/,,, l \' R A Em‘mT OF HEALTH, EDUCATION, AND WELFARE Z NIALTH SERVICE 644 T7 U5 PUBL In cm-cmmn PROGRAM ' ' 10 mm Iusmcumsm ‘* 77 fl ’ lam A 9W A CHILD-CENTERED PROGRAM TO PREVENT TUBERCULOSIS U. 5. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE COMMUNICAILE DISEASE CENTER Tuberwlosll Program Atlanta, Georgia 30333 Public Health Service Publication No. 1280 March 1965 U. 5. GOVERNMENT PRINTING OFFICE Washington: 1965 For sale by the Superintendent of Documents, US. Government. Printing Office Washington, D.C., 20402 - Price 25 cents PREFACE This publication presents a child-centered program to prevent tuberculosis. In its report to the Surgeon General of the Public Health Service on “The Future of Tuberculosis Control,” a special Task Force on Tuberculosis stated that: Adequate attention to known cases and their contacts prevents the spread of tuber- culous infection. However, persons once infected can develop disease and spread infection before it is diagnosed. Therefore, absolute prevention of the spread of infection would mean developing a population in which no one was infected. Specific efforts to prevent children from being exposed to tuberculosis, allowing them to grow up without being infected, are needed for ultimate conquest of the disease. In a controlled society, everyone who ever associated with children could be forced to be examined for tuberculosis at stated intervals. Such a situation, even if it were desirable, would waste much public health effort needed for other problems. A more practical approach is to seek, where they are most likely to be found, the persons who could infect children. The child who is already infected when he first enters school provides a clue. Granted that it is too late to prevent his infection, still, finding the source of it will protect others. Children live in a world in which there are other children—brothers and sisters, cousins, playmates—some older, some younger. In most areas, a child’s environment until he goes to school is sufficiently circumscribed that identifying the person in that environment who has or has had tuberculosis is possible, so that other children will be protected. (In crowded neighborhoods of the largest cities where the population is highly mobile, attempting to find the source of even young children's infection may be unproductive at the present time.) The proposal, therefore, is that all children be tuberculin tested at first entrance to school. Those who react will be given a chest X-ray, and their families and other persons with whom they have been closely associated will be tuberculin tested. The associates who react will receive a chest X-ray. If they are preschool children, they will be given a course of prophylactic isoniazid. Adult reactors will receive what- ever diagnostic service they need, and those who fall into high-risk groups because of their X-ray findings, age, weight, or health problems will receive a course of prophy- lactic isoniazid and/or periodic examination as long as they are associated with children. As a part of the program, all school teachers and other school employees will be tuberculin tested, and nonreactors scheduled for annual tuberculin tests. Reactors will be X-rayed and scheduled for periodic reexamination according to their risk status. Children who have been infected are at low risk of disease from about school entrance until puberty. In adolescence through young adulthood, their risk is high. To reach these young people, it is proposed that all l4-year-olds in school be tuberculin tested. The reactors will be X-rayed and in addition will receive special personal explanation of their situation and be encouraged to have periodic examinations during their high- risk period and at least through their own child-rearing age. A few may also be given prophylactic drugs. III 974 This child-centered approach will require more services than are available in most communities. Provision for continued follow-up of persons at high risk must take into account that for some years to come the number of identified persons in this group who will need periodic examination will grow.” The success of a child-centered program to prevent tuberculosis cannot be measured solely by the discovery of tuberculosis or tuberculin reactors among children, their associates, and those who work with children. The success of such a program can also be measured by the discovery of people who are at high risk of developing tuberculosis, for whom regular medical supervision can be provided, and by the children who are permitted to grow up without ever being exposed to the disease. The program that follows should be carefully planned within the context of total community needs in tuberculosis control and carried out as a part of the whole program. IV TABLE OF CONTENTS Page PREFACE.........................III |. Female and the Services They Will Need . . Children entering school—to be tuberculin tested . Children who have reactions—to have chest X-rays . Children’s associates—t0 be tuberculin tested . Children’s associates who have reactions—t0 have chest X-rays . MNHv—Ir—Ip—I Children’s associates who are pre-school children and have reactions—t0 receive prophylaxis. Children’s associates who are adults and have reactions and who 2 fall into a high risk group~to have diagnostic services, periodic chest X-rays, and, in some instances, prophylaxis. Cases found—t0 have treatment . 