Who Poses a "Significant Risk"?

The determination of whether a given individual poses a significant risk to the health or safety of others must be made on a case-by-case basis. A person who is infected with TB but who is not infectious poses no health or safety risk to others. The same may not be said of an individual who has active TB and is contagious. Individuals who are contagious pose a significant risk to the health and safety of other AOD patients and staff. Such individuals must be detected, isolated, and treated as soon as possible. Accordingly, the responsible provider will evaluate and treat the person (assuming it has the resources to evaluate and treat active TB disease) or refer him or her for appropriate evaluation and treatment.

Can a "Reasonable Accommodation" Be Made?

In determining whether a given individual poses a "significant risk" to the health or safety of others because of his or her infectiousness, the provider must also determine whether there are not "reasonable accommodations" (or modifications) that might be made to eliminate the risk of transmission. An accommodation is reasonable as long as it eliminates the risk of transmission without imposing an undue burden on the provider or requiring fundamental alterations in program services.

Thus, if a residential program already offers primary care services to its patients and has in place the engineering and other controls needed to establish respiratory isolation for patients with infectious diseases transmitted by airborne means (as discussed in chapter 6), it would be reasonable to require that program to make those services and its facility available to a patient with TB in the infectious stage. Or, if a methadone maintenance treatment program has the staff and resources to provide medication and counseling services to home- or hospital-bound clients whose illnesses make them temporarily unable to come into the program -- and it accommodates clients with other illnesses in this way -- it would be reasonable to require the program to offer the same accommodation to a patient who is temporarily home- or hospital-bound because of infectious TB. (Staff performing these duties would have to understand and employ the precautions necessary to prevent TB transmission.)

On the other hand, it would not be reasonable to require a program that did not have the resources to hire a physician who is an expert in TB to treat its infectious patients (or staff) or to provide a comprehensive array of primary care services for patients (or staff).³ It would also not be reasonable to ask a program to transform itself, for example, from a nonresidential to a residential facility with the capacity to house and treat infectious patients. And, of course, it would not be reasonable to ask a program to allow its patients and staff to be exposed to active TB disease. Reasonableness depends on the resources and circumstances of the given facility.

Patient Questionnaire

AOD providers can easily incorporate items regarding TB symptoms and history into existing admission/intake questionnaires. Such questionnaires must be formulated in language that will be easily understood by the patient. The questionnaire should pay special attention to the following symptoms: a cough that lasts for 3 weeks or more, persistent fever, night sweats, unexplained weight loss (more than 10 percent of body weight over a 90-day period), and the coughing up of blood. The questionnaire must also address the applicant's history of TB, if any, including the date of diagnosis, the type of treatment received, the duration of the treatment, and the outcome of treatment. The questionnaire should also elicit information that will help the program determine whether the prospective patient is a member of a group that is at high risk for TB. Finally, the questionnaire should inquire as to whether the patient is on any TB medications that may need monitoring.

PPD Skin Tests

Depending on State law, programs should institute PPD skin testing for all high-risk patients. PPD skin testing serves to detect TB infection and the potential need for therapy to prevent certain high-risk persons from progressing to active TB disease. State, not Federal, law will determine who can perform TB testing, and whether -- as is generally the case -- an individual's consent is required for these and other medical tests. Programs unable to provide on-site testing may have to refer patients to a medical clinic or public health department for the test. Programs that propose to do the test on-site must ensure that the relevant staff are properly trained in PPD administration, reading PPD results, and patient counseling.

Persons with a prior positive tuberculin skin test should not be skin tested again unless the results of the earlier test and subsequent medical evaluation cannot be documented. Such persons should be referred for a one-time baseline chest x-ray and medical evaluation.

Since individuals generally have the right not to undergo medical testing or treatment without their prior informed consent, programs should obtain their patients' consent to TB testing before conducting such tests. Of course, some applicants may refuse to be tested. They may fear contracting TB from the test, that the results will be used in some adverse way by child welfare officials, immigration, the criminal justice system, or others. While they would be within their rights to refuse testing, applicants should be reassured that the test cannot transmit TB, that the results will not be reported except where required by public health law, and that the test is critical to the screening process. The importance of skin testing to the screening process must be stressed to the patient or applicant. (It may be helpful to share the policy requiring employee TB screening with patients to demonstrate the shared concern for TB.)

Finally, patients must be assured that they will be assisted in getting what TB services they may need, either at the program or through an appropriate referral. While a policy of making admission to treatment contingent upon an individual's consent to undergo TB testing would probably not be found to violate Federal disability discrimination laws (as discussed in appendix D), programs should check their own State law requirements before instituting such a policy.

Other Diagnostic Procedures

Additional diagnostic measures that are necessary for applicants or patients who may have infectious TB include a physical examination, a chest x-ray, and the microscopic examination and culture of sputum or other specimens. These are discussed in some detail in chapter 3.

Reporting Suspected or Confirmed Cases of TB

As previously discussed, programs conducting TB screening must report suspected or confirmed cases of TB to local or State public health departments. Chapter 4 discusses how AOD programs may accomplish this without breaching patient confidentiality.

