Title : KK tip18 9-05-01ph.qxd (Page 1) Description : Keywords : Author : ----------------------------------------------- KAP KEYS Based on TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers CSAT’s Knowledge Application Program KAP Keys For Clinicians Based on TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov ----------------------------------------------- KAP KEYS Based on TIP 18 The Tuberculosis Epidemic These KAP Keys were developed to accompany the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. These KAP Keys are based entirely on TIP 18 and are designed to meet the needs of the busy clinician for concise, easily accessed "how-to" infor mation. For more information on the topics in these KAP Keys, readers are referred to TIP 18. Introduction TIP 6, Screening Instruments for Infectious Diseases Among Substance Abusers (1993) BKD131 Other Treatment Improvement Protocols (TIPs) that are relevant to these KAP Keys: ----------------------------------------------- 1 Recommendations for Typical Scenarios Regarding TB KAP KEYS Based on TIP 18 The Tuberculosis Epidemic Applicants for substance abuse treatment will present a variety of symptoms and histories, so risk assessments must be made on a case-by-case basis. The following scenarios may be repre sentative: • Condition: Positive PPD, no symptoms, recent negative chest x-ray. • Recommendation: Evaluate for preventive therapy. Begin substance abuse treatment. • Condition: No history of TB, two 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. • Condition: TB six 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 substance abuse therapy. • Condition: TB six months ago, did not complete course of treatment. • Recommendation: Consult public health officials. Provide full medical evaluation for infectiousness. Provide for follow- up. Do not admit without a medical determination of non infectiousness. TB Cause and Transmission TB is caused by an organism called Mycobacterium tuberculo sis or M. tuberculosis. (M. tuberculosis organisms are some times called tubercle bacilli.) The condition is spread primarily by tiny airborne particles (droplet nuclei) expelled into the air by someone with infectious pulmonary or laryngeal TB disease, typically through coughing or sneezing. Depending on ventila tion and other factors, these droplets can remain suspended in the air for several hours. Should another person inhale them, he or she may become infected with TB. TB infection and TB disease (or active TB) are not the same. Infection by M. tuber culosis does not necessarily lead to active TB disease or conta giousness. Persons who are TB-infected but who do not have TB disease do not pose a danger of transmitting TB to others, while persons with active disease do. ----------------------------------------------- Facts Regarding TB-related Discrimination These answers are intended as general guidance: For providers to make decisions consistent with these laws, they should consider the circumstances involved in their particular situations. The statements expressed herein do not reflect the official position of the U.S. Department of Health and Human Services (DHHS), do not constitute legal advice, and are not binding on DHHS. Q: Is it legal for a substance abuse treatment program to ask a substance abuse treatment services applicant whether he or she: 1) Is currently infected with TB? 2) Has an infectious TB disease? 3) Has a history of TB infection or infectious disease? 4) Is currently being treated for TB infection (prophylaxis) or infectious TB by a health care provider? A: Only if obtaining such information is needed to enable the program to provide services or to ensure its safe operation. As a general rule, a program subject to the Rehabilitation Act and/or the ADA may not ask a prospective client whether he or she has a particular disability simply for the purpose of identifying and excluding all people with that disability from the program. Q: Is it legal for a substance abuse treatment program to condi tion admission upon an applicant's consent to be tested for TB? A: For many—if not most—treatment programs, the answer will be yes. However, while a substance abuse treatment program may require a client to submit to a TB test, the program may not act in a discriminatory manner with respect to the test results. Q: Is it legal for a substance abuse treatment program to refuse to admit an applicant for substance abuse treatment services who is: 1) Known to have TB infection? 2) Known to have infectious TB disease? 3) Suspected of having TB infection/infectious disease? 4) Known to have a history of infectious TB disease? 