902 KAR 2:090. Tuberculosis detection, prevention, and control.
RELATES TO: KRS 211.180(1)(a), (c), 214.034(2), 215.520(1), (2), (4), (5), (8), (9), 215.560
STATUTORY AUTHORITY: KRS 194A.050, 211.180(1)(a), (c), 214.034(2), 215.520(1), (2), (4), (5), (8), (9), 215.560
NECESSITY, FUNCTION, AND CONFORMITY: KRS 215.520 authorizes the Cabinet for Health Services to discharge all duties relating to all matters of tuberculosis control, including: (1) clinical services for either recalcitrant or drug resistant persons with active tuberculosis; (2) the facilitation of tuberculosis programs in cooperation with the Department of Education; (3) the appraisal and provision of services for persons with tuberculosis; and (4) provision of direct assistance to local health departments, and other organizations to assist them in education, prevention, and treatment programs of tuberculosis control. KRS 215.520(2) requires the Cabinet for Health Services to promulgate administrative regulations to implement statutes governing tuberculosis. KRS 211.180(1)(a) requires the Cabinet for Health Services to implement a statewide program for the detection, prevention, and control of communicable diseases. KRS 214.034(2) permits a local health department, with the approval of the Department of Public Health, to require tuberculosis testing of a first-time enrollee in a public or private school within the jurisdiction of the local health department. This administrative regulation establishes: (1) requirements, forms, and procedures for the testing of school children for tuberculosis by a local health department; and (2) testing and treatment of persons diagnosed with tuberculosis.
Section 1. Definitions. (1) "Active tuberculosis" is defined by KRS 215.511(1).
(2) "Child" means an individual under eighteen (18) years of age.
(3) "Exception patient" means an individual with tuberculosis who has been identified by a local health department with jurisdiction as an individual in exceptional or infrequent circumstances.
(4) "Exceptional or infrequent circumstances" means:
(a) Short-term hospitalization is required for:
1. Invasive diagnostic procedures;
2. Respiratory isolation;
3. Management of drug-resistant disease; or
4. Other circumstances that a cabinet physician has determined require hospitalization to detect, prevent, or control tuberculosis; or
(b) Pursuant to KRS 215.560, security measures are required.
(5) "First-time enrollee" means a child who:
(a) Has never attended school in Kentucky; and
(b) Is entering private of public school, entry level through 12th grade, for the first time.
(6) "Isolates" is defined by KRS 215.511(2).
(7) "Tuberculin skin test" means the intradermal injection of five (5) tuberculin units of Purified Protein Derivative (PPD) by the Mantoux technique.
Section 2. Except as provided by KRS 214.036(2), the provisions of this administrative regulation shall not apply to children exempted by KRS 214.036(2).
Section 3. (1) A reaction to a tuberculin skin test shall be interpreted in accordance with "Treatment of Tuberculosis and Tuberculosis Infection in Adults and Children".
(2) If the skin test of a child indicates that treatment is needed, the child shall be treated in accordance with "Treatment of Tuberculosis Infection in Adults and Children".
Section 4. (1) The department shall authorize a local health department to test first time enrollees in a school within its jurisdiction, if it submits to the department the documentation specified by subsection (2) of this section.
(2) Required documentation.
(a) Documentation of continued transmission of at least two (2) years duration of a multidrug resistance pattern, or more virulent strain, of Mycobacterium tuberculosis; or
(b) Laboratory analysis that documents transmission, whether in consecutive or nonconsecutive years, of a multidrug resistance pattern, or more virulent strain of Mycobacterium tuberculosis; or
(c) A documented outbreak of at least two (2) years duration:
1. With multifamily involvement each year that resulted in at least five (5) cases of tuberculosis per year; and
2. Is two (2) times greater than the national tuberculosis rate per 100,000 population; or
(d) Documentation of a tuberculosis rate per 100,000 that is two (2) times greater than the national tuberculosis rate in each of the last five (5) years.
(3)(a) A local health department that has been authorized by the Department for Public Health to conduct tuberculin testing of first-time school enrollees may continue to test for an additional year.
(b) If a local health department has submitted documentation that the tuberculin reactor rate in the additional year was at least two (2) times greater than the reactor rate in the previous year, the department shall approve an additional year of testing.
(4) If a local health department has been authorized by the Department for Public Health to conduct tuberculin testing of first-time school enrollees:
(a) The local health department shall notify, in writing, the parent or guardian of a first-time enrollee that a tuberculin skin test is required;
(b) Except as provided by paragraph (c) of this subsection, a first-time enrollee shall be tested for tuberculosis by tuberculin skin test within eighteen (18) months prior to entering school by a licensed or certified health professional authorized to administer the test.
