KAP KEYS 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 

CSAT’s 

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 
KAP KEYS Based on TIP 18 

The Tuberculosis Epidemic 

Introduction 

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" information. 

For more information on the topics in these KAP Keys, readers 

are referred to TIP 18. 

Other Treatment Improvement Protocols (TIPs) 

that are relevant to these KAP Keys: 

TIP 6, Screening Instruments for Infectious Diseases Among 

Substance Abusers (1993) BKD131 
KAP KEYS Based on TIP 18 

The Tuberculosis Epidemic 

Recommendations for Typical 

Scenarios Regarding TB 

1 

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 representative: 

• 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 followup. Do not admit without a medical determination of noninfectiousness. 

TB Cause and Transmission 

TB is caused by an organism called Mycobacterium tuberculosis or M. tuberculosis. (M. tuberculosis organisms are sometimes 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 ventilation 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. tuberculosis does not necessarily lead to active TB disease or contagiousness. 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. 
KAP KEYS Based on TIP 18 

The Tuberculosis Epidemic 

Facts Regarding TB-related 

Discrimination 

2 

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 condition admission upon an applicant's consent to be tested for TB?
 

A: For many—if not most—treatment 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 overall answer:
 

• TB infection only: No. 

• Current active TB disease: Yes, if admitting the patient 

Continued on back 
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 mitigate 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 continuing 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 continuation in substance abuse treatment, that individuals with active 

TB disease undergo treatment for their TB? 

A: Yes, because individuals with active, untreated TB disease 

are—or are likely to become—infectious to others. 

Q: Is it legal for substance abuse treatment programs to have 

policies that require, as a condition of receiving and/or continuing 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 continuing in substance abuse treatment, that an applicant or client 

with a prior history of TB disease (who completed TB treatment) 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 treatment 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 redeveloping active TB. 
KAP KEYS Based on TIP 18 

The Tuberculosis Epidemic 

The Mantoux Tuberculin Skin Test 

(PPD) 

3 

The preferred method for detecting TB infection—and the only 

way to diagnose TB infection before it progresses to active disease—is the Mantoux Tuberculin Skin Test. Please note, however, 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 induration—an area of raised, swollen or 

hardened skin—at the site of the injection. A person not infected 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 disease) for developing infectious TB (such as diabetes mellitus) 

• Persons from medically underserved or low income populations, 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. 
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