5) Known to have MDR TB or a history of active MDR TB? 6) Suspected of having MDR TB? A: The answer in each case depends on the answers to two other key questions. First, would admitting this individual pose a significant risk to the health or safety of other clients or staff? If so, are there reasonable modifications the program can make to its practices, policies or rules that will eliminate or mitigate the risk? How these questions are answered with respect to specific TB-related conditions determines your over all answer: • TB infection only: No. • Current active TB disease: Yes, if admitting the patient Continued on back 2 KAP KEYS Based on TIP 18 The Tuberculosis Epidemic ----------------------------------------------- KAP KEYS Based on TIP 18 The Tuberculosis Epidemic poses a significant risk, and no reasonable modifications can be made to mitigate or eliminate that risk. • MDR TB: Yes, if admitting the patient poses a significant risk, and no reasonable modifications can be made to miti gate or eliminate that risk. • A history of TB infection and/or active TB disease?: No. • Suspected TB infection or disease, or suspected MDR TB: No. Q: Is it legal for substance abuse treatment programs to have policies that require, as a condition of receiving and/or contin uing in substance abuse treatment, that an applicant or client with TB infection undergo preventive TB therapy? A: No. Individuals generally have the right to make medical treatment decisions for themselves, and may not be subjected to medical treatment without their voluntary informed consent after being apprised of the risks, benefits and possible side effects of the proposed treatment. Q: Is it legal for substance abuse treatment programs to have policies that require, as a condition of admission or continua tion in substance abuse treatment, that individuals with active TB disease undergo treatment for their TB? A: Yes, because individuals with active, untreated TB disease are—or are likely to become—infectious to others. Q: Is it legal for substance abuse treatment programs to have policies that require, as a condition of receiving and/or contin uing in substance abuse treatment, that an applicant or client with a history of TB disease (and incomplete TB treatment) undergo TB treatment? A: Yes, at least for those with active disease. Q: Is it legal for substance abuse treatment programs to have policies that require, as a condition of receiving and/or contin uing in substance abuse treatment, that an applicant or client with a prior history of TB disease (who completed TB treat ment) undergo preventive TB therapy? A: No. Q: If a client is participating successfully in substance abuse treatment and is known to have latent TB infection or a history of prior active disease, is it legal for the substance abuse treat ment program to require, as a condition of remaining in the program, that the client undergo periodic examinations to determine if he/she has progressed to active TB? A: Yes, if such a monitoring program is carefully designed to identify those TB-infected patients who are at high risk for developing active TB, and/or are showing symptoms of redevel oping active TB. ----------------------------------------------- The Mantoux Tuberculin Skin Test (PPD) The preferred method for detecting TB infection—and the only way to diagnose TB infection before it progresses to active dis ease—is the Mantoux Tuberculin Skin Test. Please note, howev er, that all substance abuse treatment programs should obtain their patients' consent to TB testing beforehand. The Mantoux Test involves the injection of a small amount of purified protein derivative (PPD) just beneath the surface of the skin of the forearm. The result of the PPD test can be read by a trained health care professional within 48 to 72 hours of the time of injection. Generally, an immune competent person infected with TB for more than two to ten weeks will produce an immune response to the PPD that manifests itself through the development of an induration—an area of raised, swollen or hardened skin—at the site of the injection. A person not infect ed with TB will usually produce no induration in response to the PPD. Indurations are measured and recorded in millimeters, and a reaction of 5 mm or more is positive in • Persons whose chest x-rays suggest previous TB disease • Persons who are HIV-positive • Persons with risk factors for HIV infection • Close contacts of persons with infectious TB • Injection drug users whose HIV status is unknown A reaction of 10 mm or more is positive in • Injection drug users who are HIV sero-negative • Persons with known medical risk factors (other than HIV dis ease) for developing infectious TB (such as diabetes mellitus) • Persons from medically underserved or low income popula tions, including high-risk minority groups such as Asians, African Americans, Latinos and Native Americans • Immigrants from countries where TB is common • Residents of long-term care facilities • Health care workers in facilities where TB is present • The homeless All others will be considered to have had a positive reaction to the skin test only if they develop an induration of 15 mm or more. 3 KAP KEYS Based on TIP 18 The Tuberculosis Epidemic ----------------------------------------------- Ordering Information TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889. 2. Visit CSAT's Website at www.csat.samhsa.gov Do not reproduce or distribute this publication for a fee with out specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. DHHS Publication No. (SMA) 01-3572 Printed 2001