Tuberculosis Control in Substance Abuse Treatment Centers Sue Etkind, RN, MS Director Division of TB Prevention and Control

Why is TB an important consideration for Treatment Centers? Active TB is an airborne, infectious disease, transmittable to other clients and staff. TB disease (including TB in clients who are also infected with HIV) is both treatable and curable with anti-TB medications. Latent TB infection is also treatable – reducing the risk of developing active TB disease in the future by over 90% in infected persons.

Goals: Tuberculosis Control in Substance Abuse Treatment Centers 1. To ensure that there are no clients with transmissible active TB admitted to a substance abuse treatment center. 2. To ensure that there are no new staff with transmissible active TB.

Goals: Tuberculosis Control in Substance Abuse Treatment Centers 3. To identify TB high risk clients who are or maybe infected with latent TB (LTBI) and to assure that treatment for LTBI is initiated and completed 4. To identify TB high risk staff who are or maybe infected with latent TB (LTBI) and to provide education and referrals for treatment for LTBI. A decision to test is a decision to treat

Current Federal Requirements: SAMHSA/CSAT (condition of federal funding) Require the provision of (or arrangements for) Counseling the individual about TB Testing to determine whether individual is infected with TB Providing or referring infected individuals for appropriate medical evaluation and treatment NOTE: Treatment Centers are expected to defer to state policies for TB Control

IMPORTANCE OF SYMPTOM SCREENING Steps to a TB Policy: What do we know about substance abuse and TB risk? TB Disease: Persons who are substance users who have active TB disease can be more infectious Why? Sputum may be smear positive Delays in care seeking leading to more advanced disease Treatment failures Crack cocaine use – increased coughing and other pulmonary complications IMPORTANCE OF SYMPTOM SCREENING

What do we know about substance abuse and TB risk? TB Infection (LTBI): Persons who are substance users can be more at risk of acquiring TB if they spend prolonged time with an active TB case in areas that are enclosed/have limited ventilation/have high human traffic, etc. Congregate settings – correctional facilities, shelters, etc. However, the epidemiology of TB in MA and case contact investigations suggests that this type of exposure is infrequent.

What do we know about substance abuse and TB risk? TB Infection (LTBI): Substance abuse can result in immunologic impairment and clients once infected with latent TB, can be more at risk of progressing to active TB disease Substance abuse can result in compromised liver functionality. This can be exacerbated by TB treatment with potentially liver toxic drugs IMPORTANCE OF IDENTIFYING THOSE AT HIGHEST RISK OF TB INFECTION

Steps to a TB Policy Goal #1: To ensure that there are no clients with transmissible active TB admitted to a substance abuse treatment center. 1. Should we screen everyone for signs and symptoms of TB and refer them for TB follow up? All clients with a prolonged cough? (smokers, COPD, etc., etc.) NOT feasible

Steps to a TB Policy 2. If not everyone, then who should we target for symptom screening? Persons who are likely to have TB infection

IMPORTANCE OF A TB HISTORY AND TB RISK ASSESSMENT Steps to a TB Policy 3. How do we identify persons who are likely to have TB infection? IMPORTANCE OF A TB HISTORY AND TB RISK ASSESSMENT 4. Is there a diagnostic test for TB infection? Mantoux skin test with PPD (Tuberculin skin test or TST) TB blood tests

TB HISTORY CHECKLIST 1) Have you ever had a positive skin test for TB? Do you have the results written down? Date ___/___/___ result (in MM) ______ 2) Have you ever had a positive blood test for TB? Date___/___/____ result: ______ 3) Do you have a chest x-ray result written down Date___/___/___ result: normal______ abnormal______ 4) Did you take medication for your positive skin test? Have you ever been sick with TB disease? If yes, did you take medication for your illness?

TB RISK ASSESSMENT CHECK LIST 1) Have you lived with or spent time with anyone who has been sick with TB in the last 2 years? 2) Have you ever lived or traveled for more than a month in Africa, Eastern Europe, Russia, Central or South America or the Caribbean? 3) Do you have AIDS or HIV infection or other immune-compromised condition? 4) Do you have (or have you had) other medical conditions such as: Diabetes ? Cancer? Kidney disease ? Rheumatoid arthritis ? Stomach or intestinal surgery?

SYMPTOM SCREENING CHECKLIST: Persons with an identified TB risk Have you had a prolonged, unexplained cough lasting more than 3 weeks or a recent change in a chronic cough Have you recently lost weight of 10 pounds or more for no apparent reason? Have you had a fever of more 100 degrees F for over 2 weeks? Do you sweat at night? Have you felt unusually tired recently?

