 6.  FOLLOW-UP RESPONSIBILITY:  Associate Deputy Chief Medical Director 
---- (Clinical Programs) (111A).   
 7.  RESCISSIONS:  None.  This directive will expire February 5, 1993.  
Department of Veterans Affairs, VHA DIRECTIVE 10-92-019, Veterans Health 
Administration, Washington, DC  20420, February 5, 1992    THIS VHA 
DIRECTIVE EXPIRES FEBRUARY 5, 1993 
Signed 2/5/92  John T. Farrar, M.D.  Deputy Chief Medical Director  

            TUBERCULOSIS GUIDELINES FOR DOMICILIARIES
                         by Marsha Reid 
     The Domiciliary Care Programs provide residential and medical care 
to populations at high risk for tuberculosis through their substance 
abuse, homeless and general domiciliary programs.  A high incidence of 
older adults are also found in this population.  In order to facilitate 
rapid and accurate diagnosis of patients requiring prophylaxis and 
treatment for active and latent tuberculosis, guidelines were developed 
and distributed to all domiciliaries in January 1992.  These guidelines 
focus on detection and control of tuberculosis and incorporate the 
current recommendations from CDC, including skin testing and evaluation 
for anergy in selected populations.  A decision-making flow chart was 
developed as a quick reference for action based on PPD reactivity.  A 
copy of the film and poster from CDC on Tuberculosis Skin Testing was 
also provided. 
     For additional information contact Marsha Reid, Public Health 
Education Coordinator, Domiciliary Care Program, Martinsburg VA Medical 
Center.  FTS 940-4505. 

                          ANNOUNCEMENT 
                 AIDS National Conference Calls
                    by M. Peterson, Director
                 AIDS Service, VA Central Office
                          FTS 535-7182 
     The AIDS Service, VACO, has established a series of AIDS national 
conference "Hotlines" which began on January 24, 1992.  The purpose of 
these calls is to discuss issues related to HIV/AIDS, to make 
announcements in a timely fashion, and to address questions.  Since this 
is a new approach and the usefulness has not been established, monthly 
calls have been scheduled through March and bi-monthly for the remainder 
of the year.  The calls are 55 minutes in length and use the VANTS 
system.  The schedule for the next several months is as follows: 
     March 2, 1992                      11:00 AM EST
     May 4, 1992                        11:00 AM EST
     July 2, 1992                       11:00 AM EST 
     Please note that the call times are all Eastern Standard Time.  We 
look forward to talking with you. 

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