New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 161B - STANDARDS FOR LICENSURE OF OUTPATIENT SUBSTANCE USE DISORDER TREATMENT FACILITIES › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
APPENDIX A
TUBERCULOSIS SURVEILLANCE PROCEDURES
SUBSTANCE ABUSE TREATMENT FACILITIES (SATFs)
INTRODUCTION
TB Problem among Substance Abusers
From 1992 to 2001 newly reported TB cases in New Jersey
				declined by 46.1 percent (984 to 530 cases annually). New Jersey reported 530
				TB cases for the second consecutive year in 2002, ending nine consecutive years
				of declining morbidity. In 2003, TB disease resumed its downward trend dropping
				6.6 percent to 495 cases for a case rate of 5.7 per 100,000 of population. The
				number of new TB cases has dropped by an average 4.5 percent and the case rate
				by 5.0 percent annually since the peak in 1992.
During 2003, 495 cases of TB were reported in New Jersey and
				of these 58 TB Cases or 11.7 percent gave a history of substance abuse within
				the last year. This is equivalent to 11.7 percent of 530 cases in 2002 and less
				than 13.8 percent in 2001. Substance abuse was reported by TB cases in 12 of 21
				counties statewide in 2003.
With the sustained decline of TB in the U.S. over the past
				decade, TB has been retreating into well-defined risk groups. Every effort
				should be made to test only those persons at highest risk for latent TB
				infection, interpret tuberculin skin reactions accurately, and ensure
				appropriate treatment and completion of the recommended regimen. Screening
				persons other than members of high-risk groups is not recommended.
Without treatment, approximately 20 percent of persons with
				latent TB infection (LTBI), formerly called preventive therapy and a history of
				injection drug use could be expected to develop active TB over the next 20
				years. Over the same time period, approximately 70 percent of persons with HIV
				infection could be expected to develop active TB. HIV infection contributes
				most to an increased risk for progression of LTBI to active TB.
Opportunity
for Preventing TB Among
				Injecting Drug Users
Injection drug users have an increased risk for progressing to
				active TB (10 cases per 1000 person-years), and this risk is even greater for
				injection drug users co-infected with HIV and TB (76 cases per 1000
				person-years). These higher rates may reflect increased transmission, more
				recent infection in this population, and the increased risk associated with
				injection drug use and HIV infection.
Most health department jurisdictions have been successful in
				achieving the highest priority TB objectives of identifying and ensuring
				completion of therapy among active cases and ensuring complete follow up and
				treatment of TB contacts. While maintaining these efforts, accelerated progress
				towards TB elimination will occur through testing and treatment of latent TB
				infection among groups at the highest risk of developing active TB.
Fortunately, latent TB infection, if discovered, is at a stage
				where progression to infectious TB disease is almost entirely preventable.
				Prevention requires identification of the infected individual and treatment for
				the latent infection with Isoniazid for 9 months. Studies have shown that
				persons who complete a full course of treatment for latent TB infection have
				more than a 90% reduction in the risk of developing active TB compared with
				persons who are not treated.
Adherence to latent TB infection is greatly enhanced by the
				implementation of a directly observed therapy (DOT) program. Tuberculin skin
				testing should not be undertaken by a SATF unless DOT is provided by the
				facility staff.
As indicated in the table below, treatment for LTBI among
				injection drug users, with or without HIV infection, is a relatively efficient
				way to prevent active, infectious TB. Therefore, SATFs provide a unique setting
				in which to cost-effectively prevent TB in an otherwise difficult to reach high
				risk population.
TB Risk
Annual Risk of TB -
# Completing TX to
Without TX
Prevent 1 Case of
						TB
Over a 20-Year
Period
IDU & HIV Positive
.0760
1
HIV Positive
.0450
2
IDU & HIV Neg or Unk
.0100
6
No Risk
.0007
77
Objectives
For Clients
1. All clients will receive TB counseling and
			 education before admission to a SATF.
2. All clients will receive a symptom
			 assessment for pulmonary tuberculosis before admission to a SATF. Past history
			 of treatment for TB disease, tuberculin skin tests (TST) or adequate treatment
			 for latent TB infection (LTBI) will be obtained. An efficient and feasible
			 screening tool to identify those persons in need of evaluation for active
			 tuberculosis disease attending SAFTs is the implementation of a Pulmonary
			 Tuberculosis Symptom Assessment.
(See Attachment 2)
3.
All
clients with symptoms
			 consistent with pulmonary tuberculosis will promptly be referred for a chest
			 X-ray and medical evaluation for active tuberculosis.
4. Using the 2-step method, the Mantoux TST
			 status will be known on those
clients with a history of intravenous drug
			 use and/or clients with a history of HIV who are in treatment plans consisting
			 of 9 months or longer that are enrolled in long term care-residential SATFs or
			 methadone maintenance -opioid pharmacotherapy facilities
within 30 days
			 of admission.
