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ii. Patient Specific Standing Orders reduce the potential for error and free up
the prescribing provider from having to be the only one monitoring and
dispensing.
f. Verbal Orders
i. RN PCMOs can accept orders for acute treatment from any licensed
provider (physician, NP, PA, dentist, podiatrist etc.). These orders must be
noted as verbal/telephone order and should be signed by the prescribing
provider at the earliest convenience.
10. STANDING ORDERS OVERVIEW
The plan in the eCHAM or TGs is the condition-specific standing order
Condition-specific plans with possible standing orders may contain an
ALWAYS Report caution, which safeguards those patients who may be more
complicated (Examples: Volunteers with multi-system disease, or PCVs with
more concerning symptoms). These patients would not be covered by the
standing order, and the RN PCMO would actively consult the referral doctor
(prescribing provider).
If there is no eCHAM plan for a certain condition the D/OMS may approve a
Peace Corps specific plan from the TGs (Example: TG 845 Malaria Diagnosis
and Treatment).
If a different treatment plan is created; it must be clear which instructions the RN is
to follow. Any new plan:
- Must be plainly written (preferably in a format similar to the eCHAM)
- Must be signed by the supervising physician (D/OMS or designee).
- Must be on file at Peace Corps headquarters and the RNPCMO
Health Unit
Patient-specific Standing Orders for chronic medication refills and monitoring may be
granted by the prescribing physician at Post as designee of the D/OMS (TG 605
Attachment C).
A. Granting Standing Order Privileges
Only the D/OMS or designee who must be a licensed physician employed or
contracted by the federal government can grant RN PCMO standing orders
The Credentialing Committee recommends to the prescribing physician what skill
level the RN PCMO is at and if he/she has met the requirements of the organization
which would allow the RN PCMO to practice using standing orders
RN PCMOs practice under the medical authorization of the supervising
physician (D/OMS or designee)
Standing orders authorizing the RN PCMO to follow the eCHAM treatment
plan (or other written guideline, including TGs), without consulting a
Office of Health Services
December 2015
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December 2015
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When an RN PCMO treats a patient using standing orders without contacting the
prescribing provider, the RN will record this in the Volunteers medical record.
E. Renewing standing orders or change of supervising physician
Standing orders must have re-evaluation and renewal every two years to
emphasize the importance of maintaining knowledge and skills.
The RN PCMO functions only under the medical supervision of the prescribing
physician.
If standing orders are not renewed, the RN PCMO may no longer treat patients using
standing orders and must report each patient to the prescribing provider, as
directed in the eCHAM.
F. Revoking standing orders
The supervising physician (D/OMS) can revoke a standing order if that physician
determines that an RN PCMO does not have the skills or resources as outlined above
to treat patients for that specific problem without contacting the physician
Revocation of standing orders must be in writing after consultation with the RN
PCMO, RMO and the QI Unit
- Revoked Standing Orders may be reinstated after a period of successful
remediation
G. Change of RN PCMO employment
Standing orders are specific to a nurse and a physician.
If a RN PCMO changes employment to a different Peace Corps facility, or itinerates in
the agency, their original standing orders carry over with them.
Questions:
Questions regarding RN standing orders should be directed to the D/OMS or Quality
Improvement Unit RN Supervisor in the Office of Health Services.
December 2015
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Peace Corps
Technical Guideline 615
ANAPHYLAXIS
1. PURPOSE
To provide guidance in the recognition and treatment of anaphylaxis and to define the
supplies and treatment protocol required to manage anaphylaxis.
2. BACKGROUND
Allergic reactions can occur to various drugs and other environmental allergens. They can
vary in severity from mild pruritus to life threatening anaphylaxis.
Types of allergic reactions
TIME
CLINICAL MANIFESTATIONS
Immediate ( < 1 hr )
3. ANAPHYLAXIS
Anaphylaxis is the most severe and dangerous form of allergic reaction. The reaction may
occur within seconds or can take hours to develop. In some cases, symptoms of anaphylaxis
can return several hours after the initial episode.
The cause for anaphylaxis may remain unidentified in as many as two thirds of the case. The
following is a list of more common causes of anaphylaxis:
April 2007
Page 1
Anaphylaxis
TG 615
Latex
Exercise
4. PREVENTION OF ANAPHYLAXIS
Volunteers should be educated about the dangers of using a drug or eating a food to
which they may be allergic.
A medical history for allergies is taken prior to the administration of any drug.
Volunteers should remain in the Health Unit for at least 20 minutes following
immunization or injected medication.
If there is any doubt as whether a particular medication can be used, contact the APCMO
or OMS.
Skin testing, drug challenges and desensitization can cause anaphylaxis; they must not be
used in-country except under the direction of OMS.
5. TREATMENT OF ANAPHYLAXIS
As prompt appropriate therapy can be lifesaving, the anticipation of a possible anaphylactic
reaction is vital and preparations for emergency treatment must be made.