14-year-olds or young people in 7th, 8th, or 9th grades— to be tuberculin tested. Young people who have reactions—t0 have an immediate chest X-ray, 3 educational counseling, and subsequent annual chest X-rays. 'Cases found—to receive /treatment . School employees—to be tuberculin tested . School employees who have reactions—to have chest X-rays immediately and periodically thereafter. School employees who have reactions and who fall into a 3 high risk group-40 have diagnostic services, regular medical supervision, and, in some instances, prophylaxis. ll. Workers, Tools, And Facilities . . . . . . . . . . . . . 5 Workers— Physicians . Nurses X-ray technicians. Laboratory technicians . Clerks Volunteers and/or aides . GQO‘OOU‘IW Organizations TABLE OF CONTENTS — Continued Page Workers—Continued School administration ................. 6 Tools .......................... 7 Facilities ........................ 7 III. Decisions What tuberculin test is to be given .............. 9 Who will administer and read the tuberculin test ........ 9 When the tests can be given and read ............. 9 What will be called a reaction ................ 9 Where the reactors can be examined ............. 9 What procedure will be set up for measuring the infection 9 rate and plotting where infection is occurring in the community. How the diagnostic and treatment services noted in ...... 9 Chapters V, VI, and VII will be provided. IV. Step One—Tuberculin Testing ............. 11 V. Six-Yeur-Olds And The People They live With ..... 13 For six-year-old reactors .................. 13 For associates of six-year-old reactors ............ 13 VI. Fourteen-Year-Olds, or 7th, 8th, or 9th Graders For fourteen-year-olds or 7th, 8th, or 9th graders ........ 15 VII. Adults Who Work With Children For school employees and others who work with children ..... 17 Appendix I Testing and Reading .................... 17 Appendix 2 Letters, Forms, and Records ................ 29 Appendix 3 Reporting and Evaluation of Tuberculin Test Results ...... 39 VI A CHILD-CENTERED PROGRAM TO PREVENT TUBERCULOSIS I. PEOPLE AND THE SERVICES THEY WILL NEED The second recommendation of the Surgeon Ceneral’s Task Force Report on the Future of Tuberculosis Control stated that “it is in the interest of the Nation’s health that services necessary for tuberculosis control be available to all persons who need them without regard to their ability to pay or legal residence, and that they should not be withheld as a means of punishment. It therefore recommends that services provided under grants to the States he thus free of restriction.” In planning a child-centered program, the following information will be helpful in-determining how many children and adults will need tuberculin tests, X-rays,.and medical services—or just what the workload will be. Children~entering school — to be tuberculin tested Count children in kindergarten and/or in first grade but do not expect to test more than 85 percent. Some children will be absent; other children will have skin conditions that prevent testing; and some parents will not give permission. Children who have reactions — to have chest X-rays Very few children in the first grade will have reactions—in most areas, not more than one or two per hundredfibut every child with a reaction has at some time been associated with a person with active tuberculosis. Children’s associates — to be tuberculin tested An associate is a person in the family or in close association with a tuberculin reactor, as distinguished from a contact who is in close contact with a diagnosed case oftuberculosish The number of associates can be roughly estimated at four per child reactor—2 adults and 2 other children. 1 Children's associates who have reactions —to have chest X-rays Because these associates are a select group, the percent who have reactions will be higher than in the general population—a rough estimate would be about 40 percent. Children’s associates who are preschool children and have reactions — to receive prophylaxis This will be about 25 percent of the associates who have reactions. Children’s associates who are adults and have reactions and who fall into a high risk group — to have diagnostic services, periodic chest X-rays, and, in some instances, prophylaxis These will probably total less than 10 percent of the adult associates who have reactions. Cases found — to receive treatment The number of cases found will not necessarily be one for each child who reacts because the association may have occurred in the past or the case may have become inactive. However, the program is not complete until every effort has been made to identify the source of each child’s infection and action taken to prevent other children from being infected from the same source. Example of estimated services: 10,000 — first grade children to be tuberculin tested. 