5. Clients with newly
			 identified positive TSTs will receive a chest X-ray and be evaluated for active
			 TB within 10 days of the TST.
6. At
			 least 90% of clients with a positive TST will be started on treatment for LTBI,
			 unless medically contraindicated, within 10 days of the evaluation for
			 TB.
7. Directly observed therapy
			 (DOT) will be provided by the SATF for clients receiving treatment for latent
			 TB infection or TB disease.
8. At
			 least 85% of clients placed on treatment will complete the recommended regimen
			 within 12 months.
For Employees
1. All employees will receive TB counseling
			 and education at time of employment.
2. All employees will receive a symptom
			 assessment for pulmonary TB at the time of employment. (See Attachment 2) Past
			 history of previous treatment for TB disease, tuberculin skin tests (TST), or
			 adequate treatment for latent TB infection (LTBI) will be documented.
3.
All
employees with symptoms
			 consistent with tuberculosis will promptly be referred for a chest X-ray and
			 medical evaluation for active tuberculosis.
4. Using the two-step method, the Mantoux TST
			 status will be known on
all
employees within 30 days of employment
			 at the SATF.
5. All employees with
			 a newly identified positive TST will receive a chest X-ray and be evaluated for
			 active TB within 10 days of the TST.
6. At least 90% of employees with a positive
			 TST will be started on treatment for LTBI, unless medically contraindicated,
			 within 10 days of the evaluation for TB.
7. At least 85% of employees placed on
			 treatment will complete the recommended regimen within 12 months.
Federal and State Requirements for TB Testing
The Substance Abuse and Mental Health Services Administration
				(SAMHSA), through its Center for Substance Abuse Treatment (CSAT), stipulates
				that facilities receiving Block Grant funds provide, or arrange for, TB
				services for each individual receiving substance abuse services. TB services
				may include:
Counseling the individual with respect to TB, testing to
				determine whether the individual has been infected with mycobacterium
				tuberculosis to determine the appropriate form of treatment for the individual,
				and
Providing for or referring the individuals infected by
				mycobacterium tuberculosis for appropriate medical evaluation and
				treatment.
Source
:
				Public Law
				102-32145 CFR 96 - Rules and Regulations; Section
				96.121 - Definitions and Section 96.127 - Requirements Regarding
				Tuberculosis
State
: The
Standards for
				Licensure
include requirements for TB testing and follow up (if
				indicated). The
TB Surveillance Procedures
provide more
				specific guidance in carrying out the requirements and are based on recent
				scientific findings and on newly published recommendations. Therefore, SATFs
				should be guided by the
TB Surveillance Procedures
in
				developing and updating their TB-related policies and procedures.
Purpose of
Tuberculosis Surveillance
				Procedures
Each year, over 50,000 substance abusers are admitted to SATFs
				in New Jersey. In 2003, there were 54,543 individuals admitted to substance
				abuse centers and 10,827 were injecting drug users. Since injection, drug users
				and/or clients with a history of HIV are at high risk for progressing to active
				infectious TB once infected and since TB is feasibly preventable among these
				individuals with LTBI, the purpose of the
Tuberculosis Surveillance
				Procedures
is to:
Identify and treat persons with active, infectious TB
and
Identify and treat, with the initiation of DOT, high risk
				persons with LTBI to prevent the development of active, infectious TB
These
Procedures
will cover the
				following:
Initial examination, follow up, and treatment procedures for
				both clients and employees.
Annual examination requirements for employees.
Procedures following exposure to infectious TB.
Documentation of results and reporting requirements.
At the end of this document is a list of
resources
to assist SATFs in implementing these
Procedures
.
I.
CLIENTS
A.
INITIAL EXAMINATION
1.
Counseling and Evaluation for Signs
			 and Symptoms of TB
All newly admitted clients to a SATF will be counseled about
				tuberculosis infection and disease. All clients will also be evaluated for
				signs and symptoms of tuberculosis. The symptoms of pulmonary tuberculosis may
				include productive, prolonged cough, chest pain, and/or hemoptysis. Systemic
				symptoms of tuberculosis may include fever, unexplained appetite loss,
				unexplained weight loss (10 pounds or greater), night sweats (regardless of
				room temperature), chills and/or persistent fatigue. If the client is
				determined to have symptoms and/or clinical evidence suggest of active TB
				(regardless of the results of the TST), the SATF will immediately isolate the
				client in a separate area of the facility away from other clients, until the
				need for hospitalization has been determined. Local hospitals can be used for
				inpatient care when necessary. The SAFT should contact the NJDHSS, TB Program
				at (609)-588-7522 for consultation and referral.
2.