A protocol for the treatment of anaphylaxis and the necessary supplies must be available
wherever and whenever immunization and parenteral medications are given. If
immunizations are given in locations other than the Health Unit (such as training or
conference sites), the basic medications and equipment must be available at that site.
5.1
April 2007
Page 2
Anaphylaxis
TG 615
Equipment:
5.2
Age >35
Some experts use glucagon 1mg SC, IM, or IV when epinephrine cannot be given or
when epinephrine does not produce a response (e.g., use of beta blockers.) Obtain
expert assistance in these situations.
April 2007
Page 3
Anaphylaxis
TG 615
5.3
5.4
(1)
(2)
B-Agonist
Bronchospasm refractory to epinephrine may respond to a nebulized B-agonist such as
albuterol sulfate or metaproterenol. Continuous nebulization of the B-agonists may be
necessary for persistent bronchospasm. The use of anticholinergic therapy with
nebulized ipratropium bromide(Atrovent) is an additional option in the management of
bronchospasm.
5.5
Antihistamine
Antihistamines should be used in all cases, although their role in severe or persistent
anaphylaxis is limited. Diphenhydramine hydrochloride is the most commonly used H1
antihistamine. The typical dose 25 to 50 mg every 4 to 6 hours. For severe reactions, a
loading dose of 1 to 2 mg/kg IV to a maximum of 100 mg is recommended.
Blockade of H2 receptors may be beneficial with simultaneous H1 antihistamine
therapy. Cimetidine 300 mg IV, followed by oral administration of cimetidine 300 mg
every 6 hours for 2 days, should be considered for patients with persistent symptoms.
5.6
Corticosteroids
Corticosteroids have an onset of action of approximately 4 to 6 hours after
administration and therefore are of limited benefit in the initial treatment of the rapidly
deteriorating anaphylactic patient. Their benefit may be realized in persistent
bronchospasm or hypotension. An initial intravenous loading dose of hydrocortisone
(Solu-Cortef) 250 mg to 1 gm, or methylprednisolone (Solu-Medrol) 125 to 250 mg,
followed by oral prednisone over 7 to 10 days, is an acceptable regimen after the
anaphylactic episode.
5.7
April 2007
Page 4
Anaphylaxis
TG 615
Start infusion at
Increase slowly, up to
a maximum of
45 kg
100 lb
14 ml/hr
34 ml/hr
55 kg
120 lb
16 "
41 "
65 kg
142 lb
20 "
49 "
75 kg
165 lb
22 "
56 "
85 kg
187 lb
25 "
64 "
95 kg
210 lb
28 "
72 "
April 2007
Page 5
Anaphylaxis
TG 615
Subjective & Objective
The clinical manifestations of anaphylaxis are best considered according to the organ system
that is effected (this allows therapy to be planned and understood):
Assessment
Differential diagnosis
Vasovagal collapse
Panic attack
Airway obstruction
Plan
April 2007
Page 6
MANAGEMENT OF ANAPHYLAXIS
TG 615 ATTACHMENT A
MODERATE ANAPHYLAXIS
MILD ANAPHYLAXIS
SEVERE ANAPHYLAXIS
Assess airway
Epinephrine without delay
Assess airway
Epinephrine without delay
Benadryl 50 mg IM
Benadryl 50 mg IM
Hypotension or upper
airway obstruction
continues
Symptoms resolve
Bronchospasm
continues
Bronchospasm
continues
0.5 mg (2.5 ml of a
0.02% solution) via
nebulizer
Methylprednisolone
125 mg IV, or
Hydrocortisone 500 mg IV, or
Prednisone 60 mg PO
Symptoms resolve
Methylprednisolone
250 mg IV, or
Hydrocortisone 1 gm IV
Persistent upper
airway obstruction
Intubation,
cricothyroidotomy, or
tracheostomy
Persistent hypotension
Dopamine
4-10 mcg/kg/min
(see text)
Peace Corps
Technical Guideline 620
Fever occurs when the regulatory system maintains the bodys temperature at higher than
normal levels. Fever often accompanies infection. The infecting bacteria or viruses
release toxins (exogenous pyrogens) which cause certain immune cells to release
chemicals (endogenous pyrogens) which cause the hypothalamus to raise the bodys
temperature.
The thermoregulatory system tries to keep the bodys temperature at the higher pyrogeninduced temperature by inducing shivering if the temperature is below this new set-point,
or sweating if the temperature is above it. This produces the alternating sweating and
shivering (rigors) seen in febrile patients.
In young, otherwise healthy adults, infection causes most fever. Other causes of fever
(certain cancers, drug fever, auto-immune diseases) are rare.
Fever in itself is usually dangerous only if 106o F (41o C); however, fever almost
always causes uncomfortable symptoms. In young children, fever can be associated with
febrile convulsions.
Most common infections (and their associated fevers) resolve spontaneously. This is true
for most colds, flu, bronchitis, etc. In these cases, cautious observation and symptomatic
treatment are all that is required.