8,500 — actually tested (85 percent x 10,000) 128 — children who have reactions (1.5 percent of 8,500) 512 — associates (4 x 128) 205 — associates who have reactions (40 percent x 512) (103 children; 102 adults) 51 — preschool children among associates who have reactions. (25 percent of 205) 10 - adults among associates who are in high risk group (10 percent x 102 adult associates) This would mean that 9,012 would need tuberculin tests, 333 would need chest X-rays, 51 children would be placed on prophylaxis, and 10 adults would require diagnostic services. l4-year-olds or young people in 7th, 8th, or 9th grades — to be tuberculin tested Count children in the grade to be tested but do not expect more than 85 percent. Young people who have -'reactions—to have an immediate chest X-ray, educational counseling, and subsequent annual chest X-rays The percentage of young people in this age group who have reactions will vary from community to community or from neighborhood to neighborhood. In most areas it will be between 3 and 6 percent, but in high incidence neighborhoods it will be much higher. Cases found — to receive treatment These young people are enteringr a high risk age group if they are infected, and a number of cases among them can be expected. School employees — to be tuberculin tested Every school employee should be included; teachers, bus drivers, recreation directors—anyone associated with children. School employees who have reactions — to have chest X-rays immediately, and periodically thereafter Probably 20 to 30 percent will have reactions. School employees who have reactions and who fall into a high risk group —to have diagnostic services, regular medical su- pervision, and in some instances, prophylaxis These will probably total less than 10 percent of the school employees who have reactions. 771—817 0—6—2 3 .d‘lgilflfi-Arfl I'llh .I.-‘ 4, w. I II. WORKERS, TOOLS, AND FACILITIES The number of workers needed and the tools, equipment, and facilities re- quired to carry out a successful child-centered program will depend on the number of children, associates. and adults to be tuberculin tested, X-rayed, and provided with medical services. Before the program begins, it is most important to have calculated the number of workers needed for the pro- cedures that will follow the initial screening phase. Many programs have no effect on the tuberculosis problem because sufficient provision is not made for X-raying the reactors, for diagnositic examination, and for treatment services. In addition, a number of people will require these services for a number of years. Considerably more time will be needed to plan the pro- gram, examine the associates of reactors, and provide the required medical services than will be needed for tuberculin testing and reading. As with any successful undertaking, someone will be needed to coordinate the program’s many details and someone will be needed to evaluate the success of the program as it progresses. WORKERS Physicians may be needed to administer the tuberculin tests, unless they can be given by nurses, and to counsel the parents whose children are reactors. Physicians will be needed in the clinics to interpret X-rays and provide medical services for patients under treatment, including those receiving chemoprophylaxis. They will be needed to give medical exami- nations and to evaluate the diagnostic reports. Nurses will often administer the tuberculin tests and read the test results. They assume the major responsibility of explaining the significance of the tuberculin test to the parents whose children have reactions so that they will understand the importance of the other procedures. Nurses will be needed to obtain medical histories of each family with a reactor in order to determine who the associates are and to identify the source of infection. If a physician gives the test, the nurse can assist him. Nurses will be needed to interview patients and take personal medical histories. Nurses will be needed to interview and counsel patients returning for diagnostic services, and to 5 obtain information needed by the physician. When aerosol equipment is used to take sputum samples, a nurse can instruct and reassure the patient. X-ray technicians will be needed to X-ray all the reactors and to give repeat X-rays to persons with suspicious findings on their original X-rays. Laboratory technicians will be needed for examining sputum specimens of persons who have suspicious X-rays. Clerks will be needed to record the results of the tuberculin test; to prepare correspondence to parents, teachers, and others; to transcribe the notes of physicians and nurses; and to coordinate and maintain up-to-date records. Volunteers and/or Aides can help organize the program at the school and can serve as receptionists at clinics. They can often take temperatures and weigh