SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Columbia, South Carolina

OFFICE OF THE DIRECTOR OF MENTAL HEALTH

DIRECTIVE NO. 911-12

 

(8-100)

TO: All Organizational Components

SUBJECT: Tuberculosis: Prevention, Treatment, and Control


I. PURPOSE:

The purpose of this directive is to establish a uniform guideline for the assessment of patients and employees for early detection and treatment of persons with tuberculosis infection or active/suspected tuberculosis disease.

II. POLICY:

It is the policy of the S.C. Department of Mental Health to prevent and control tuberculosis in patients and employees.

III. PROCEDURE:

A. Procedure for Patients:

All patients admitted to the South Carolina Department of Mental Health Inpatient Facilities shall be assessed for risk/symptomatology of tuberculosis and questioned regarding history of previous tuberculosis infection (i.e., documented positive PPD), disease or recent exposure. This assessment for factors that would indicate a higher risk of developing clinical tuberculosis shall be documented in the medical record.

Mental Health Center clients referred for admission to day treatment programs and residential programs shall be assessed for signs and symptoms of active tuberculosis disease prior to admission to the programs.

1. Risk Factors:

All DMH inpatient facilities shall begin to assess patients on admission for the following risk factors using patient history, medical record and/or family/significant others as sources of information.

- HIV+ or At Risk for HIV and/or Suspected of HIV+ and HIV status unknown
- Radiographic Evidence of Old TB
- Recent contacts of newly diagnosed pulmonary TB cases
- IV Drug Users
- Recent skin test converters
- Pneumoconioses
- Gastrectomy
- Intestinal Bypass
- Weight is 10% or more below ideal body weight
- Chronic renal failure
- Diabetes Mellitus
- Conditions requiring prolonged high dose corticosteroid therapy and other immunosuppressive therapy
- Some hematologic disorders (e.g., leukemia and lymphomas)
- Other malignancies
- Foreign Born Persons
- History of BCG vaccine
- Residents of Long Term Care Facilities (e.g., correctional institutions, nursing homes, mental institutions etc.)
- Low Income Medically Underserved

2. Symptomatology:

Screening which includes Tuberculin Skin Testing, chest x-rays, and physical examination shall be considered for all patients manifesting the following symptoms:

- Productive prolonged cough (over three weeks duration)
- Weight loss
- Night sweats
- Fever and chills
- Fatigue/malaise
- Loss of appetite
- Hemoptysis

3. Tuberculin Skin Test (Mantoux PPD):

a. Two Step Tuberculin Skin Test (Mantoux PPD): On the initial skin test (no PPD history within a year), two-step testing shall be performed to detect boosting phenomena that might be misinterpreted as skin test conversions.

b. Test Dose:
If there is any question regarding a history of a positive PPD reaction, then a test dose shall be administered following the manufacturer's instructions.

c. Acute Psychiatric, Acute Medical and Alcohol and Drug Treatment Facilities:
Tuberculin Skin Testing shall be performed on all patients with a history of non-reactive PPD and risk factorsor symptomatology consistent with tuberculosis infection or active tuberculosis disease.

d. Long Term Care and Chronic Psychiatric Facilities:
Tuberculin Skin Testing shall be completed on all patients with a history of non-reactive PPD by the sending facility within at least three (3) months prior to transfer to a Long Term Care or Chronic Psychiatric Facility. The Long Term Care and Chronic Psychiatric Facilities shall perform Tuberculin Skin Testing on all patients with a history of non-reactive PPD annually thereafter for the duration of their hospitalization.

e. Mental Health Centers:
Prior to admission to Day Treatment Programs clients shall be assessed for signs and symptoms of active tuberculosis disease and if clinically indicated a Tuberculin Skin Test shall be performed. If symptoms of active tuberculosis are identified or suspected with any client of the Mental Health Center, the client shall be referred to the local county health department's TB control clinic or to their private physician.

4. History of Bacillus of Calmette and Guerin Vaccine:
Since there is no reliable method of distinguishing tuberculin skin reactions caused by BCG from those caused by natural infections, tuberculin reactions of greater than or equal to 10 mm in BCG vaccinated persons usually indicate infection with Mycobacterium tuberculosis and the patient shall be evaluated for tuberculosis disease.

5. Chest X-Rays:
Any patient with a positive PPD shall be referred for an initial chest x-ray (PA and lateral) unless a recent x-ray is available (within the last three months). The chest x-ray findings shall be forwarded to the attending physician for evaluation and treatment/referral in accordance with the current facility policy. Routine annual chest x-rays are not recommended. Chest x-rays should be repeated when clinically indicated.

6.  Isolation, Evaluation and Treatment:

Patients with known or suspected active tuberculosis shall be referred to an appropriate acute medical facility for isolation, evaluation and treatment. TB precautions and respiratory protective equipment shall be used in compliance with OSHA Regulations to prevent the transmission of disease when caring for patients with known or suspected active tuberculosis (i.e., when entering AFD isolation rooms and rooms where cough inducing procedures are being performed). Patients may be admitted or transferred to other DMH facilities when stabilized on antituberculosis drugs and are documented to be non-infectious.

7. Transporting TB Patients:

To prevent transmission of disease, patients with known or suspected active tuberculosis shall be appropriately masked and transported by personnel who have been trained in the use of respiratory protective equipment. DMH hospitals within the Columbia area shall utilize the convalescent ambulance service to transport patients with known or suspected active tuberculosis.