March 2006
Page 1
Fever
TG 620
If the history and/or examination indicate that this may be a serious infection, if a
probable source of the fever is identified (e.g., UTI), or if the patient has been exposed to
any potentially serious infectious diseases, investigations and treatment are appropriate.
Use of anti-pyretics
March 2006
Page 2
Fever
TG 620
SERIOUS FEBRILE ILLNESS (CONT.)
ASSESSMENT
The urgency with which a febrile patient is investigated and/or treated depends on:
Whether the diagnosis is known and is one which requires treatment
Whether this may be a serious infection
AND
The condition of the patient
PLAN
Diagnosis known: treat accordingly
Diagnosis not yet made: supportive care, appropriate tests, and frequent review
A patient who is very unwell, or who may have a serious illness, may be investigated (if
possible) and then given empiric antibiotics to cover the most likely infections (even before
the exact diagnosis is known.) Obtain expert consultation.
Central nervous system (headache, neck stiffness, altered mental status, etc.):
Lumbar puncture (if meningitis suspected)
Respiratory system (cough, sputum production, raised respiratory rate, crackles and/or
wheezes, reduced air entry, etc.):
Sputum microscopy and culture
Chest X-Ray
TB skin test and possibly sputum for TB culture and acid fast smear if cough persists
for > 2 weeks (see TG 645 Pulmonary Tuberculosis)
March 2006
Page 3
Fever
TG 620
Many infectious diseases first present with a common set of symptoms (often called a
prodrome) which may include: fever, malaise, nausea, vomiting, myalgia (muscle pains),
arthralgia (joint pains), headache, and photophobia (eyes sensitive to bright light.)
More specific symptoms may also develop; these can make a particular diagnosis more
likely. Examples of such symptoms include: neck-stiffness, diarrhea, abdominal pain, or
rash.
The presence, type, and distribution of a rash provide vital clues in the diagnosis of a
febrile patient.
5.1
Definitions
Description of a rash
It is important to be able to describe rashes accurately. The following terms are
commonly used to describe them:
Macule:
Papule:
Vesicle:
Pustule:
Petechia:
Purpura:
Types Of Rash
Two main types of rashes are associated with infectious diseases:
5.3
Maculopapular:
Hemorrhagic:
March 2006
Page 4
Fever
TG 620
Hemorrhagic rashes are the most severe types of illness presenting with fever and rash.
Meningococcal septicemia is one of the few conditions in this group which is both lifethreatening and treatable with antibiotics. If meningococcal septicemia is suspected
treat as for bacterial sepsis (see section 6.)
Additional information which is helpful when evaluating febrile patients with a rash:
Severe bacterial infections, including blood stream infections, deep abscesses, and CNS
infections, can rapidly overwhelm the bodys defenses, often leading to multi-organ
system failure (septic shock.)
Catastrophic illness or shock may also be due to non-bacterial conditions, such as cardiac
events or surgical emergencies. Empiric antibiotics are appropriate in addition to other
diagnostic and supportive measures when a severe bacterial infection is suspected.
Blood cultures should be done along with cultures of all potential sites (urine, sputum,
wounds, etc.) Empiric antibiotic treatment can be changed if cultures or other tests
confirm the organism or rule out bacterial infection.
Patients with severe sepsis should receive a broad-spectrum, intravenous regimen that is
effective for both gram-negative and gram-positive bacteria. The choice of drugs should
be modified according to the patients own microbiologic culture data and the resistance
patterns prevalent in the patients community or hospital.
Contact the APCMO or OMS when managing a Volunteer with a severe and possibly
life-threatening illness such as sepsis or shock.
March 2006
Page 5
Fever
TG 620
A loading dose of gentamycin or tobramycin is adequate for 8 hrs, a loading dose of amikacin is
adequate for 12 hrs. Consult with APCMO or OMS to discuss continuing or changing antibiotic
coverage.
March 2006
Page 6
Peace Corps
Technical Guideline 635
Common Skin Infections
1.
PURPOSE
This guideline provides a summary of the management of bacterial, parasitic, and fungal skin
infections.
The recommendations provided in this guideline are designed to address the empiric treatment of
syndromes commonly seen by the PCMO. The treatments listed concentrate on the antibiotics or
medications which are most useful to stock in the health unit. Occasionally, due to drug allergy or
intolerance, alternate drugs may be necessary. Consult the UpToDate for additional or more
detailed information.
2.
Impetigo
Impetigo is a superficial, contagious skin infection caused by Staph aureus and/or Group A
Strep. It often begins with a vesicle which later ruptures to form a thick, yellow crust.
Antibiotic treatment is warranted due to a high recurrence rate. Unlike strep pharyngitis,
treatment does not appear to prevent the development of post-streptococcal
glomerulonephritis. Good handwashing should be encouraged.
