Army Action Plan: Latent Tuberculosis Management

LATENT TUBERCULOSIS MANAGEMENT SOP: 031 Page 1 of 10
DETAINEE HOSPITAL SOP NO: 031GUANTANAMO BAY, CUBA
Me: LATENT TUBERCULOSIS MANAGEMENT
Page 1 of 10 Effective Date: 16 Jul 03 SCOPE: Deludes Hospital
Each (1) Latent llaberculosis Infection Management Algorithm
(2)
InitiallAnatial Tuberculosis Patient Quesdonnaire

(3)
Ciuidelines for Liver Function Test monitoring While on INH Therapy

(4)
INH Therapy Monthly Patient Questionnaire

(5)
INH Therapy Medical Provider Review

J. BACKGROUND:
Identification and treatment of latent tuberculosis infection (LTBI) in detainees offers improved Force Health Protection for Joint Task Force personnel in close contact with the detainee population by decreasing the probability of tuberculosis disease among detainees, and protects other detainee from the potential spread of disease between detainees. The policies and procedures slated in this SOP have been coordinated with the Centers for Disease Control (CDC) and the United States Public Health Service.

ik.132LICY:
This is a revision of the Latent Tuberculosis Infection Management in Detainees SOP
dated 21 Mar
03 and supercedes that document. This SOP should be used in concert with the SOP for Active Tuberculosis Management. Exceptions to thispolicy mum be based on compelling clinical evidence and will be discussed with the Infectious Disease staff
physician prior to implementation.
JR. PROCEDURES;
a
As per the Active Tuberculosis Management SOP, all detainees will be screened for clinical and radiological evidence of active tuberculosis; this includes placing a Tuberculin Skin Test ('1ST). The plan for identification, evaluation, treatment. and monitoring of LTB[ in detainees is demonstrated in enclosure (1). Detainees that have been ruled out for active tuberculosis disease will enter the
LTBIflowchart at the point were previous evaluations ended.
LATENT TUBERCULOSIS MANAGEMENT

SOP: 031 Page 2 0111
o The following sections deal with the deecriptice, definitions, and amplification of the Latent Tuberculosis Infection Management flowchart. The areas involved in current operations and many of the potential areas considered as possibilities for future operations have high incidences of tuberculosis. Foreign-bons persons that migrate to the U.S. continue to demonstrate incidences of tuberculosis that reflect
the level of the country of origin for as long as five yaws after migration. Thiswould result in a number of cases of tuberculosis disease in the detainee population with subsequent potential acposure of JTF personnel. Identification
and treatment of LTBI in detainees will decrease this potential.
o All detainees will receive a TST in conjunction with inprocessing upon arrival. TST screening will use STU of Purified Protein Derivative (PPD) in the standard Menlo= method. The medical staff responsible for detainee healthcare should insure that all personnel placing and reading the PPD are trained adequately and understand the importance and limitations of this test.

o The classification of the PPD reaction depends on the clinical situation of the detainee. Most detainees are recent arrivals from high-prevalence countries and will be considered abnormal with a faction of 10mm or more. Detainees considered positive at 5mm of induration should have the reason for this deviation from standard documented in the health record. For example, detainees with chest x-ray findings of fibrotic changes consiitent with old healed tuberculosis, those with recent active TB canteen, and those with HIV infection or other immunocompromising conditions should be considered PPD abnormal with

induration of 5 rem or more.
a Detainees with a negative PPD on initial testing will have the PPD repeated at the nett monthly weigh-in. Implementation of the Iwo-step PPD' will identify detainees with prior tuberculosis infection and is standard for persons enrolled in a periodic PPD screening program. Two-step testing is used to reduce the likelihood that a boosted reaction will be misinterpreted as a recent infection. If the reaction to the first test is classified as negative, a second test should be done. An abeam, reaction to the second test probably represents a boosted reaction (past infection or prior BCCI vaccination). On the basis of this second test result, the person should be classified as previous infected and cared for accordingly. This would not be considered a skin lest conversion. If the second teat result is
also negative, the person should be classified as uninfected. In these persons, anabnormal reaction to any subsequent test is likely to represent new infection withneerridosir (skin test conversion). Two-step testing should be used for the
initial skin testing of adults who will be retested periodically.
o Detainees with the second PPD classified as negative will be enrolled in an annualPPD program. This does not preclude the routine clinical use of the PPD as an

o Detainees classified as having a positive PPD on initial or second testing,

adjunct to appropriate clinical evaluations.
LATENT TUBERCULOSIS MANAGEMENT SOP: 031 Page 3 of 10
•
• normally 10mm induration will be evaluated for signs and symptoms suggestive
of tuberculosis disease [enclosure (2)].
o If there is suggestion of tuberculosis disease, the detainee will undergo an
appropriate clinical evaluation as outlined in the Active Tubaculosh
Mmtagement SOP. If evaluation is not suggeedue of tuberculosis disease