patients or be of considerable help at clinics by supervising children while their parents are being interviewed. Volunteers can also arrange for patient transportation to the clinic and make patient participa- tion in the program easier. Organizations (1) The tuberculosis association has an important role in the program. This role will vary widely from one community to another according to the resources and on-going program of the association. In all areas they can help by providing, information and interpretation of the program and by publicizing it. In many areas, the association can support part of the activities or actually provide them. (2) The backing of the medical associations is essential to any successful program. It is especially important to enlist the active participation of appropriate medical association committees such as school health and pediatric groups. (3) The interest and support of the Parent-Teacher Association is essential to the success of any school-centered program. Their meetings provide an opportunity to explain what the program is about and their membership contains motivated volun- teers. School administration—Where school health services are provided un- der auspices other than the health department, the authorities responsible should be included in early planning. These include school health councils, 6 faculty committees, teachers’ associations, and other appropriate groups and individuals who may be concerned. In any community, many other groups and organizations will be interested in a child-centered program to prevent tuberculosis and can be called upon for assistance. TOOLS Tuberculin testing equipment will be needed.\ (See appendix 1) X-ray equip- ment will be needed for screening and for confirmation. Forms, letters, stationery, and typewriter will he needed for record-keeping, correspondence, and evaluation. (See appendix 2) Clinic supplies will be needed, including thermometers, scales, etc. Drugs will be needed for prophylactic treatment. FACILITIES If established clinic facilities are not available, appropriate space must be made available for examination of reactors. In addition to an examining room, there must he places for physicians and nurses to hold private inter- views. Appropriate space will be needed for X-ray equipment and if aerosol equipment is used, a properly ventilated room will be needed. -'.'l-'II'.II|i."'|L13-:Il .III' III. DECISIONS What tuberculin test is to be given The Mantoux is the most accurate tuberculin test. If a multiple puncture test is used for the sake of convenience. the Mantoux test should be used to confirm reactions to the multiple puncture test, unless the reaction to the multiple puncture test is very severe. Who will administer and read the tuberculin test If possible, the same pcrson should administer all the tests in any one specific program. Also, one person should read all the tests in a specific program. When the tests can be given and read The testing program must he scheduled in consultation with school officials. If children are tested earl) in the school year, there will be time to complete all tests and examine the associates. What will be called a reaction The presence of atypical infection in the community will affect the size of reaction considered positive. (See appendix 3) Where the reactors can be examined There must be room for the doctor and the nurse to talk with parents and space for X-rays and otIu-r examinations. What procedure will be set up for measuring the infection rate and plotting where infection is occurring in the community (See appendix 3) How the diagnostic and treatment services noted in Chapters V, VI, and VII will be provided 9 IV. STEP ONE—TUBERCULIN TESTING This chapter is called “step one” to emphasize the fact that tuberculin testing is only the first step in a child-centered program to prevent tuberculosis. When the tuberculin test is completed, a report should be sent immediately to all parents regardless of the test results. (See appendix 2) Caution: Plans must be carefully scheduled so that the school program will not be disrupted. In planning for time, it takes about as long to tuberculin test as it does to line the children up to be tested. 77l—Xl7 ()—65—3 11 V. SlX-YEAR-OLDS AND THE PEOPLE THEY LIVE WITH For six-year-old reactors Promptly explain to the parents what their child’s reaction means. X-ray all the reactors. Provide clinical and diagnositic examinations for any children with suspici- ous X-ray findings. Be sure all children with active disease start treatment immediately. Start chemoprophylaxis for all children who have recently become reactors or who have recently been exposed to an active case of tuberculosis. Reexamine reactors each year for at least two years and X-ray them annually beginning with the seventh grade. For associates of six-year—old reactors Take a careful health history of the family and their friends and neighbors, including causes of death, to find the source of infection. Tuberculin test the family members and other close associates. X-ray all the reactors. (If a reactor is a pregnant woman, she should have an X-ray at time of delivery and three months post partum.) Provide clinical and diagnostic examinations for each person with a suspi- cious X-ray. Be sure that anyone with active disease starts treatment immediately. Start chemoprophylaxis for all preschool children who are reactors but who are not diagnosed as having active tuberculosis, and for adults in special risk groups as indicated. Provide for continuing periodic X-rays of reactors who are children, or adults as long as they are associated with c ildren, at intervals determined by their risk status. 