Steps to a TB Policy 5. Wouldn’t it just be easier to test everyone? False positives with TST Chest x-ray Treatment with liver toxic drugs Resources needed Remember: A decision to test is a decision to treat

Minimum Standards Needed to Meet the Goals Obtain TB history and TB risk assessment Perform Symptom Screening for anyone with an identified risk Make referral for TB medical evaluation and follow up for those at risk Perform repeat screening and testing when indicated Provide TB education about symptoms, and need for immediate follow-up should symptoms develop

CLIENTS

Procedure for TB Screening and Targeted Testing Obtain a TB history and risk assessment before admission All clients with NO identified TB history or TB risk may be admitted. No further evaluation is necessary Clients WITH an identified TB history or TB risk must have a TB symptom screen documented

TB history or risk identified and Symptomatic (Goal #1) Early identification with active, potentially infectious TB is critical to preventing TB transmission If symptoms suggest a possible case of active TB Isolate the client immediately (if possible) and have client wear a mask Refer client to health care provider, clinic or hospital ED for prompt evaluation including an x-ray

Diagnosis of TB Case/Suspect Health care provider will report case/suspect TB case management will begin in conjunction with local health department public health nurse (PHN) Before client is re-admitted to Treatment Center, the PHN will assure the client is on TB therapy, not infectious and is medically cleared.

Diagnosis of TB Case/Suspect The supervision of TB therapy for the client and follow-up exam will be the responsibility of the health care provider and PHN Treatment Center staff may be asked to assist with performing directly observed therapy (DOT) of client TB medication doses if indicated by the provider and if resources are available PHN will conduct a contact investigation in collaboration with Treatment Center

Diagnosis of TB Case/Suspect All contacts will be tested for TB (if not previously positive) If the contact tests positive or the contact has symptoms consistent with TB Treatment Center will need to ensure medical treatment to rule out TB disease If contacts is prescribed treatment for LTBI, assistance with DOT may be suggested, if resources are available

TB Case/Suspect Discharge to the Community Upon discharge to the community, all clients on treatment for LTBI must be referred to the PHN at a local health department where the client will reside Clients that leave before testing completion should be counseled about the importance of the TB evaluation process and given TB clinic information

Non-Symptomatic Clients with TB history or risk: Goal #2 No documented history of TB test Admit and assure that a TB test is done on site or by referral Have documented history of positive TB test (once positive – always positive) Admit to facility, repeat testing is NOT indicated Provide client with information about TB symptoms, the TB fact sheet, and TB/HIV connection pamphlet

Non-Symptomatic Clients with TB history or risk Have documented negative TB test Admit to facility if tested within 3 months (negative TB test = no exposure) Why <3 months? <3 months = amount of time needed for recent exposure to be reflected in the TST, so if negative this is a “true” negative >3months = cannot assume no exposure as too much time has elapsed. Must do another TB test.

Non-Symptomatic Clients with TB history or risk If > 3months, admit and retest or refer for testing Provide client with TB/HIV fact sheet and copy of risk assessment NOTE: NO retesting is required throughout a continuous treatment episode (i.e. transfer between facilities/programs)

Positive TB tests: What next? On-site TB Testing: Report positive TB tests to the MA Department of Public Health Office of Integrated Surveillance and Informatics Services (ISIS) on the LTBI form

Positive TB tests: What next? Goal #2: To identify TB high risk clients/staff who are or maybe infected with latent TB (LTBI) and to assure that treatment for LTBI is initiated and completed A decision to test is a decision to treat Refer the client to a health care provider or TB clinic for medical evaluation and treatment initiation for LTBI if indicated (prevention) Continue TB treatment on-site by DOT if resources allow (methadone maintenance/ needle exchange program successes)

IMPORTANCE OF SYMPTOM SCREENING Pregnant Clients Same admission and follow-up What if a pregnant client has active TB disease?: Can endanger newborn baby at delivery Can endanger the pregnancy or complicate the pregnancy because of unusual drug reactions IMPORTANCE OF SYMPTOM SCREENING

Pregnant Clients Observations: Only the tuberculin test is recommended for TB testing during pregnancy (no blood tests for infection) TB testing not contraindicated Pregnancy has no effect on the performance of the TB skin test

Pregnant Clients Shielded chest x-ray can be done any time during pregnancy, but may defer to at least 2nd semester in asymptomatic and low risk women LTBI treatment may be initiated during pregnancy, although in many cases it is delayed until soon after delivery

Children and Adolescents Children or adolescents who are clients are screened following the recommendations for client screening If a treatment center admits a client with small children or adolescents, these “non-client” children or adolescents can be admitted and then screened following client screening recommendations.