or if theclinical evaluation for active tuberculosis disease is negative. the detainee is
evaluated for treatment of LTBL
o Evaluation for LTBI henna should include an attempt to document any history of ointment for LTBI or disease. This history may be difficult to obtain and unreliable. Determine if there are any preexisting medical conditions that are a contraindication to treatment or are associated with an increased risk of adverse effects of treatment. Review current and previous drug therapy for potential adverse reactions or intaactions. Baseline laboratory testing is not routinely indicated for all patients at the start of Irmo= for LTBI. Baseline hepatic
measurements of serum AST (SOOT) or ALT (SOFT) and bilirubin are indicated for pstients whose initial evaluation suggests a liver disorder. Baseline testing is also Maned for persons with a history of chronic liver disease (e.g., hepatitis Bor C. and others who are at risk of chronic liver disease). Testing should be considered on an individual basis, particularly for patients who are taking other medications for chronic medical conditions [see enclose= (3)]. Active bend* and end-stage liver diseases are relative entraindications to the use of honlazid or pyratiamidcle for treatment of LTBI. Use of these drugs in such patients must
be lilidertoken with caution.
o If there are no contraindications for LTBI 11001101t, the steward course for detainees will be isoniazid, INH, 900mg, twice weekly for nine months. Peripheral neuropathy, caused by INH's interference with metabolism of
pyridoxine, is uncommon at a dose of 5 mg/kg. However, in this detaineepopulation, where some may be malnourished, treatment with pyridoxine could be considered 0.e. Pyridoxine 100 mg twice a week given with INH). In persons with conditions in which =empathy is common (e.g., diabetes, urem alcoholism, malnutrition, and HIV infection). pyridoxine should be given with
MH..
o
All detainees on LTBI treatment will be monitored at least monthly [see'encl. (4and 5)]. This evilustion will include screening for signs and symptoms of activeTB diocese. and signs or symptoms of hepatitis. Routine laboratory monitoringduring treatment of LTBI is indicated for persons whose baseline liver Anictions test arc abnormal and for other persons with a risk of bowie disease [see enclosure (3) for father details]. Thom should be laboratory testing, such as liverfunction studies for detainees with symptoms compatible with bepstounticity or auric acid measurement to evaluate detainees who develop acute arthritis, toevaluate possible adverse reactions that occur during the treatment regimen.
'

00'6010
LATENT TUBERCULOSIS MANAGEMENT
SOP: 431 Page 4 ON
o
Disoontinustion of INH should be considered for detainees with liver functions three times nomad levels with symptoms, liver ftuictions five times normal !reelswithout symptoms, or when otherwise clinically indicated.
o Please refer to encl. (5) concerning detainee refusals of medication. After completion of LTBI trestman detainees will be smarted annually [encl. (2)1
o
Detainees with contraindicatione for LTBI treatment should be re-evaluated The risk-benefit of LTBI treatment must be considered. Alternate regimens, per reference (b) should be considered. If clinically appropriate, treatment should
proceed. These cues may require mere ftequau or more robust monitoting. IfLTBI bailment is contraindicated, these.00ntraindications will be documented i the detainee health record. The detainee will be followed with annual screenings.n A sample queetionnsire for these annual screenings can be found in enclosure (2).
o Application of the Latent Tuberculosis Infection Management program will require tracking of PPDs, medications, and monitoring in a databsselspreadsheetthat will provide reports to Me .1TF Surgeon periadicslly on the status of the
program.
a
For detainees who refine medication for LTBI, the following considerations will
be used in determining the appropriate comae of action:
¦ There is no risk of inducing INH resistance in detainees who periodically refuse INH. The goal of therapy is to have the denture take at least a total of 52 doses in 9 months or 76 doses in 12 months. If the total number of doses
meets these guidelines, therapy is considered to be complete.
a Detainees continually refusing medications will not be required to lee INH per
SOUTHCOM policy. They will be screened annually with a medical screening

questiomai
m oo the yearly adversary of their negative chest x-ray. generally
obtained at their in-processing date.
anatase TST
Second TST

Placed at lOrem
item Annual TST
Plexd one month

monthly Induration•
After initial 1ST indentioae Or
weigh-in after
When
during monthly

arrival Clinically
weigh-in

indicated
Mom Or owe117
. induration •

Evahodat
Positive kw
Tukwila*
Dime

Demme **
.lir
Evaluation Sq active Of
Went Tabereulads
Medan

Consider Risk-Benefit Coerreasdinstians
Related to Treatment of
LTBI
No
Conasindiesticeis

Begin Treatment INH 900mg Consider Alternate Twice Weekly Regimens of Therapy for DOT (cemiter LTBI
Cliakul
\ LTBI Trauma Considered
Monthly

Contraindicaled
Evaluadons (see
sect 4 • 5)

