All personnel first entering duty in the regular Navy, the Naval Reserve, the Marine Corps, and the Marine Corps Reserve for periods of duty in excess of 30 days, including duty for training, and all persons beginning employment as CIVMARs for the Military Sealift Command must have the result of a tuberculin skin test documented in their medical treatment record. Whenever possible, a person with a history of active disease, a history of a previous reaction to a tuberculin skin test, or a history of INH therapy must provide adequate documentation of any prior tuberculin skin tests, clinical evaluations, hospitalizations, diagnoses, and treatments. Adequate documentation includes copies of pertinent medical records, immunization records, or a physician's statement on letterhead stationary. Transcribe pertinent information into the medical treatment record. If such documentation is not available, apply a 5 TU tuberculin skin test.
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All personnel first entering duty in the regular Navy, the Naval Reserve, the Marine Corps, and the Marine Corps Reserve for periods of duty in excess of 30 days, including duty for training, and all persons beginning employment as CIVMARs for the Military Sealift Command must have the result of a tuberculin skin test documented in their medical treatment record.
Whenever possible, a person with a history of active disease, a history of a previous reaction to a tuberculin skin test, or a history of INH therapy must provide adequate documentation of any prior tuberculin skin tests, clinical evaluations, hospitalizations, diagnoses, and treatments.
Adequate documentation includes copies of pertinent medical records, immunization records, or a physician's statement on letterhead stationary. Transcribe pertinent information into the medical treatment record. If such documentation is not available, apply a 5 TU tuberculin skin test. Interpret and manage any reaction per the guidelines of this instruction.
Annual Screening. Required for personnel in operational units and in units with a high risk for tuberculosis exposure or outbreaks, including:. Triennial Screening. Required for all other personnel, such as those in low- risk areas e.
Appropriate times for required periodic testing include:. All personnel must have a tuberculin skin test or annual clinical evaluation in the case of a previously- known old reactor documented within the 1- year period before separation from the naval service.
Entry into Naval Service. Obtain a chest radiograph only if clinically indicated for the diagnosis or evaluation of suspected tuberculosis, or another medical condition, or if required for programs with special physical qualifications. There is no requirement for a chest radiograph as a routine part of the tuberculosis screening program for entry into the naval service.
Separation From Naval Service. Obtain a chest radiograph only if clinically indicated for the evaluation of tuberculosis or another medical condition or if required for programs with special requirements. There is no requirement for a routine chest radiograph as part of the separation physical examination.
Screening of Dependents. Screening of dependents who are contacts of a case of active disease is handled on a case- by- case basis. This instruction does not preclude the routine screening of categories of dependents when recommended by appropriate professional organizations, e.
In general, tuberculosis screening of dependents follows the procedures and techniques set out in this instruction. Per reference a , the only approved tuberculin skin test material for the routine Mantoux test is the premixed Tween- stabilized intermediate strength PPD 5 TU equivalent available as NSN or NSN Premixed Tween- stabilized low strength PPD 1 TU equivalent , available as NSN , is used for low- strength tuberculin skin tests, when indicated.
The use of multiple- puncture tuberculin tests in all children and adolescents shall be discontinued. Use a disposable 1 ml tuberculin syringe graduated in 0.
Do not use the hypodermic jet injector for PPD administration. Only trained Medical Department personnel can perform the tuberculin skin test. The senior MDR must verify in writing that all personnel administering and interpreting the Mantoux test are trained and competent. The technique for the Mantoux method of tuberculin skin testing is depicted in figure 1 and briefly described below. Fill the syringe immediately before use, because the solution can be absorbed on the plastic of the syringe.
The injection site should be clean and dry. A properly applied skin test will raise a small, pale, sharply demarcated wheal on the skin, which quickly disappears. If no wheal appears, the PPD has been injected subcutaneously; immediately apply another skin test on the opposite arm. Use 0. The test must be read by an MDR who is both trained and experienced in reading and interpreting tuberculin skin tests.
Redness without induration has no significance; ignore it. Measure and record them accurately. Find the margins of induration by drawing the index or middle finger lightly across the reaction. Use a flexible millimeter ruler to measure the transverse diameter of the induration. If the measurement falls between two millimeter divisions of the scale, use the lower reading. If necessary, the extreme edges of induration may be outlined by drawing onto the skin with a ballpoint pen.
From 1 inch beyond any palpable induration, apply the tip of the pen to the skin and draw a line toward the induration. When a distinct change in rolling resistance is felt, remove the pen tip from the skin. That is one edge of the induration. Repeat the steps on the opposite side of the induration.