March 2016
Page 1
Skin Infections
TG 635
Treatment of impetigo
Clean site, apply mupirocin (Bactroban) three times a day for 5 days (discontinue and
reevaluate if lesions worsen)
Or, for more severe infections:
Dicloxacillin 250-500mg orally four times daily for 7 days
Or
Cephalexin 250-500mg orally four times a day for 7 days
Or, for penicillin/cephalexin allergic
Erythromycin 250mg orally four times daily for 7 days
If MSRA is suspected/confirmed
Clindamycin 300-450 mg orally four times daily for 7 days
Or
Trimethoprim-sulfamethoxazole 1-2 doubles strength tablets orally twice daily for 7 days
Or
Doxycycline 100mg orally twice daily for 7 days
2.2
Skin abscess
Skin abscess (boils, furuncles, carbuncles) are a localized skin infection, often starting in hair
follicles, and containing a collection of purulent material. A carbuncle involves multiple hair
follicles and may be associated with fever and malaise. The majority are caused by Staph
aureus.
Treatment
Warm compresses promote drainage and are usually sufficient for small boils. Large
abscesses require incision and drainage; antibiotics are not required unless there are multiple
lesions or systemic symptoms.
If antibiotics required, use:
Dicloxacillin 500mg orally four times daily for 5-10 days
or
Cephalexin 500mg orally four times a day (or 500mg twice a day) for 5-10 days
If MSRA is suspected use:
Clindamycin 300 to 450mg orally three to four times daily for 5-10 days
or
Trimethoprim-sulfamethoxazole 1 to 2 DS tablets orally twice daily for 5-10 days
or
Doxycycline 100mg orally twice daily for 5-10 days
For repeated episodes, consider intranasal (and possibly under the fingernails) mupirocin
(Bactoban) twice a day for 5 days to eliminate Staph Aureus colonization.
March 2016
Page 2
Skin Infections
TG 635
2.3
Cellulitis
Cellulitis is non-localized infection of the skin and connective tissue. It is usually caused by
Beta-Hemolytic Strep (Groups A, B, C, G and F) or Staph aureus (including methicillinresistant strains). Cellulitis presents as a warm, erythematous, tender areas of skin, often
associated with regional lymphadenopathy. The lower extremities are the most common site.
Signs of systemic toxicity such as fever, malaise and nausea may be present. Cellulitis must be
closely monitored (observed daily by the PCMO) until a clear response to treatment is seen.
IV therapy is appropriate when fever or systemic symptoms are present.
Purulent cellulitis (associated with purulent drainage or exudate, in the absence of a
drainable abscess) should be managed with empiric therapy for infection with MRSA.
Treatment of purulent cellulitis
______________________________________________________________________________________________
_________
Elevation of the affected area facilitates gravity drainage of edema and inflammatory
substances.
Clindamycin 300 to 450 mg orally three to four times daily for 5-7 days
Trimethoprim-sulfamethoxazole one to two DS tablets orally twice a day for 5-7 days
Doxycycline 100 mg orally twice daily for 5-7 days
(Treatment may be extended for up to 14 days. More severe infections require IV
therapy)
______________________________________________________________________________________________
March 2016
Page 3
Skin Infections
TG 635
Amoxicillin 500 my orally three times daily with Doxycycline 100 mg orally twice daily for
5 7 days
(Treatment may be extended for up to 14 days. More severe infections require IV
therapy)
2.4
Bites
Clean all bite wounds promptly and thoroughly with soap and water.
Human bites commonly become infected with staph aureus, strep or oral anaerobes. Cat
and dog bites may also transmit Pasturella multocida. Prophylactic antibiotics should be
given within 12 hours of a bite to prevent infection.
Check immunization records to confirm that the Volunteer had a tetanus booster within
the past 5 years.
X-ray the finger, hand, etc. if a deformity is present to rule out a fracture (increased risk of
osteomyelitis.) Contact RMO or OHS if a fracture is seen.
Anti-rabies treatment may be indicated for dog, cat, bat, and many terrestrial mammal
bites which occur in rabies-endemic areas. Refer to Technical Guideline 300
Immunization. Rodent bites (e.g., squirrels, rats, mice, rabbits or hares) do not normally
require anti-rabies treatment.
SPECIAL NOTE: Bites from several species of Asian monkeys may transmit Herpes B
virus (formerly referred to as Herpesvirus simiae) which produces a progressive,
sometimes fatal infection in humans ultimately involving the nervous system.
Monkeys who are the natural hosts of the Herpes B virus are all members of the Macaca
genus, which includes rhesus monkeys and pigtail macaques. Captive monkey
populations have a 30-100% rate of infection. Herpes B virus produces a mild disease in
these species, which is similar to herpes simplex in humans.
African or New World monkeys may become infected if they are in close contact with
infected monkeys; however, this is unlikely in wild or domestic monkeys outside of Asia.
In addition, monkeys other than those of the Macaca genus rapidly become ill after
infection and so rarely transmit the virus.
Cleaning the wound within 5 minutes for at least 15 minutes decreases the likelihood of
herpes B virus. Consult OHS for monkey bites occurring in Asia or from monkeys which
are in close proximity to Asian monkeys (zoos, laboratories). Prophylaxis treatment with
acyclovir or valacylovir should be considered. In addition, provide antibiotic treatment for
all monkey bites as described below.
