I. Program TB Policy Review

All programs should immediately initiate a thorough review of their existing policies and procedures on TB control and prevention. Using the attached DOH Memorandum 92-7 as a referral, all programs should:

• review existing policies and procedures concerning:

  • early identification and treatment of TB clients and staff;
  • environmental control;
  • employee screening;
  • current strategies for cooperation with Public Health Authorities;
  • current strategies on client's compliance with TB medication.
• produce and make available to employees a written copy of the policies and procedures governing TB control and prevention in the program;
• educate employees about tuberculosis and TB prevention; i.e.,

  • the cause and transmission of TB
  • definition of infectious TB and the distinction between TB disease and infection;
  • the signs and symptoms of TB;
  • the factors associated with disease development (e.g., HIV);
  • TB screening and follow-up;
  • Anergy;
  • compliance with TB medication regimen (including discussion of side effects of medications, MDR-TB and the role of DOT).

To assist programs in developing education programs, a copy of the Centers for Disease Control Core Curriculum on Tuberculosis is enclosed with this Bulletin. Further information and assistance is available through the County Health Department in your area. For additional assistance from OASAS, contact Rebecca Rosenfeld of the AIDS Resource Unit at (212) 870-8498.

II. Early Identification and Treatment of TB

The best method of TB control is early case finding and treatment. It is essential that any TB control program recognize this priority: clients with active TB must be identified and treated.

Completion of TB therapy is crucial in preventing the spread of TB including multiple drug resistant TB (MDR-TB). Noncompliance with TB treatment is common because TB disease must be treated for a long time (6-18) months) after hospital discharge and regimens for treatment of TB must contain multiple drugs to which the organisms are susceptible. Noncompliance is a major problem in TB control; when patients fail to complete their drug therapy they not only become sick again, but they may also become infectious again thereby spreading the disease. The drug and alcohol provider community must play a primary role in ensuring that their clients complete their therapy.

The New York State Department of Health Directly Observed Therapy (DOT) Program may assist some providers with reimbursement for helping their clients take their TB medications. Currently this reimbursement program is open to Article 28 drug and alcohol treatment programs with Medicaid patients; however, it is anticipated to be expanded to Article 31 alcoholism treatment programs and other substance abuse providers. All Article 28 drug and alcoholism treatment providers in New York City may qualify as a Level I or Level II provider. Eligible programs should consider enrollment in the DOT program to offer these services to their clients with active TB. OASAS is working with the State Department of Health on the DOT model's responsiveness to the needs of our provider community and clients.

Further information on the DOT program can be obtained by contacting Susan Klein at (518) 474-2353 or Brenda Naizby at (518) 474-7000 of the State Department of Health.

In addition, the New York City Department of Health can facilitate referral of your clients with active TB to DOT providers; contact the New York City TB Hotline at (212) 788-4162 for further information.

III. Environmental Control

There is understandable concern about the adequacy of some drug and alcohol treatment settings to control the spread of TB.

The safest, most secure and cost-effective method of removing TB bacilli from the environment remains somewhat unclear and a range of options are currently being examined (i.e., improvements in ventilation; installation of ultra violet lights and/or HEPA filters; use of personal protective devices). OASAS is in the process of engaging an environmental consultant to assist us and our programs in making the best choices to limit the spread of TB infection in their environment. As soon as this consultant is available, information and perhaps site review sessions will be scheduled.

IV. Client and Employee Screening for TB

A critical element in controlling the spread of tuberculosis is the early identification and treatment of persons with infectious TB. Consequently, an ongoing program of client and employee screening is an essential first step in a TB control program.

Client Screening - Since tuberculosis places other clients and staff at risk of infection, and since TB is a particular threat to HIV-infected clients and staff, it makes good sense that all drug and alcohol treatment providers incorporate PPD testing into their admissions process. Therefore, all programs whose license requires a physical exam or health assessment should now include a determination of each client's PPD status upon admission, either through on-site testing or referral. Follow-up services where indicated (i.e., chest X-ray for positive results; anergy panel for negative result in an HIV-infected client) should also be conducted.

Programs should not condition admission on the administration of the PPD; however, one should be completed as soon as possible after admission. If there is a question of active disease based on the client's presenting symptoms (unexplained weight loss, fever, night sweats, cough, cough tinged with blood, chest pain), the client should be evaluated immediately for active TB.

All clients who are not infected with the tuberculosis bacillus should be re-tested annually.

Employee Screening - The United States Department of Labor, Occupational Safety and Health Administration and the Centers for Disease Control, recommend an employee screening program for personnel who work with substance abusers, and have issued guidelines on employee screening for TB that include:

• pre-employment screening
• six month screening for workers at the highest risk of exposure; annual testing for all other personnel
• Positive reactors should be referred to their personal physician for additional diagnostic tests and treatment if needed.

All licensed treatment program should immediately initiate an employee screening program with staff members at highest risk re-tested every six months if negative. All other staff members should be tested yearly.

New employees should be tested upon hire unless there is a previous positive test. Programs should move aggressively to develop baseline PPDs on all staff members.

V. Cooperation with Public Health Authorities

The New York State Department of Health and the local Departments of Health have the lead responsibility for the management and control of tuberculosis.

Cooperation with public health authorities in TB control projects poses special problems to drug and alcohol providers because of Federal confidentiality restrictions. Resolution of the tension inherent in the approaches of the two systems concerning the use of patient identifying information is possible through the use of the appropriate safeguards. To facilitate this communication, programs should seek a written informed consent from clients on admission which would permit communication with the local health authority if the patient develops clinical TB.

VI. OASAS Task Force on Tuberculosis

In developing a comprehensive strategy on TB prevention and control, a coordinated response which is grounded in an ongoing dialogue with the provider community is essential to success. Consequently, an OASAS Task Force on Tuberculosis has been formed to coordinate actions to meet the needs of clients and employees of the OASAS and local service providers. The Task Force is working with representatives from the provider communities and other State agencies to respond to the TB epidemic on behalf of our clients and workforce.

More information about the Task Force, or the contents of this Bulletin, are available from the co-chairs:

• Upstate
• William Barnette
• (518) 474-5102
• Downstate
• Francis A. McCorry, Ph.D.
• (212) 870-8498
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