Measure the distance in millimeters between the ends of the two pen marks. Do not use rubber stamps or automatic imprinting devices. Enter the complete absence of induration as "zero mm. Immediately apply a PPD test on the opposite arm. Enter the indura- tion and the time interval since test application on the SF Manage the person as a tuberculin reactor per enclosure 2.
If there is uncertainty as to whether the area of induration is 15 mm or greater, the test should be repeated as in the previous paragraph. Retest the person at the next opportunity. Techniques for Screening Large Numbers of Individuals. Within a command, the best opportunities for tuberculin skin are in the medical clinic or in sickbay during medical check- in, during annual record and immunization review and update, and during visits for other medical requirements.
A tickler or recall system based on birth month is often useful. Occasionally, a more aggressive program using the "house call" approach may be necessary e. A qualified MDR goes to the work-space e. The MDR returns to the workspace in 48 to 72 hours to read the test. The percentage of tests read may be higher with this method. Significant Reactor Rate. If the rate of newly- identified reactors is greater than 2.
Most countries that use BCG vaccine have a significant risk of tuberculosis infection in their population. While the vaccine may be effective in reducing the risk of serious tuberculosis disease e. It is not used in the United States. The reaction is usually less than 10 mm induration and disappears within 8 years of vaccination. There is no reliable way to distinguish tuberculin reactions caused by BCG from those caused by natural infection.
Such a person should be managed per enclosure 2. History of Tuberculosis Disease or Tuberculin Reaction. Persons with a history of tuberculosis disease, a history of a previous reaction to intermediate strength PPD skin test or a history of INH therapy must provide adequate documentation of their prior evaluations, diagnoses and treatments whenever possible.
Adequate documentation includes a copy of pertinent medical records, a copy of immunization records, or a physician's statement on letterhead stationery. If documentation is not available, follow the guidelines of this instruction and document in the member's medical treatment record the following: tuberculin skin test result, clinical evaluation including chest x- ray, if indicated , diagnosis, and appropriate preventive treatment. When a person gives a history of a significant or severe reaction to PPD, but has no documentation of such a reaction, repeat the tuberculin skin test.
This method is standardized and the results are easier to interpret. However, if the person gives a history of a large vesicular reaction, the health care provider may use low strength 1 TU PPD, which may reduce but not eliminate the risk of another large reaction. A history of a previous erythema nodosum reaction may also be an indication to use low strength PPD.
A reaction of 5 mm induration or greater to a 1 TU test is signifi-cant; handle the person like a reactor with a 10 mm induration to a 5 TU test. If the reaction is less than 5 mm induration, apply a 5 TU PPD immediately and read and interpret the test in the normal manner. Hypersensitivity does not develop from simple tuberculin skin testing, no matter how often a person undergoes such testing. The hypersensitivity, as measured by the amount of induration produced by PPD testing, may gradually decrease over the years in some persons.
These persons may have no reaction, or only a small amount of induration, to tuberculin when first tested many years decades after their initial infection. However, a tuberculin skin test can stimulate or recall the hypersensitivity to its original degree of indura-tion within several days. This effect does not appear in response to the skin test which stimulated it, but produces an increased reaction a "boosted" response on the next test.
The booster phenomenon is most common in persons over age 55, but can occur at any age. In this situation, the first PPD skin test produces little or no induration, but the boosted reaction, which occurs in response to a test routinely administered a year or more later, is read as a positive skin test response.
This positive response is then falsely attributed to a tuberculosis infection newly acquired in the year between the first and the subsequent test. In reality, this "positive" result is simply the boosted response. If the reaction to a first test is classified as not significant as defined in table 1, apply a second test a week later.
Use the results of the second test as the baseline for subsequent testing. If the reaction to the second test is significant, manage the person as infected. If the reaction to the second test is not significant, manage the person as uninfected. Do not use the two- step procedure for recruit or officer accession screening or other active duty screening programs.
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BUMEDINST 6224.8B - Tuberculosis Control Program Flashcards Preview
To provide guidelines for a tuberculosis control program of screening, preventive therapy, case identification and treatment, and contact investigation to control tuberculosis among members of the Navy, the Marine Corps, and in other medical beneficiaries. Tuberculosis continues to be a public health problem in the United States and in the U. The Navy continues to experience local epidemics of the transmission of tuberculous infection onboard ships or in other closed environments. Tuberculosis constitutes an important opportunistic infection among individuals infected with the human immunodeficiency virus HIV. Morbidity and mortality from tuberculosis can be reduced by the early identification and treatment of persons with tuberculosis disease. In addition, early detection and treatment of persons with tuberculosis disease reduces the potential that infection will be transmitted to others.
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