Mantoux Tuberculin Skin Test
			 (TST)
Purpose
: The purpose of the TST is to identify
				clients who have been infected with TB so that these persons can be (a)
				evaluated for active, infectious TB and (b) if active TB is ruled out, placed
				on treatment to prevent the future development of active TB.
Who Will Be Tested
Clients with a history of intravenous injection drug use and/or
				clients with a history of HIV infection who are in treatment plans consisting
				of 9 months or longer that are enrolled in long term care- residential SATFs or
				methadone maintenance -opioid pharmacotherapy facilities, where DOT is
				feasible. The provision of a DOT program by SATF staff is an essential
				component of the tuberculin testing procedure.
Exceptions
: Clients presenting
written
documentation of a (a) prior positive
				Mantoux TST reaction, (b) prior or present TB disease,
or
(c) adequate treatment for latent TB infection
				(LTBI).
Note
: A
verbal
				history
from the client of prior testing or treatment results
				is
not sufficient to exclude testing
. Unless
				written documentation can be provided, the TST must be performed.
Note
: Tuberculin
testing is not
				contraindicated for persons
who have been vaccinated
with BCG
. These persons should receive a TST and
				be managed without regard to the history of BCG.
Administration of the Mantoux TST
The Mantoux TST is performed by the intradermal injection of
				0.1 ml of Purified Protein Derivative (PPD) tuberculin containing 5 TU
				(tuberculin units) into either the volar or dorsal surface of the forearm. The
				injection should be made with a disposable safety tuberculin syringe with a
				short (one-quarter to one-half inch), bluntly beveled, platinum (26-gauge) or
				steel (27-gauge) needle. The injection will be made just beneath the surface of
				the skin, with the needle bevel facing upward to produce a discrete, pale
				elevation of the skin (a wheal) 6 mm to 10 mm in diameter.
To prevent needle stick injuries, needles will not be recapped,
				purposely bent or broken, removed from disposable syringes, or otherwise
				manipulated by hand. After use, syringes and needles will be placed in
				puncture-resistant containers for disposal. Institutional guidelines regarding
				universal precautions for infection control will be followed.
Reading the Mantoux TST
The Mantoux test is read between 48 to 72 hours after
				administration by a trained health care provider. Positive reactions (see
Interpretation of TST Results
section for definition of
positive
) tend to persist for several days and can be read up
				to 7 days from the date of testing. However, if an individual who fails to
				return within 48 to 72 hours has a negative test, the TST must be
				repeated.
If the result of the initial test is negative, administer a
				second test one to three weeks later. If the second test is positive, the
				person is classified as infected; if the second test is negative, the person is
				classified as uninfected. If the new client has documentation of having
				received a single negative TST within the past year, only a one-step Mantoux
				test is required upon employment.
Readings should be made in good light, with the forearm
				slightly flexed at the elbow. The basis of the reading is the presence or
				absence of induration, which may be determined by inspection (from a side view
				against the light as well as direct light) and by palpation. The diameter of
				induration (raised, hardened area) should be measured using a tuberculin ruler.
				Erythema (redness) or bruise without induration should not be measured. The
				reaction is measured transversely to the long axis of the forearm and recorded
				in millimeters of induration. If no induration is found a00 mm@ will be
				recorded.
Documentation in the medical record should include date of
				administration, date of the reading, measurement in millimeters of induration,
				name of administrator and/or reader, site of placement, brand name of the PPD
				solution, lot# and expiration date of PPD solution.
Interpretation of TST Results
A
Positive
TST indicates the probable presence of
				TB organisms in the body. Persons with a positive TST must receive follow up
				evaluation (including a chest X-ray) to rule out active TB and will be
				considered for treatment of LTBI if active TB is ruled out.
A
Negative
TST indicates the probable absence of
				TB organisms in the body. Persons with a negative TST do not require further
				evaluation unless symptoms compatible with active TB are present (see Section
				I.A.1.)
Depending on the HIV status, the TST reaction size should be
				interpreted as follows:
HIV Status
TST
						Reaction
Interpretation
Positive or Unknown
0 - 4
						mm
Negative
5+ mm
Positive
Negative
0 - 9 mm
Negative
10+ mm
Positive
Anergy Testing
Because results of anergy testing in HIV infected populations
				in the US do not seem useful to clinicians making decisions about treatment for
				latent TB infection,
anergy testing is no longer recommended as a routine
				component of TB screening among HIV-infected persons
. However, some
				experts support the use of anergy testing to help guide individual decisions
				regarding treatment for latent TB infection, and some recommend that a
				tuberculin skin test be performed on patients previously classified as anergic
				if evidence indicates that these individuals' immune systems have responded to
				therapy with antiretroviral drugs. Experts in TB/HIV illness should be
				consulted about anergy testing and specific treatment recommendations. Referral
				for consultation is available by contacting the NJDHSS, TB Program at
				(609)-588-7522.