Screening for tuberculosis (TB) in institutional settings usually involves testing for latent tuberculosis infection (LTBI) and additional evaluation of those who are infected. In some correctional facilities, it may be more practical to screen with chest x-rays to identify individuals with lung abnormalities suggestive of pulmonary tuberculosis. While the chest x-ray method is more expensive, it can be an acceptable technique to identify and segregate tuberculosis suspects; however, use of the chest x-ray screening method on intake is to be followed by testing for latent TB infection within 14 days.
  (1) Tuberculin skin test.
    (A) The tuberculin skin test utilizing purified protein derivative (PPD) is the standard method of identifying persons infected with Mycobacterium tuberculosis, the causative agent of TB. The intradermal Mantoux PPD test, not a multiple puncture test, shall be used to detect latent tuberculosis infection.
    (B) The Mantoux PPD test is the only type of testing material that is supplied by the Texas Department of Health (department).
  (2) Administration of tests.
    (A) The Mantoux PPD test can be applied by anyone properly trained in tuberculin skin testing procedures including applying, reading, and interpretation.
    (B) Unlicensed personnel should be supervised by licensed health care workers according to the requirements of the Board of Medical Examiners and Board of Nurse Examiners in conformity with the Texas Medical Practice Act and the Nurse Practice Act, §218.11, and other applicable laws.
  (3) Interpretation of tests for latent tuberculosis infection.
    (A) The Mantoux PPD test shall be read 48 to 72 hours after injection. However, if the person is not available for the scheduled reading, positive reactions may still be measurable up to one week after testing. The reading shall be based on measurement of induration (palpable swelling), not erythema (redness). The diameter of induration shall be measured transversely to the long axis of the forearm and recorded in millimeters.
    (B) A reaction of 5 mm or greater shall be considered positive in persons who are human immunodeficiency virus (HIV) infected, who are recent contacts to TB cases, who have apical fibronodular infiltrates on chest x-rays consistent with prior tuberculosis, or persons with organ transplants and other immunosuppressed persons receiving the equivalent of 15 mg/d or greater of prednisone for 1 month or more. All other persons tested in a correctional facility will be considered positive if their skin test reaction is 10 mm or greater.
    (C) Absence of a reaction to the tuberculin test does not exclude the diagnosis of TB or latent TB infection. Persons who have symptoms consistent with active tuberculosis shall be evaluated for disease even if they have a negative skin test.
    (D) The PPD test can be read by anyone properly trained in tuberculin skin testing procedures including applying and reading.
    (E) Positive tuberculin reactions in Bacillus Calmette-Guerin (BCG)-vaccinated persons usually indicate infection with TB. Such persons shall be evaluated for treatment of latent TB infection. Skin tests shall be interpreted without regard to a history of BCG vaccination.
  (4) Scope. Skin test screening for tuberculosis shall be performed on employees and volunteers as well as inmates of county jails and correctional facilities as follows.
    (A) Employees.
      (i) Employees who share the same air with inmates shall be screened at time of employment and at least annually thereafter according to this section unless the employee or volunteer is exempt as described in clauses (ii), (iii), or (iv) of this subparagraph. A certificate or similar document may be used to record results. The recommended certificate is located in §97.179 of this title (relating to the Tuberculosis Record).
      (ii) Employees with a history of a positive tuberculin skin test shall provide documentation of the test and any appropriate medical follow-up or a certificate signed by a physician or registered nurse. The documentation shall be included in the certificate or a similar document.
      (iii) Employees are exempt from screening if the screening conflicts with the tenets of an organized religion to which they belong.
      (iv) Employees may be exempt from screening if medically contraindicated based on an examination signed by a physician. The only valid contraindication is a documented history of severe reaction to a tuberculin skin test.
      (v) Employees with a history of negative skin tests who are close contacts to a known or suspected case of TB shall be skin tested after exposure. If the test is still negative, they shall be retested 90 days after break in contact with the known or suspected case of TB occurs.
    (B) Volunteers.
      (i) All volunteers who share the same air space with inmates on a regular basis (more than 30 hours per month) shall be screened prior to becoming a volunteer and at least annually thereafter according to this section unless the volunteer is exempt as described in clauses (ii), (iii), or (iv) of this subparagraph. A certificate or similar document may be used to record results. The recommended certificate is located in §97.179 of this title.
      (ii) Volunteers with a history of a positive tuberculin skin test shall provide documentation of the test and any appropriate medical follow-up or a certificate signed by a physician or registered nurse. The documentation shall be included in the certificate or a similar document.
      (iii) Volunteers are exempt from screening if the screening conflicts with the tenets of an organized religion to which they belong.
      (iv) Volunteers may be exempt from screening if medically contraindicated based on an examination signed by a physician. The only valid contraindication is a documented history of severe reaction to a tuberculin skin test.
      (v) Volunteers with a history of negative skin tests who are close contacts to a known or suspected case of TB shall be skin tested after exposure. If the test is still negative, they shall be retested 90 days after break in contact with the known or suspected case of TB occurs.
    (C) Inmates.
      (i) With the exception of those inmates who meet the criteria in clauses (iii), (iv) or (v) of this subparagraph, all inmates who reside (or are expected to reside) in the facility for seven days or longer shall be screened according to this section. A certificate or similar document may be used to document results. The recommended certificate is located in §97.179 of this title (relating to Tuberculosis Record).
      (ii) Every inmate shall have a screening test on or before the seventh day of incarceration and at least annually thereafter if the inmate is not known to be a previous positive reactor.
      (iii) Every inmate must have a screening test unless the inmate has documented results of at least one screening test during the previous 12-month period or documented history of a positive tuberculin skin test. An inmate with a history of a positive tuberculin skin test shall provide documentation of the test and any appropriate medical follow-up. The documentation shall be included in the certificate or a similar document.
      (iv) Inmates are exempt from screening if the screening conflicts with the tenets of an organized religion to which they belong.
      (v) Inmates may be exempt from screening if medically contraindicated based on an examination signed by a physician. The only valid contraindication is a documented history of severe reaction to a tuberculin skin test.
      (vi) Inmates with a history of negative skin tests who are close contacts to a known or suspected case of TB shall be skin tested after exposure. If the test is still negative, they shall be retested 90 days after break in contact with the known or suspected case of TB occurs.
  (5) X-ray screening programs.
    (A) Correctional facilities may elect to perform chest x-rays on inmates on intake instead of a skin test screening program; however, use of the chest x-ray screening method on intake is to be followed by testing for latent TB infection within 14 days.
    (B) If inmate chest x-rays screening is done on inmates, the requirement for skin test screening of staff and volunteers will remain in effect.
  (6) Frequency of screening tests.
    (A) Frequency. Annual (or more frequent) tuberculosis (TB) screening of employees, volunteers, or inmates is required. When a specific situation indicates an increased risk of transmission, more frequent TB screening is recommended.
    (B) Repeat tests. Employees or volunteers who have a verified record of a previous positive test for TB do not have to have repeat tests.

Source Note: The provisions of this §97.173 adopted to be effective May 16, 1994, 19 TexReg 3370; amended to be effective December 15, 1997, 22 TexReg 12056; amended to be effective April 1, 2004, 29 TexReg 3192