March 2016
Page 4
Skin Infections
TG 635
3. SCABIES
Scabies is a common skin infestation caused by Sarcoptes scabei, a virtually invisible mite which is
transferred by close or skin-to-skin contact, often, but not necessarily sexual contact.
Scabies is characterized by dozens to hundreds of tiny, punctate excoriations, and nodules and a
few superficial burrows. Interdigital areas, the penis and scrotum, umbilical and pubic regions,
ankles, and breasts are the classic sites of involvement. Inflammatory nodules on both the penis and
scrotum may occur in males and on the areola in females.
Mites survive for only 2-3 days when separated from the host. Close physical contact is the primary
mode of transmission. Contaminated clothing or bedding may also cause infections.
The diagnosis of scabies is based on the clinical presentation and can be confirmed by scraping
burrows (short elongated wavy papules often found on the webs of the fingers) with a No. 15 blade
and applying the scrapings to a glass slide along with drops of oil or water. When the preparation is
examined under a low-power microscope, intact mites, eggs, or waste material may be seen.
Clothes and bedding should be washed in hot water and close (intimate) contacts treated to prevent
reinfection.
Treatment of scabies
Permethrin 5% cream
After an evening shower or bath, apply the cream to the entire body from the neck down
(including perineum.) Wash the cream off the next day (8-14 hours later.) One 60 gm tube
should treat 1-2 persons. Treat close physical contacts. A second treatment 1-2 weeks later
may be considered.
Itching may continue for one to two weeks following successful treatment due to the hypersensitivity
reaction to mites, feces and eggs. Antihistamines can help control the itching. Symptoms should
progressively improve. If symptoms worsen despite adequate treatment, consider re-exposure.
4. PEDICULOSIS (LICE)
Lice infest three main areas of the body; the scalp, the pubic region, and the trunk. Infestations of
these areas have the following differentiating characteristics:
March 2016
Page 5
Skin Infections
TG 635
Examination reveals adult lice in the hair with nits attached to hair shafts.
Head lice can easily be spread by casual head to head contact and by objects such as shared
combs or hats.
Pubic lice infest the pubic region and sometimes the axilla or eyelashes.
Commonly associated with poor hygiene and causes diffuse erythematous macules, wheals, and
excoriations, often with secondary bacterial infection (e.g., impetigo, cellulitis.)
The lice usually reside on clothing and only come onto the skin to feed.
Trench fever, relapsing fever, and typhus are transmitted by the body louse in endemic areas.
Treatment of Pediculosis
Medication
Permethrin 1% cream/liquid
Apply to the effected areas for 10 minutes and then wash off. Retreatment in 7 10 days
may be necessary.
or
Lindane shampoo/lotion 1% (is no longer recommended as first line treatment due to
neurologic toxicity. Use only for treatment failures or inability to tolerate other
therapies.)
Apply to affected areas, wash off after 4 minutes. Do not retreat.
Remove nits with a fine-toothed comb
Environmental
Capitis All hats, brushes, towels, linens or other items in contact with the infected person
should be washed in hot water or placed in a plastic bag for two weeks to prevent reinfestation.
Corporis All infested clothes, bedding and towels should be washed in hot water or placed in
a plastic bag for two weeks. With continued good hygiene, medication may not be necessary.
March 2016
Page 6
Skin Infections
TG 635
Pubis All clothes, bedding and towels should be washed in hot water or placed in a plastic
bag for two weeks. Recent sexual partners should also be treated.
Produces scaling, erythematous rash with raised borders and central clearing.
Produces an erythematous, pruritic rash with raised borders on perineum and upper, inner
thighs; scrotum is usually spared.
Produces pruritic, scaly soles, painful fissures between the toes, and occasionally vesicular
dermatitis of the instep of the sole.
Primarily a disorder of children. Produces irregular or round eczematous areas on the scalp
which may have hair loss or broken hairs. Must be treated with systemic antifungalscontact OMS if suspected in a Volunteer.
5.1
Diagnosis of tinea
Diagnosis can often be made clinically.
March 2016
Page 7
Skin Infections
TG 635
For confirmation or in uncertain cases, obtain skin scrapings by scraping the edge of the rash
with a scalpel blade.
5.2
Dissolve scrapings or hair in 10% potassium hydroxide solution (KOH test) and examine
under a microscope for hyphae or spores.
Clinical presentation
The rash usually affects the trunk, neck, proximal extremities. The face, scalp and genitalia are less
commonly involved. It consists of small hypo or hyper pigmented patches that coalesce as they
enlarge.
Office of Health Services
March 2016
Page 8
Skin Infections
TG 635
Although tinea versicolor can be mildly itchy, it mainly presents a cosmetic problem.