13 VI. FOURTEEN-YEAR-OLDS OR 7th, 8th, or 9th GRADE REACTORS For fourteen-year-olds or 7th, 8th, or 9th graders Promptly explain the meaning and importance of the tuberculin reaction to the student and the parents. X-ray all the reactors. Provide clinical and diagnostic examination for each student with a suspici- ous X-ray. Be sure all students with active disease start treatment immediately. Start chemoprophylaxis for all students who have recently become reactors or who have recently been exposed to an active case of tuberculosis. Start chemoprophylaxis for all reactors who are at special risk of developing tuberculosis because they have suspicious X-rays, are underweight, or have diabetes. Provide annual chest X-rays for all reactors through the child-rearing age. (Set up a system of reminders) 15 fiL-w nun n .AI :IEIH I). VII. ADULTS WHO WORK WITH CHILDREN For school employees and others who work with children Promptly explain to the adult what the tuberculin reaction means. X-ray all the reactors. Provide clinical and diagnostic examinations for all reactors with suspici- ous X-rays. Be sure all adults with active disease start treatment immediately. Chemoprophylaxis should be considered for all reactors if they are untreated inactives; if they have a suspicious chest X-ray; if they have diabetes or silicosis; if they had a negative tuberculin test within the past 2 years; or if they are on steroid therapy. X-ray all reactors annually or at other intervals determined by their risk status. .Make sure all nonreactors have an annual tuberculin test as long as they work with children. 17 Equipment for tuberculin testing Covering the tuberculin bottle top 18 Appendix 1 TESTING AND READING These instructions apply to the Mantoux test. If any other tuberculin screening method is used. confirm the reaction with a Mantoux test. For other tests, follow insructions of the manufacturer. Equipment needed Tuberculin, preferably PPD, which when mixed can be stored in a refrig- erator for at least 6 months without practical loss of potency if carefully kept away from light. Tuberculin syringes with fused markings, colored plungers, and good clips. The markings measure the proper dose. will not fade, and the clips hold the plungers firmly in place. Glass caps to cover the bottles containing antigen. These caps prevent contamination of the solution after the filler needles have been inserted. Filler needles, 20 gauge, llé-inch steel for filling syringes from solu- tion containers. They are easy to use; they save wear and tear on the needles used for intra- dermal injections; and they are long enough to reach to bottom of the diluent vials. Needles, 26 gauge, 14—inch platinum (70%l—iridium (20%), gold plated, packed in plastic needle holders or containers. are recommended by the WHO Standard Tuberculin Test Guide. They are easy to flame-sterilize between tests; they last a long time; and they stay sharp. If glass tubes are used. they can serve as props for the syringes and protect the needles from damage and contamination when not in use. 19 Gauze squares 2”x2“ and sponges for cleaning the arms and for sterile packs. They are convenient, have no lint, and are readily available. Towels, 30”x17” Tincture of iodine with glass applicator to sterilize the rubber stoppers. Ethyl or isopropyl alcohol (70%) It has a high bactericidal effect, and will remove iodine from the rubber stoppers. Flexible millimeter ruler with scale on top border to measure the reactions. It is convenient and accurate. Alcohol lamps to flame the needles. They are convenient and do not smoke. 2O Caution: Do not test persons who have: Acute illness—colds, fever, etc. Any skin condition that covers more than half of the forearm. Fresh smallpox vaccination. 21 Flaming the needle Ejecting drop of tuberculin The injection 22 To give the Muntoux test: Clean inside surface of forearm with alcohol sponge. Grasp under part of forearm with left hand about four fingers down from the elbow and exert pressure downward and backward to pull skin taut. Pick up syringe with right hand and hold firmly between index finger, middle finger, and thumb with the plunger top toward the base of palm. The thumb should be on a line with the numbered gradations of the syringe. This gives a full view for measuring the amount of solution given. Hold syringe at a right angle to the arm and insert the needle, bevel tip upward, between the layers of skin, on inside surface of the upper forearm where the skin is taut; then loosen left hand pressure so the skin relaxes. Advance the plunger by exerting pressure on it with the base of the palm. Inject 1/10 of 1 cc. (two major divisions of the numbered gradations of the syringe) and withdraw the needle rapidly. A white elevated area or wheal is produced when the injection is properly performed. Flame bevel tip of needle until tip is red. Eject drop of tuberculin from needle after each flaming. Be sure the person tested knows date to return for test reading. 