Symptoms or Findings
No Concern of Camera

Appropriate
Clinical
Follow-up

Clinker Evairesion

With Periodic
Continue with With C.onsklaretion
Screening (use
INH be total of For Pomaded
end 2)
Nine Mondu of Diceednuadon of
Terapy INH Therapy (see
Ertel 5: tbr refusals.
see End 611

(a )Varled clinical situations reaxiereend L
1111-Weeunent a &Serene parameters of induration. Ten millim
for most of the demises received. is
eters the level
(•
cases where signs and symptoms are highly suggestive oftebereulosis disease. begin nestronn concurrent with
laboratory evahraion and conlinnstion.

n27 A7;WEll;;017X-1

.4P
LATENT TUBERCULOSIS MANAGEMENT
SOP: 1131 Page 14'10
Detainee Number:

Age of Detainee: Due: Initial/Annual Tuberculosis Patina Questionnaire
Are you experiencing any of the following problem
Fever for more than 7 days Yes or No
Cough for more than 2 weeks in a row Yes or No
Sweating at night for more than 7 days Yes or No
Coughing uP Moody Phlegm Yes or No
higgiclablikkantga

History of TB, previous emement for 111, or BCG vaccine in put?
History of liver dineseihepatiddiatmdice?
Date and Result of LastPPD (no need to repeat once positive)
Results of hepatitis/HIV screening at inproceseing
Current Medications:

Allergies: Medical officer evaluation (if indicated from above symptoms):
Are repeat/new LFT monitoring recommended? Date drawn

Results Is a repeat CXR needed (if annual screening, repeat is recommended)? Ordered? _Resuliof CXR? Have AFB smears/cultures been or are being collected?
Further actions requirecVMediestions Prescribed? Enclosure (2)
0050'1'3
NOV00231
LATENT TUBERCULOSIS MANAGEMENT
SOP: el Page 7 ef 10

GaIddiem for Liver Piled= Test Mesita* While as !NH Therapy
Baseline LFTs for ; History of river disease Hepatitis B nifice Antigen positive or *tali& C Antibody positive Concurrent Emmy with ether possible %matelot& medications
Signs or symptoms of liver diseaseHIV Infection Prignonoy/Less than 3 months post-pent=
Monthly Ins hollowed for: Misery of eleintedIFTs at Lanoline (disooadnue monitoring if
asymptomatic and LFTs normalize)Pentons at risk for hem& disease (Le. parsons with* Hem. 11/• withelet*id Mon Lanoline. chronic liver dime% etc.)
All prisons Amid be Ocreened monthly for

of
ofheitatotadrity [see INH TherapyMonthly Patient Questionnaire =loan (2)1
program medical officer in chine of the LTBI
am Co'O* or review the INH

(3)]. Medial Provider
Perso (enclosre
ns 'dadaist as having signs or symptoms of porrible hepatototdcitrwill beevaluated fintheiby a medical officer to decide
whether Rather testing ancl/or
discondnoence of the mediation is 'whaled.

fi
Enclosure (3)

0050'1'4

LATENT TUBERCULOSIS MANAGEMENT Detainee Number. Age of Detainee: SOP: •31 Page of IS Date:
I. [NH Therapy Monthly Patient Questionnaire Are you experiencing any of the following problems: Fever for more than 7 days Yes Cough for more then 2 weeks in a row Yes Sweating at night for more than 7 days Yes Coughing up bloody phlegm Yes Nausea or vomiting for more than 7 days in a row Yes Abdominal pain for more than 7 days in a row Yes Yellow discoloration of skin Yea or or or or or or or No No No No No No No
Y.
Enclosure (4)
00S1( .1 5
NOV00233

LATENT TUBERCULOSIS MANAGEMENT SOP: 031 Page 9 of 10
Detainee Number Age of Detainee: Date:
piTH Theranv Medical Provider Rivkin MAR Review: Number of doses refined in last month? Does their course of medication need to be amended? Signature of staff modifying the MAR Medical officer evaluation (if indicated from above symptoms):
Are repeat/new LFT monitoring recommended? Date drawn Resider is a repeat CXR needed? Result of CXR? Further actions required? Ordered?

Enclosure (5)
0050'4'6
LATENT TUBERCULOSIS MANAGEMENT
SOP: 031 Page 10 of 10

STANDARD OPERATING PROCEDURES
Detention Hospital
REVIEWED AND APPROVED BY:
Officer. In Charge
IMPLEMENTED BY:
Director for Administration
Senior Enlisted Advisor
ANNUAL REVIEW LOG:
Br By: By: By: By: By:
SOP REVISION LOG:
Revision to Page: Revision to Page: Revision to Page: ' Revision to Page: Revision to Page: Revision to Page:
ENTIRE SOP SUPERSEDED BY:
Title: SOP NO:

• Date
Date Date
Date: Date: Date: Date: -Date: Date:
Date: Date: Date: Date: Date: Date:
Date:
0 0 5 0' :1 7
NOV00235
DODDON-000637