Diagnosis
The presentation is distinctive and the diagnosis is often made clinically. A KOH preparation of the
scales shows both hyphae and budding yeast. See section 5.1. Woods lamp will only be positive in
approximately one third of the cases
Treatment of pityriasis versicolor
Selenium sulfide 2.5% (Selsun) lotion or shampoo
Apply undiluted to affected skin for ten minutes then wash off. Repeat for 7 - 14 consecutive days.
Monthly application may prevent recurrence.
Inform the Volunteer that it will take 2 - 3 months before the lesions regain the same color as the
surrounding skin.
REFERENCES
UpToDate:
March 2016
Page 9
Peace Corps
Technical Guideline 645
PULMONARY TUBERCULOSIS
1. PURPOSE
To provide basic information concerning tuberculosis screening, preventative therapy for
dormant infections, and the diagnosis and treatment of active pulmonary tuberculosis as they
relate to Volunteers serving overseas.
2. BACKGROUND
Tuberculosis is an infection caused by the acid fast bacillus Mycobacterium tuberculosis.
The term tuberculosis infection is often used to refer to inactive infection, and the term
tuberculosis disease to refer to active pulmonary or extrapulmonary TB (see below.)
Distribution
Tuberculosis is present worldwide. All Volunteers are considered to be at risk of exposure,
particularly as tuberculosis is endemic in many Peace Corps countries.
In most developing countries it is estimated that the rate of new TB infections ranges from
1%-2.5% per year. This rate refers to the risk of an uninfected person becoming infected
the majority of infections are asymptomatic as described below. Overall, about one third of
the population of the world is infected with tuberculosis.
The immunosupression associated with HIV infection has led to a worldwide increase in
tuberculosis. TB is a leading cause of death in adults throughout the world, and is the most
common cause of death due to an infectious agent worldwide.
Pathophysiology
There are two categories of infection, inactive (dormant or latent TB) and active TB.
Inactive tuberculosis
Initial TB infection involves the pulmonary macrophages, regional lymph nodes, and
hematogenous spread to many organs including the apices of the lungs. After 2 to 10
weeks, the hosts immune response halts infection and inactive (latent) infection
results.
A positive tuberculin skin test is often the only indication of TB infection at this
stage. Persons with reduced immunity may not show a positive reaction despite
infection. Active TB is one cause of a decreased immune response to tuberculin skin
testing (see below.)
May 2005
Page 1
Pulmonary Tuberculosis
TG 645
Most persons will not show x-ray evidence of initial infection of the alveoli and
regional lymph nodes or of hematogenous spread to the lung apices or other organs.
Calcified granuloma may be seen on the chest x-ray in inactive TB. Viable bacilli are
often present in these foci.
In most cases, the mycobacteria are controlled by the bodys defenses and the patient
does not develop symptoms. TB infection may remain inactive for the life of the
patient or may reactivate when the patients immunity is reduced (e.g., old age, HIV
infection, malnutrition, use of steroid drugs).
More often, TB infection remains dormant for months or years, and reactivates in
about 10% of those infected. The risk of reactivation is highest in the first two years.
In adults, about 85% of TB disease occurs in the upper parts of the lungs and about
15% is extrapulmonary. After reactivation of pulmonary TB, infection may spread to
the bronchi, larynx, and other regions of the lungs as drainage develops from infected
areas.
Tuberculosis has become resistant to many antibiotics and multi-resistant strains are
emerging. Treatment of active cases of tuberculosis involves the use of three or four
antibiotics for prolonged periods.
Transmission
Tuberculosis is spread primarily by airborne droplets expelled during coughing or sneezing
by a person with untreated pulmonary or laryngeal tuberculosis. Infectious droplets may
remain suspended in the air for several hours.
Close contacts of persons with undiagnosed and/or untreated pulmonary tuberculosis are
at high risk of being infected. Close contacts are those living in the same household,
close friends or fellow workers. About 29% of close contacts become infected.
May 2005
Page 2
Pulmonary Tuberculosis
TG 645
Infectiousness varies depending on the duration and intensity of exposure. Persons in the
same household, especially those sharing a bedroom, are at highest risk of infection. See
table, below.
New infection can usually be detected by tuberculin skin testing six weeks following the
initial exposure.
are coughing, or
are undergoing cough-inducing procedures, or
have sputum smears positive for AFB
AND they
Patients are not considered infectious if they meet all of these criteria:
have received adequate therapy for 2-3 weeks,
have a favorable clinical response to therapy, and
3 consecutive sputum smears on different days are negative for AFB
3. PREVENTION
Transmission of infection is through contact with active cases and can be reduced by:
Identifying and treating the close contacts of a person with active disease.
Avoiding face-to-face contact with persons suspected of having active TB and who are
coughing.
High levels of hygiene such as washing hands and utensils, sterile spirometry equipment,
etc.
Peace Corps applicants are tested prior to service to establish a baseline TB skin test
measurement , i.e., size of reaction, if any, in mm. Applicants with evidence of TB
infection will be evaluated to rule out active disease and be considered for preventive
therapy as per CDC guidelines (see section 5.)