23 Caution: Do not give a test in the same spot known to have been used for a previous test. When the tuberculin is lost outside the skin, try again about one inch diago- nally below the first attempt. Do not give a second test when a full dose of tuberculin has been injected too deeply. Record the date, the site (right or left arm), and the type and strength of antigen used. ' Refill syringe. 24 To clean and sterilize equipment: The testing and cleaning materials must be used solely for tuberculin testing. The active ingredient of the tuberculin antigen which adheres to glass has to be destroyed. Separate all the parts—needles, clips, etc. Rinse all the parts individually in tap water and keep wet. Prepare cleaning solution of one teaspoon of sodium hydroxide or trisodium phosphate—or a comparable dishwasher detergent—40 a pint of water. Place all items in a stainless steel pan and cover with a cleaning solution. Bring solution to boil and continue boiling for 15 minutes—be sure items are covered with solution during boiling. Remove from heat but do not drain. Place pan with contents under running tap water and flush each item 10 times. Cover items in pan with distilled water and return to heat. Bring to boil and continue boiling for 5 minutes. Remove from heat and rinse with copious amounts of distilled water 3 times —soak 15 to 30 minutes between each rinse. Dry, reassemble, and prepare for sterilization in the usual manner. Use tongs or forceps to remove items from cleaning solution and rinse tongs or forceps after each use to prevent corrosion. 25 The tuberculin reaction Measuring the induration 26 To read the test: The test should be read 48 to 72 hours after it is given. Record the date read. Use a good light and a flexible millimeter ruler and have someone record the results as dictated. The margins of the induration can be found by touch. Read the induration or hardness in the skin at the point where the needle entered. This indicates a tuberculin reaction. Do not read the erythema or redness of the skin which surrounds the indura- tion. This is due to congestion of the capillaries. Measure the induration in millimeters transversely across its widest diameter. Record “0” millimeters if there is no induration, even if there is onl Y erythema. When the reader is inexperienced, have an experienced reader do an inde- pendent reading of the same test group and compare the results. To care for reactions: Avoid interfering with the test spot as much as possible. Keep the test spot clean. Relieve soreness with a clean gauze with vaseline. 27 . . , - - I I‘ ‘ . . . .. .. l I-I \ I I I Ii \ I -- fill-fl- . .. . . “TI. . II I u .— . . H . . . . . . . 3 — . . . sv ._ .. u... . _ . . . _ .. _ u m __ w. r , H. m . . . g: I ll ; . .. . . . . . . . w w . w . . . .E... . Appendix 2 lETTERS, FORMS, AND RECORDS (SAMPLE) (For 6- and 14-year-olds) Name TUBERCULIN TEST REQUEST AND RECORD CARD Sex Age in Years Street or RFD Post Office School Parent or Guardian County School District Grade Family Doctor l hereby request that my son or daughter receive a tuberculin test and periodic follow~up X-rays if necessary. DO NOT WRITE BELOW THIS LINE Address Signature of Parent or Guardian Date Type & Strength Measurement of Material Used lnduration (OVER) FRONT VIEW 29 (SAMPLE) (For 6- and 14-year-olds) Dear Parents: A tuberculin test program will be conducted in the school soon. This is a health service which is strongly recommended by your school authorities. A reaction to this test means that the child has had contact with someone having tuberculosis in active form and is infected with the germs of tuberculosis. It does not mean that he is ill with tuberculosis at present, but he may be at some time in his life. A chest X—ray will be given every positive reactor. Superintendent of Schools BACK VIEW A letter explaining the test should go to each parent. (SAMPLE) (For 6- and 14-year-olds) (Date) To parents of students in schools of Beginning (date), your health department will conduct its annual school tuberculin testing program. The tuberculin test consists of placing the test solution in the layers of the skin to show whether the person is infected with the germs that cause tuberculosis. The question may be asked why your son or daughter should have this tuberculin test. The answers are: 1. It will tell you and your child whether or not he has been exposed to tuberculosis during the past year and indicates whether or not a chest X-ray is needed. 