Children and Adolescents Note that for children < 5 years of age, there is an increased risk of acquiring more severe forms of TB disease (e.g. meningitis) if infected with latent tuberculosis. However, the risk assessment form can identify those children who are at risk for LTBI who should be tested. Children in this age group who have a positive tuberculin skin test or blood test may show no outward symptoms, and are strongly encouraged to have a medical evaluation

CLIENTS WHO LEAVE BEFORE TESTING COMPLETION Clients should be counseled about the importance of completing the TB evaluation process and given the telephone number of a TB clinic to contact for an appointment upon discharge. (A list of the current TB Clinics can be found on the TB Division website). The client will need to be provided with the results of testing to date (date of skin test planting, etc.).

REPEAT CLIENT SCREENING On-going: Educate clients about changing signs and symptoms (such as weight loss, new cough or change in chronic cough, etc.) which may reflect TB disease and the need for medical follow up immediately, should such symptoms develop.

REPEAT CLIENT SCREENING Annual evaluation: For clients who reside in a facility more than a year: For clients with a documented positive tuberculin skin test or TB blood test: NO FURTHER TESTING is indicated. These clients need to have an annual TB risk assessment done and, if a new risk has developed (e.g. Diabetes and/or symptoms) the client needs to be referred for a medical evaluation.

REPEAT CLIENT SCREENING Annual evaluation: For clients who reside in a facility more than a year: For clients with no documented TB history or risk or a documented negative tuberculin skin test or TB blood test: Conduct an annual TB risk assessment and, if a new risk has developed (e.g. Diabetes and/or symptoms) the client needs to be referred for a tuberculin skin test or TB blood test.

STAFF

Staff Staff must show freedom from active TB disease after hire and before working with clients or other staff. Proof of freedom from TB disease can be obtained by: TB medical clearance documentation from their primary care provider. OR An on-site TB history and TB risk assessment completed (with appropriate follow up as needed)

Staff For staff who have an on-site TB history and TB risk assessment completed: All staff with NO identified TB history or TB risk may have client contact. No further evaluation is necessary (Flowchart 1). Staff with an identified TB history or TB risk must have a TB symptom screen documented (Flowchart 2).

Symptomatic Staff with a TB History or Risk Early identification of active TB is critical to preventing TB transmission If the medical evaluation results in active TB disease being ruled out then staff may have client and staff contact.

Symptomatic Staff with a TB History or Risk If a medical evaluation results in a diagnosis of suspected active TB disease, the following will occur: TB case management for the staff member will begin in conjunction with the local board of health/health department public health nurse (PHN) case manager. The PHN will assure that the staff member is on TB therapy, not infectious, and is medically cleared to have client contact.

Symptomatic Staff with a TB History or RiskRisk The supervision of TB therapy for the staff member and follow-up examinations will be the responsibility of the health care provider and the PHN in collaboration with the TB Division.

Non- Symptomatic Staff with TB History or Risk No documented history of a having a TST or TB blood test done, or the history is unknown: Must have a TST or TB blood test completed on site or by a private provider and the results documented before having client contact. Any staff who is newly TST or TB blood test positive, should be referred to a TB clinic (or to their health care provider) for a medical evaluation. Report any positive TST or TB blood test identified through on-site testing to the Department of Public Health’s Office of Integrated Surveillance and Informatics Services (ISIS), on the LTBI reporting form.

Non- Symptomatic Staff with TB History or Risk Documentation of a negative past TST or TB blood test: May have client contact if they have documentation of a negative TST or TB blood test that was done less than 3 months before hire. No further testing is needed at this time. May have client contact if the testing was done more than 3 months before hire however, the individual should make arrangements for a TST or TB blood test as soon as possible and follow up as needed.

Non- Symptomatic Staff with TB History or Risk Documentation of a history of a past positive TST: May have client contact if they have documentation of the past positive TST or TB blood test with a follow up normal chest x-ray (CXR).

Repeat Staff Screening On-going: Educate staff, with a TB history or TB risk, about changing signs and symptoms (such as weight loss, new cough or change in chronic cough, etc.), which may reflect TB disease and the need for medical follow up immediately, should such symptoms

Repeat Staff Screening Annual Evaluation For staff with a documented positive TST or TB blood test: NO FURTHER TESTING is indicated. These individuals need to have an annual TB risk assessment done and, if a new risk has developed (e.g. Diabetes and/or symptoms), the staff member should be encouraged to have a medical evaluation from a TB clinic or medical provider. For staff with a documented negative TST or TB blood test: These individuals need to have an annual TB risk assessment done (on-site or by a medical provider, and, if a new risk has been identified (e.g. Diabetes and/or symptoms), the staff member should be encouraged to have a repeat TST or TB blood test. Unless a new TB risk is identified, repeat testing is not indicated if staff maintains continuous employment within the Agency.

Questions?