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All Volunteers are screened for TB at Close of Service (COS). Volunteers are also
screened at mid-service, if clinically indicated. Use of multiple-puncture techniques
(Tine tests) and/or self-reporting of reactions by Volunteers is allowed only at midservice and only when unable to observe Volunteers 48-72 hours after testing. See
section 4.2.
Volunteers who were identified TB skin test positive during the pre-service screening
in the U.S. should not be tested at the mid-service health evaluation or at COS. Routine
chest x-rays are not necessary as long as they remain asymptomatic.
Volunteers reporting symptoms suspicious of TB or who have had close contact with a
person who has active TB must be TB skin tested.
Some Volunteers may have had BCG vaccination in their past. It is OMS policy to
disregard a history of BCG vaccination when interpreting TB skin test results if the
BCG was performed more than five years prior to the TB test. If a Volunteer has had a
BCG vaccine within 5 years of the TB skin test, PCMOs should consult OMS for
guidance on test interpretation.
4.1
4.2
The Mantoux test (intradermal test) is required to accurately measure the size of the
TB skin test reaction. It must be administered and measured by the PCMO or other
trained provider. The Mantoux test is required at COS and is strongly encouraged
at mid-service, however multiple puncture testing may be done at mid-service if
unable to arrange for direct observation of the Mantoux test.
The injection should be made with a disposable tuberculin syringe, inserted just
beneath the surface of the skin on the volar (inner) aspect of the forearm. The
injection is made with the needle bevel facing upward to produce a discrete, pale
elevation of the skin (a wheal) 6 mm to 10 mm in diameter. Do not compress the
wheal. Deeper injection (into the subcutaneous tissues) will produce false negative
test results.
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The Mantoux test is read 48 to 72 hours after the injection. The reading should be
based on measurement of induration (hardness), not erythema (redness). The
diameter of induration should be measured across the long axis of the forearm and
must be recorded in millimeters.
The preferred method of reading a Mantoux test is to use a ball-point pen placed
about an inch from the center of the injection site. Draw a line toward the center,
stopping when the tip of the pen reaches an area of resistance (which indicates
induration.) Continue drawing lines from all quadrants towards the center.
Measure the longest axis of induration and record in the health record. See below.
Measure
longest
axis
Injection
site
Volunteers must not be expected to read the Mantoux test. Only PCMO-observed
test results are acceptable. If it is necessary to screen for TB using the Tine test (at
mid-service only), follow the recommendations listed below.
If a Volunteer fails to return within 72 hours but does return within 7 days and has a
positive test (see flowchart), the test result can be accepted and documented in the
health record. Negative test results obtained more than 72 hours after injection
must be repeated.
Document the result of the skin test in millimeters in the progress notes in the
Volunteer health record. It is insufficient to simply indicate a positive or
negative test result.
To increase the sensitivity of the Tine test when read by the Volunteer, the
following criteria should be used:
Check the test site daily. Report ANY redness, swelling, or firmness that is present
after 48-72 hours to the PCMO. The size of the reaction is not important. ANY
REACTION PRESENT AFTER 48-72 HOURS IS SIGNIFICANT and may mean
that infection with TB is present.
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Any reaction reported by the Volunteer must be follow up by Mantoux testing and
reading by the PCMO or other health provider. PCMOs are strongly encouraged to
become proficient in TB skin testing and to avoid allowing testing by other
providers unless they can demonstrate expertise in both applying and measuring the
test.
In areas where TB is highly endemic and where mid-service testing using the
Mantoux test is not feasible, it is reasonable to perform a Mantoux test on
Volunteers who are in the capital for other reasons and who havent had a Mantoux
test in at least 6 months. This will permit Mantoux testing of many Volunteers in
addition to Tine testing of all Volunteers at mid-service. IST events may provide
another opportunity to perform Mantoux testing.
4.3
For example, Mantoux testing may be repeated to confirm a positive test performed
by another provider or to recheck a test which was difficult to read.
Volunteers who were vaccinated with BCG in the past should be TB skin tested
and, if positive, treated with preventive therapy (following the protocol described in
section 5.)
EXAMPLE 2:
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EXAMPLE 3:
For Volunteers serving overseas, the TB skin test is considered positive if the interval
change in induration is:
5 mm and the Volunteer is in any of the following high risk groups:
10 mm and the Volunteer in the high risk groups listed above or any of the following high
risk groups:
Recent arrivals from high-prevalence countries
Injection drug users
Residents and employees of high-risk congregate settings, e.g., correctional
facilities, nursing homes, homeless shelters, hospitals
Mycobacteriology laboratory personnel
Persons with clinical conditions that make them high risk, e.g., substance
abuse, diabetes, etc. See Table A, Section 5.1 below.
15 mm
All Volunteers
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Measure area of
induration, if any
0-4 mm increase?
Symptoms of TB
present?
OR
Close contact of
active case?
YES
10 mm increase?
5-9 mm increase?