2. This information is use- ful to your health officials because it provides a means for locating new cases of tuberculosis in the community. 3. Persons with a positive test who were previously nega— tive may need treatment to prevent disease from developing later on. Accompanying this letter is a request card to be signed for this skin test. For those children who had positive reactions last year, a request card is attached for their annual chest X-ray examination. Health Officer 31 A letter or note explaining the test results should go to the parents regardless of what reaction was recorded. (SAMPLE) (For 6- and 14-year-olds) Report of negative tuberculin test for Name of child Your child’s tuberculin skin test which was recently administered as part of the school program showed a negative reaction. This is good news because it shows that your child has not been infected with the germs that cause tuberculosis. Your child should have a repeat tuberculin test when recommended by your private physician, your health depart- ment, or the school health program. If at any time you have any concern about your child’s having been exposed to tuberculosis, a tuberculin test can be given by your phy- sician or the local health department. Thank you for your fine cooperation. We appreciate your continued support in preventing children from exposure to tuberculosis. Health Officer (SAMPLE) (For 6-year-olds) Report of a positive tuberculin test for Name of child Dear Parents: Your child’s tuberculin skin test which was recently administered as part of the school program showed a positive reaction. This does not necessarily mean that he or she has active tuberculosis, but rather that there has probably been contact with a case of active tuberculosis at some time. Any positive reaction should be followed up with a chest X-ray. It is extremely important too that every member of a positive child’s household also receive a tuberculin test or a chest X—ray. These testslmay be obtained at the Health Center on Monday, Tuesday, Wednes- day, or Friday from 8:00 a.m. to 12:00 noon and from 1:00 to 4:45 p.m. We would appreciate your calling the Public Health Center to arrange for a clinic appointment. The tuberculin test and chest X-ray recommended above may be obtained from your private physician should the family wish to do so. If this is the case, would you please call the Center and give them this information? THE PARENTS MUST ASSUME RESPONSIBILITY for seeing that the student with the positive reaction and the household members have the needed tests and chest X—rays. Health Officer (SAMPLE) (For 14-year-olds) Report of a positive tuberculin test for Name of child Dear Parents: Your child’s tuberculin skin test which was recently administered as part of the school program showed a positive reaction. This does not necessarily mean that he or she has active tuberculosis, but rather that there has probably been contact with a case of active tuberculosis at some time. Any positive reaction should be followed up with a chest X—ray. It is extremely important too that every member of a positive child’s household also receive a tuberculin test or a chest X-ray. These testslmay be obtained at the Health Center on Monday, Tuesday, Wednes- day, or Friday from 8:00 a.m. to 12:00 noon and from 1:00 to 4:45 p.m. We would appreciate your calling the Public Health Center to arrange for a clinic appointment. The tuberculin test and chest X-ray recommended above may be obtained from your private physician should the family wish to do so. If this is the case, would you please call the Center and give them this information? THE PARENTS MUST ASSUME RESPONSIBILITY for seeing that the student with the positive reaction and the household members have the needed tests and chest X-rays. Health Officer 34 A record may be needed for each person tested. The test results should be recorded on the child’s school health record. (SAMPLE) Individual Record of Tuberculin Sensitivity Birth Name Sex Race _ Year (last) (first) (middle) Home address City County Birthplace _.____._____— School Father ______.___ Mother Test Date of Not Not Remarks“ Test T St th Date of lnduration in Tested Read ype reng Reading Millimeters *Reason not tested or not read. (SAMPLE) Student summary tabulations by rooms, grades, or schools. Number and Percent of Reactors in 6-Year Old Group by Sex - - Number Percent N b El bl um er lg] e Tested & Read Reactors Reactors Male Female Male Female Male Female Male Female (SAMPLE) Number and Percent of Reactors in l4-Year Old Group by Sex El' 'bl Number R t Percent Number 1g! e Tested & Read eac ors Reactors Male Female Male Female Male Female Male Female Associates (SAMPLE) Number of Associates of 6-Year Old Reactors Referred for Tuberculin Testing and Results of Testing by Age and Sex N b Number E12313; Tested Reactors and Read Percent Reactors Age (Years) Male Female Male Female Male Female Male Female Under 5 10-14 15-19 20-24 25-44 45-64 65+ Totals 37 You will need forms for: School