Treatment of Those with TB

No TB services protocol would be complete without provisions for treatment or appropriate referral for treatment.

Training of Intake Personnel

Intake personnel must be able to identify the signs and symptoms of active TB. Applicants who are suspected of being infectious should be isolated and referred for treatment. Appropriate intake policies should be in writing. Public health officials should be consulted in drawing up practical and safe intake procedures.

Infected Applicants

There is no reason to deny AOD treatment to TB-infected applicants who are not infectious. In fact, it would be illegal to discriminate against them on the basis of their illness. Such persons may safely participate in AOD treatment whether or not they are on medication. If they are on medication, of course they will need to be monitored, since failure to adhere to treatment can lead to their becoming infectious or developing drug resistance.

Applicants With a History of TB

If a substance abuser has a history of TB, the provider or the evaluating physician must ascertain whether he or she completed previous TB therapy. Ultimately, only a proper medical evaluation can determine whether the applicant is currently infectious and whether it would be best to defer admission until further TB treatment is provided.

Recommendations for Typical Scenarios

Applicants for AOD treatment present with a variety of symptoms and histories. Risk assessments must therefore be made on a case-by-case basis. The following scenarios may be representative:

• Positive PPD, no symptoms, recent negative chest x-ray. Recommendation: Evaluate for preventive therapy. Begin AOD treatment.
• No history of TB, 2 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. It would likely be legally defensible for a program to decide either to proceed with admission or to defer admission until the individual's potential infectiousness has been ruled out.
• TB 6 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 AOD therapy.
• TB 6 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 non-infectiousness.

Followup Procedures

Patients should receive periodic followup or evaluation while in treatment. AOD providers and public health entities should collaborate on screening, evaluation, and necessary followup, including annual PPD skin tests (recorded in millimeters of induration for patients with prior negative PPDs, unless they are anergic). Where appropriate, this followup should include one-time chest x-rays (e.g., for a person with a newly positive PPD result) or sputum smears (where a patient has symptoms that could be due to TB). Screening at more frequent intervals is recommended where there is a high risk of exposure to TB.

Monitoring TB Treatment

Patients with TB disease who do not take their TB medication pose a significant threat to other patients and program staff. Nonadherence to the recommended course of treatment can lead to a recurrence of infectiousness or the development of MDR TB. Program staff should be involved in monitoring patients in TB treatment (or on preventive therapy).

In cases of suspected or confirmed nonadherence, a program should coordinate with local public health and medical providers to determine why the patient is nonadherent and to make sure that the patient resumes his or her treatment. Among other things, the program and local health officials might arrange to have a public health worker come to the facility and distribute the necessary medication on-site or arrange for the program to provide directly observed therapy. A program that disregards nonadherence is neglecting its responsibilities to the patient and others at the facility.

Substance Abuse Relapse

Substance abuse relapse can trigger a breakdown in other areas of the substance abuser's life. Where an AOD patient on TB medication relapses, special care should be taken to apprise the primary health care provider to make sure that the patient completes his or her TB treatment. A patient on TB treatment who relapses and experiences a prolonged interruption in TB treatment should be referred for medical evaluation.

Trainers

A program should seek the assistance of State or local public health departments in establishing a TB training program. Collaboration on the training of staff and patients can strengthen the relationship between the program and those government entities responsible for tracking and treating TB and other communicable diseases. In exchange, the program might offer to train the latter in substance abuse issues.

Education of Staff

All staff should be trained in the basics of TB, including prevention, transmission, diagnosis, treatment, and followup. Any such training should address staff concerns about infection and disease. Staff should be advised that the safest way to proceed in dealing with TB in the AOD setting is to observe the TB services protocol. All staff should know the signs and symptoms of TB and must immediately refer employees or patients in need of medical evaluation to the program's TB services coordinator.

Counselors will need to be trained to field patients' questions about TB. Counselors should therefore be familiar with PPD skin testing, the importance of chest x-rays for individuals who react positively to PPD tests or have HIV infection, the basic symptoms associated with TB, the dangers of nonadherence, and other pertinent issues. All staff should be reminded of the importance of annual testing for employees.

Counselors should also be familiar with the health and social services network so as to be able to refer patients appropriately for both TB and other services. Counselors should be familiar with the key contacts at each of the agencies or organizations in the network. Counselors should be advised that part of their job in dealing with the agencies and organizations in the health and social services network is to advocate for program patients. Optimally, a program should have an employee trained to administer and read PPD skin tests or even provide directly observed therapy.

Education of Patients

Patient education and training should include the same basic information about TB, HIV, and other communicable diseases as is given to staff. Rather than relying exclusively on staff to convey this information, programs might employ methods such as peer education, group education, and joint staff and patient training. In this regard, it should be noted that peer counseling is a particularly effective means of bridging barriers to cooperation. Accordingly, a program might wish to give certain patients special training and responsibilities with respect to the training of other patients in the basics of TB.