ࡱ> { bjbjzz 8O!PPPddd8@dְb(###$8r?QP#J#^#"##?F +++#RP+#++O`."D|xgR$.\0ְ \$|\J\P1##+#####??'###ְ####\######### :   Condition for protocol: To detect infection with Mycobacterium tuberculosis. Policy of protocol: The nurse (RN or LPN) will implement this protocol for tuberculin skin testing (TST). Condition-specific criteria and prescribed actions: For persons adopting these protocols: The criteria listed below include indications, contraindications, and precautions for implementing the TST protocol. However, the criteria must be reviewed and further delineated according to the licensed prescribers parameters. Additional criteria and prescribed actions may be necessary. The prescribed actions are examples and may not suit your agencys clinical situation and do not include all possible actions. A licensed prescriber must review the criteria and actions and determine the appropriate action to be prescribed. Annual review of this protocol is suggested. The terms Mantoux, TB skin test, tuberculin skin test, and PPD are often used interchangeably. Mantoux refers to the technique for administering the test. Tuberculin (also called purified protein derivative or PPD) is the solution used to administer the test. The preferred term for the test is tuberculin skin test or TST. CriteriaPrescribed ActionIndicationContact to an infectious case of TBAdminister TST. Targeted testing of persons at high risk for TB (e.g., foreign-born, homeless, HIV-infected, injection drug user, etc.)Administer TST.Admission to a nursing home or boarding care homeAdminister two-step TST. Admission to a correctional facility (i.e., jail, prison)Administer TST. Administer two-step TST to offenders that will be incarcerated for one year or more.Pre-employment screening for healthcare workers and correctional facility staffAdminister two-step TST. Pregnant/lactating women at high risk for TBAdminister TST. Pregnancy and lactation are not contraindications for TSTs. If woman declines TST, arrange for her to have a TB blood test (i.e., QuantiFERON, T-Spot).BCG-vaccinated personsAdminister TST. Prior BCG vaccination is not a contraindication for TST. Contra-indicationPrevious severe adverse reaction to tuberculin or any of its componentsDo not administer TST. Arrange for patient to have a TB blood test (i.e., QuantiFERON, T-Spot).Documented previous positive TST or TB blood test Do not administer TST. Repeat testing yields no meaningful information.Documented history of previous active TB disease or latent TB infection Do not administer TST. Repeat testing yields no meaningful information.Precaution< 6 months oldSome infants < 6 months old who are infected with M. tuberculosis may not react to a TST. A negative result may be a false negative. Contact MDH TB Program at 651-201-5414 for guidance.Immunization with a live-virus vaccine within past 6 weeksDefer TST until 4 - 6 weeks after immunization with live-virus vaccine.Suspected active TB disease (based on signs, symptoms, and risk factors) Administer TST and refer for immediate medical evaluation. A negative TST result does not rule out active TB disease.Low risk for TB infection or active TBTesting of low risk persons is discouraged.  SUPPLIES: A vial of tuberculin, a single-dose disposable tuberculin syringe, a ruler with millimeter (mm) measurements, 2x2 gauze pads or cottonballs, alcohol swabs, a puncture resistant sharps disposal container, record-keeping forms for the patient and provider, and a pen. ADMINISTRATION: Choose a site free of lesions, excess hair, and veins. The usual site for injection is the volar aspect of the forearm. Clean injection site with an alcohol swab. Allow area to air dry completely before the injection. Intradermally inject all of the tuberculin using a to inch 27-gauge needle with a short bevel. This will produce a 6-10 mm wheal. If a wheal of 6-10 mm is not produced, another test should be done immediately at a site at least 2 inches from the original site. Use a cotton ball to dab the area lightly and to wipe off any drops of blood. Do not apply pressure or use a bandage on the test site. Instruct patient to avoid scratching the test site. Document: Name and signature of person administering test Date and time test administered Location of test (e.g., right forearm, left forearm, alternate site) Tuberculin manufacturer, lot number and expiration date Provide written reminder to patient to return for reading in 48 to 72 hours. READING: Confirm that TST was applied within 48 to 72 hours prior to reading. If < 48 hours, patient must return after 48 hours and before 72 hours. If patient returns up to 7 days after the test was administered and the size of induration meets the criteria for a positive result, the result can be accepted. If reading the TST after 72 hours and there is no induration or the size of the induration does not meet the criteria for a positive result, the TST must be repeated. Use a millimeter ruler to measure the diameter of induration perpendicular to the long axis of the arm. Categorize results using table below. Document: Name and signature of person reading test Date and time test read Exact number of mm of induration (if no induration, document "0" mm) Interpretation of reading (i.e., positive or negative, based on individual's risk factors) Caution: Persons with symptoms of active TB disease or who are HIV infected or severely immunocompromised may have a false negative TST. TWO-STEP TST: If the first TST is negative, give a second 0.1 mL of 5TU tuberculin (Tubersol or Aplisol) ID 7 21 days following the first TST. Have patient return in 48 to 72 hours and use the table Classification of TST results to determine the result. FOLLOW-UP OF PATIENTS WITH A NEWLY-POSITIVE TST: Persons with a newly identified positive TST should be referred to a provider for a physical examination and chest x-ray to rule out active TB disease within _____days. Table: Classification of TST results Category of Person TestedTuberculin Skin Test (TST) Result (induration)< 5 mme" 5 mme" 10 mme" 15 mmRecent contact of infectious TB caseNegativePositivePositivePositiveHIV-infectedNegativePositivePositivePositiveImmunosuppressed or organ transplant recipientNegativePositivePositivePositiveFibrotic changes or scarring on chest x-ray NegativePositivePositivePositiveForeign-born from (or extensive travel to) high-prevalence country1NegativeNegativePositivePositiveInjection drug userNegativeNegativePositivePositiveResident/employee of high-risk congregate setting or health care worker2NegativeNegativePositivePositiveMycobacteria lab personnel2NegativeNegativePositivePositiveHigh-risk clinical conditions3NegativeNegativePositivePositiveChild < 4 years of ageNegativeNegativePositivePositiveChild or adolescent exposed to high-risk adultsNegativeNegativePositivePositiveNo risk factors (TB screening discouraged)NegativeNegativeNegativePositiveBCG vaccination is not a contraindication for TST; disregard BCG history when interpreting TST result. In instances of repeated testing (other than contacts), an increase in TST result of e" 10 mm within 2 years is considered a TST conversion indicative of recent infection. Substance abuse, diabetes mellitus, silicosis, cancer of the head or neck, hematologic or reticuloendothelial disease such as Hodgkins disease or leukemia, end stage renal disease, intestinal bypass or gastrectomy, chronic malabsorption syndromes, low body weight (i.e., 10% or more below ideal for the given population). 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