employee. (SAMPLE) Number and Percent of Reactors by Sex and Age Number Number Percent Age Eligible 33::ch Reactors Reactors (Years) Male Female Male Female Male Female Male Female 15-19 20-24 25-44 45-64 65+ Totals 38 Appendix 3 REPORTING AND EVALUATION OF TUBERCULIN TEST RESULTS The purpose of tuberculin testing is to distinguish between those persons who are infected with tubercle bacilli and those who are not. How effectively this can be done under diflering circumstances depends upon the appropriate use of data. A suitable size limit for those reactions that will be considered negative can be established by careful analysis of the distribution of reac- tions. The size of the reaction defined as positive should vary according to the prevalence of nonspecific sensitivity (as evidenced by large numbers of small reactions) in the geographic area under consideration. As the tests are read, sort results according to the recorded size of the reac- tion to determine how many persons have reactions of 0-1 mm., 2-3 mm., 4-5 mm., etc. The resultant frequency distribution of reactions represents basic data and should always be tabulated. This arrangement of data should be made for each group: 6-year-olds, 14-year-olds, school employees, and associates of child reactors. Then when the distribution is examined, the size at which reaction can reasonably be expected to indicate tuberculous infection in the particular community can be determined. The distribution of tuberculin reactions for a group of patients hospitalized for tuberculosis at the Battey State Hospital, Rome, Georgia, is shown in figure 1. Figure 1—Distribution of sizes of reactions to 5 TU of PPD=S for 1,592 patients in a tuberculosis hospital in Georgia 20 Story of the Tuberculin Test ‘5'— / PERCENTAGE T \ 5—W7 // / / /77}777m 0 4 8 12 16 20 24 28 32 36 INDURATION IN MILLIMETERS 39 The fact that this pattern is reasonably similar to the pattern of sensitivity to the S TU dose of tuberculin in tuberculosis patients all over the world suggests a universal characteristic of persons with clinical tuberculous disease, despite such obvious factors as age, race, sex, kind or stage of disease, nutritional status, etc., that may otherwise cause the groups of patients to differ considerably from one another. (The Story of the Tuber- culin Test, Chapter VII, pp. 24-.) A distribution curve showing size of tuberculin reactions among 2 groups in the general population presents a different picture from that just shown for tuberculosis patients. Figure 2 shows a marked difference between the curves for natives of the lower Yukon area of Alaska and the population of two counties, one in the State of Georgia and the other in Alabama. Other evidence shows that almost all small reactions in one area., i.e. Alaska, mean true tuberculin reactions whereas almost all small reactions in another area, i.e. Georgia and Alabama, mean nonspecific infection. Figure 2—Comparison of distributions of sizes of reactions to 5 TU PPD among unvaccinated persons 15 years or older in two geographic areas 20-— | _,‘ MUSCOGEE AND RUSSELL COUNTIES ,_ ’,_ ‘ a PERCENTAGE LOWER YUKON INDURATION IN MILLIMETERS Half of the reactions in the Muscogee-Russell County area are smaller than 7 mm.; in contrast, half of the reactions in the lower Yukon area are larger than 16 mm. The total prevalence of tuberculosis among adults with some reaction to the 5 TU dose was very different in the two areas, being nearly 30 percent in the lower Yukon area and only 1.2 percent in the Muscogee- Russell County area. In the lower Yukon area there was no significant difference in frequency of tuberculosis among persons with different sizes of tuberculin reactions; whereas in the Muscogee-Russell County area there was a marked and progressive increase in the frequency of tuberculosis with increasing sizes of the tuberculin reaction. 40 Authorities believe there could be at least two explanations for such a re- lationship. One is that allergy to tuberculoprotein is harmful to the host and that demonstrable disease is more likely to occur among those with high levels of allergy. The second explanation is that in some areas among persons with small reactions the infection is not with tubercule bacilli but with something much less pathogenic, while among persons with large reactions the infection is almost always with tubercule bacilli. Those interested in detailed discussion of evaluating the distribution of tuberculin reactions should read The WHO Standard Tuberculin Test, WHO/ TB/Technical Guide/3, dated February 22, 1963, prepared by Mogens Magnusson, Tuberculin Laboratory, Statens Seruminstitut, Copenhagen, and The Story of the Tuberculin Test from an Epidemiological Viewpoint by Phyllis Q. Edwards and Lydia B. Edwards (Amer. Review Resp. Diseases, Vol. 81, No. 1, Part 2, pp. 1-47, January 1960). 41 US. GOVERNMENT PRINTING OFHCE : I965 0—77I-BI7 U. C. BERKELEY LIBRARIES \IIIIIIIIIIIH CU'MHEE'RE? a!” . ;’ Public Heulih Service Publication No 1280 l" U. C. BERKELEY LIBRARIES \I\\I\I|IIM\I\I\I cumaaaaau