8. Follow-Up:

Patients being discharged who require follow-up shall be referred to their local county health department.

B. Procedure for Employees of DMH Inpatient Facilities and Mental Health Centers:

All employees, volunteers, consultants and contracted employees (physicians, nurses, counselors, etc.) with direct patient contact and a history of non-reactive PPD, shall be skin tested at no charge for the presence of tuberculosis.

Inpatient employees are those personnel that work directly in a facility where DMH clients routinely stay for overnight visits.  These not only include psychiatric hospitals, nursing homes, inpatient addictions centers but community residential care facilities and crisis stabilization programs.  Other settings should be considered on a case-by-case basis such as staff that routinely meet with clients in inpatient settings described above or similar facilities.  In some circumstances, an employee of a mental health center must be tested as if an inpatient employee (such as working at a center-operated community residential care facility.

The pre-employment tuberculin skin test (Mantoux PPD) shall be administered prior to contact with patients unless a documented skin test has been performed within three months prior to employment. Employees transferring from one DMH facility to another shall provide copies of results of the most recent PPD skin test.

Tuberculin skin testing shall be repeated at least annually thereafter.

1. DMH Inpatient Employees - Two Step Tuberculin Skin Test (Mantoux PPD):

On the initial skin test (no PPD history within a year), two-step testing shall be performed for inpatient employees to detect boosting phenomena that might be interpreted as skin test conversions.

2. DMH Mental Health Center Employees - One Step Tuberculin Skin Test (Mantoux PPD):

On the initial skin test (no PPD history within a year), testing shall be performed for inpatient employees to detect boosting phenomena that might be interpreted as skin test conversions.

3. Test Dose:

If there is any question regarding a history of a positive PPD reaction, then a test dose shall be administered following the manufacturer's instructions.

4. History of Bacillus of Calmette and Guerin (BCG) Vaccine:

Since there is no reliable method of distinguishing tuberculin skin reactions caused by BCG from those caused by natural infections, tuberculin reactions of greater than or equal to 10 mm in BCG vaccinated persons usually indicate infection with Mycobacterium tuberculosis and the employee shall be evaluated for tuberculosis disease.

5. PPD Conversions or History of Positive PPD:

Any employee presenting for employment with a positive PPD shall have documentation of a negative chest x-ray that was performed within at least three (3) months prior to employment. An employee converting from negative to positive during employment shall be referred for an initial chest x-ray according to the facility/center policy. Evaluation and follow-up shall be provided by the local county health department. Employees referred to the Health Department for preventive treatment do not require physician clearance prior to returning to work.

a. Chest X-Rays:

Routine annual x-rays of tuberculin reactors are not recommended as they cause unnecessary exposure to radiation, do not prevent tuberculosis and are not a substitute for preventive treatment.

b. Annual Evaluation:

Annual evaluation of employees with positive PPDs shall include an assessment for signs and symptoms of tuberculosis and education regarding the need for prompt evaluation of any pulmonary symptoms suggestive of tuberculosis.

6. Employees with Active Tuberculosis:

Any employee requiring treatment foractive tuberculosis must be cleared by a physician in consultation with DHEC before returning to work. Clearance must be provided by the Occupational Health Services physician if an employee's case of active tuberculosis is determined to be work related.

7. Contact Investigation:

Contact investigation shall be conducted according to DHEC protocol. DHEC Tuberculosis Control personnel are available to assist in investigating possible exposures and transmission of disease.

8. Tuberculosis Training:

All employees, volunteers and contracted employees with direct patient contact shall receive education about tuberculosis appropriate to their job before initial assignment and subsequently on a periodic basis (e.g., annually).

IV. Reporting:

a. All positive PPD reactions and suspected or diagnosed cases of tuberculosis shall be reported to the facility Infection Control Coordinator immediately.

b . In accordance with the State Statute 44-31-10, all known or suspected cases of tuberculosis shall be reported to the Facility Director, the Infection Control Committee, and DHEC by the Infection Control Coordinator.

c . TB infection (Positive TB Mantoux skin test) and TB disease of employees are both recordable on the OSHA 200 log, except on pre-employment screening.

d. A P-16 "Report of Injury" form shall be completed and processed on all employee cases of active tuberculosis.

V.References:

Federal Register. Draft Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities, Second Edition; Vol 58, No. 195, Tuesday, October 12, 1993.
South Carolina Department of Labor, Licensing and Regulation. Enforcement Policy and Procedure for Occupational Exposure to Tuberculosis, Memorandum 94-X-93, February 25, 1994.
CDC. Guideline for Preventing the Transmission of Tuberculosis in Health-Care Settings, with Special Focus on HIV-Related Issues, MMWR, December 7 1990.
CDC. Core Curriculum on Tuberculosis, Second Edition, April 1991.
DHEC. South Carolina Department of Health and Environmental Control, Regulation Number 61-17, Standards for Licensing Nursing Homes, February 28, 1992.

VI. Relevant Directives:

This directive hereby rescinds and replaces South Carolina Department of Mental Health Directive #790-94 titled "Tuberculosis: Prevention, Treatment, and Control " dated August 30, 1994.


John H. Magill, State Director 

John H. Magill, State Director of Mental Health

 

Approved: October 31, 2012