TB infection
unlikely
Obtain CXR
Consult OMS
YES
TB infection likely
TB infection
unlikely
Consider:
Retest in 3 months
(close contacts)
Inactive TB
recent converter
TB Preventive Therapy
indicated
(see Section 5)
May 2005
Active Tuberculosis
Consult OMS
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5. TB PREVENTIVE THERAPY
Preventive therapy with isoniazid (INH) greatly reduces the risk of developing active
disease. Persons determined to be at risk of developing active TB are candidates for
preventive therapy regardless of age.
Prior to Peace Corps service, applicants are required to have a TB skin test. Those who
qualify for TB preventive therapy as defined by the CDC/American Thoracic Society are
required to start therapy prior to service.
5.1
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Table A
Table B
HIV infection
The elderly
Diabetes
Silicosis
Prolonged corticosteroid therapy
Other immunosupressive therapy
5.2
5.3
have a history of previous INH associated hepatic injury or other adverse reaction
have acute or active liver disease
currently are abusing alcohol or injecting drugs (provide close monitoring)
have or are at risk for peripheral neuropathy
are pregnant (generally delay INH until after delivery)
are likely to be infected with INH-resistant M. tuberculosis
are highly unlikely to complete therapy (e.g., some homeless persons)
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Begin treatment with INH 300 mg daily for at least 9 months (12 months if
immunosupressed). Nine months of INH is more effective than 6 months. The
Office of Medical Services recommends that 9 months of therapy be used wherever
possible. Medical Officers should consult OMS if a Volunteer is unable to
complete 9 months of therapy.
Pyridoxine 25mg daily (vitamin B6) should be given to reduce the risk of peripheral
neuropathy
** INH should not be started if monthly follow up by telephone or, when necessary, by
an office visit and liver enzyme monitoring is not possible. For example, an
asymptomatic Volunteer who is found to be TB skin test positive at COS and who
plans on traveling in developing countries for several months should not be started
on INH until after return to the U.S.
5.4
Signs consistent with liver damage such as loss of appetite, nausea, vomiting,
persistent dark urine, yellowish skin, malaise, or unexplained elevated temperature
of greater than 3 days duration and abdominal tenderness (especially right upper
quadrant).
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YES
Able to provide 9
months of follow-up?
(see text)
NO
Consult OMS
YES
6. ACTIVE TUBERCULOSIS
Initiate multi-drug regimen for initial control after consultation with OMS.
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Initiate a contact investigation. Identify the Volunteers close contacts and inform them
that they should be tested for TB. If close contacts are Volunteers, skin test them, if they
have positive skin tests treat them as converters. Notify local authorities, if appropriate.
Non compliance is a major problem as drug resistance may develop if medications are
not taken consistently and for a long enough period of time. Assess compliance of the
PCV, and count pills regularly. (See attached TB Medication Monthly Symptom
Checklist.) Follow-up missed appointments.
History of exposure to persons with potentially active TB, such as working in a hospital, a
household contact or close friend known to have TB, known cases occurring at work such as a
school.
Symptoms include anorexia, easy fatigability, weight loss, chilly sensations, afternoon remittent
fever, productive prolonged cough, bloody sputum and night sweats.
Objective:
Physical findings are not specific. Auscultation of the lungs may appear normal.
Perform Mantoux skin test. The PCMO must read this result personally. (The skin test may be
negative in a person with active TB disease.)
Obtain a series of 3 early morning sputum specimens (see obtaining a sputum specimen) for acidfast bacilli (AFB) stain and TB culture. This is the most definitive diagnostic test!
Culture results normally take 2 weeks if broth media is used and 3 to 6 weeks for conventional
solid media. AFB smear results are available quickly. Request drug susceptibility tests for culture
if available. WHO labs with trained personnel may be available in-country.
Assessment:
Consult OMS for a differential diagnosis. If sputum smear is AFB negative it may need to be
repeated. Abnormalities on chest x-rays are suggestive of, but are never diagnostic for,
tuberculosis. Definitive diagnosis may require medical evacuation to a more advanced facility.
Respiratory precautions are necessary when TB is strongly suspected. AFB smear positive
patients are the most infectious, and should generally complete 14 days of treatment with several
drugs and be AFB smear negative before travel is considered.
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SPUTUM SAMPLE COLLECTION
Breathe deeply three times (you should have a tickling feeling at the end of
a very deep breath).
After the third breath, cough hard and try to bring up sputum from deep in
the lungs.
Expectorate the sputum into a sterile container, collecting at least one
teaspoonful.
REFERENCES
May 2005
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TG 645 ATTACHMENT A
occasionally
rarely
not at all
1.
Loss of appetite
Y/N ____
2.
Nausea
Y/N ____
3.
Vomiting
Y/N ____
4.
Malaise
Y/N ____
5.
Dizziness
Y/N ____
6.
Headaches
Y/N ____
7.
Yellow eyes
Y/N ____
8.
Y/N ____
9.
Dark urine
Y/N ____
Y/N ____
Y/N ____
____/____/_____