(c) A first-time enrollee who had been tested for tuberculosis by a tuberculin skin test within eighteen (18) months prior to his entering school shall not be required to be retested, if a "Tuberculin Skin Test Certificate", dated and signed by the physician, advanced registered nurse practitioner, or authorized representative of the local health department that administered the test, has been submitted to the local health department with jurisdiction.
(d) If a physician certifies in writing that tuberculin skin testing is medically contraindicated, an enrollee shall receive a chest x-ray, unless documentation is provided of a completed course of prophylaxis or multiple drug treatment for previously diagnosed tuberculosis infection or disease in accordance with "Treatment of Tuberculosis and Tuberculosis Infection in Adults and Children".
(e)1. If an enrollee has not been tested prior to entering school, he shall be permitted to attend class for a period not to exceed thirty (30) days.
2. Before the expiration of thirty (30) days from entering school, proof of having been tested for tuberculosis pursuant to the provisions of this subsection shall be submitted to the local health department with jurisdiction.
3. If the proof required by this subsection is not submitted within thirty (30) days of entering school, the enrollee shall not be permitted to attend school until proof is submitted to the local health department with jurisdiction.
(f) The "Tuberculin Skin Test Certificate" shall include the following information:
1. Complete name of student;
2. Birthdate of student;
3. Address of student;
4. Date test given to student;
5. Type of test;
6. Millimeters of induration at forty-eight (48) hours to seventy-two (72) hours posttesting;
7. Date read;
8. Name of licensed or certified health professional who read the test; and
9. If the provisions of paragraph (c) of this subsection are applicable, the date an x-ray was taken.
(g) A copy of a enrollee’s "Tuberculin Skin Test Certificate" shall be transmitted by the local health department with jurisdiction to the enrollee’s school.
Section 5. Drug Susceptibility Testing. Drug susceptibility testing shall be conducted to determine the efficacy of prescribed drug therapy for a person with active tuberculosis as provided by this section.
(1) Drug susceptibility testing of initial isolates from clinical specimens obtained from a patient with active tuberculosis shall be performed by a:
1. Licensed pursuant to KRS 333.030; or
2. Exempted from licensure by KRS 333.040; and
3. Qualified to perform drug susceptibility testing for Mycobacterium tuberculosis; or
(b) The Division of Laboratory Services of the Kentucky Department for Public Health.
(2)(a) Repeat drug susceptibility testing of a specimen ordered by a physician from a patient who has continued to produce specimens that are culture positive for tuberculosis after three (3) months of treatment shall be made on the latest isolate obtained from the patient.
(b) Testing conducted pursuant to the provisions of this section shall be performed by a laboratory specified by paragraphs (c) and (d) of this section.
(c) A laboratory:
1. Licensed pursuant to KRS 333.030; or
2. Exempted from licensure by KRS 333.040; and
3. Qualified to perform drug susceptibility testing for Mycobacterium tuberculosis.
(d) The Division of Laboratory Services of the Kentucky Department for Public Health.
Section 6. (1) Within seventy-two (72) hours of the hospitalization of an exception patient, a local health department shall interview an exception patient to determine if the patient is covered by health insurance, including Medicaid.
(2) If the patient is without health coverage, the local health department shall:
(a) Request the Cabinet for Families and Children to evaluate the patient for Medicaid eligibility; and
(b) Assist the Cabinet for Families and Children in efforts to obtain health coverage.
(3) If an exception patient is not covered by health insurance, and is not eligible for health care insurance, reimbursement for tuberculosis inpatient services for the patient shall be made to the provider by the Cabinet for Health Services through the local health department at:
(a) The Medicaid per diem rate; or
(b) Other rate, if approved in advance by the Cabinet for Health Services.
(4) Reimbursement for tuberculosis inpatient services, or for voluntary placement in a half-way house, for an exception patient shall be made by time-limited payment through a contract or memorandum of understanding between the local health department and the admitting facility if the admitting assess a charge.
Section 7. Incorporation by Reference. (1) The following material is incorporated by reference in this administrative regulation:
(a) "Treatment of Tuberculosis and Tuberculosis Infection in Adults and Children (1994)", American Lung Association; and
(b) "Tuberculin Skin Test Certificate, 12/98", Form EPID 391A.
(2) Material incorporated by reference may be inspected, copied, or obtained at the Office of the Commissioner, Department for Public Health, 275 East Main Street, Frankfort, Kentucky, 40621, 8 a.m. through 4:30 p.m., Monday through Friday. (10 Ky.R. 258; eff. 8-3-83; Am. 12 Ky.R. 55; eff. 8-13-85; 16 Ky.R. 669; eff. 11-29-89; 21 Ky.R. 577; eff. 9-21-94; 23 Ky.R. 1463; 2190; 2522; eff. 11-20-96; 25 Ky.R. 620; 1619; eff. 1-19-99.)