The Division of Global Populations and Infectious Disease Prevention, Bureau of Infectious Disease and Laboratory Sciences, updated its purified protein derivative (PPD) distribution policy in 2014 based on review of health care access. Since then, insurance coverage without co-pays has been mandated for persons at risk for tuberculosis (TB) infection. We strongly encourage third-party billing for tuberculosis (TB) testing by PPD or interferon-gamma release assay (IGRA) in health care settings. Health care providers should directly procure PPD for their insured patients.
Our goal is to align distribution of publicly-purchased PPD with public health priorities. Therefore, the Division has established an ordered set of priorities for TB testing with state-supplied PPD.
Priorities for DPH-purchased PPD include (in order):
- Individuals identified as contacts to a person with infectious TB (contact investigations)
- Newly arrived individuals with TB-related conditions identified during overseas medical examinations (Class A/B TB)
- Staff and guests of homeless shelters tested in the context of TB outbreak investigation and control
- Children with TB risk (as identified through DPH-approved TB Risk Assessment) for whom delays in primary care access would preclude timely school entry
- Uninsured individuals at high risk for TB infection and disease
Additional information on priority populations and situations
Contact investigations: Contact investigations are conducted under the direction of local health departments and in coordination with DPH tuberculosis response teams. Contacts may be at high risk for infection and progression to disease.
Class A/B TB: Immigrants with TB conditions identified overseas require additional testing and evaluation for TB within 30 days of arrival in Massachusetts. Local public health nurses are the point of contact for TB testing and link new arrivals with TB clinics. The DPH Division of Global Populations and Infectious Disease Prevention tracks testing and evaluation outcomes for these persons.
Homeless shelters: Routine testing of shelter guests is recommended only for those shelters that have or have recently had an outbreak situation and those that house persons at high risk for TB. Baseline and annual testing of shelter staff who have direct contact with clients is also recommended in these shelters. DPH will review requests for PPD based on epidemiology and proposed protocol for testing. Baseline and annual testing of volunteers who have direct contact with clients in shelters of concern, as outlined above, is best managed through primary care.
Children with TB risk needing school-entry testing: DPH recommends linking children with a primary care provider for the immunizations, TB testing, and physical examination required for school entry and for ongoing care. Some local public health or school nurses have the capacity to vaccinate and administer and read TSTs at the time of school registration. DPH will provide PPD for this purpose only in those cases where a primary care appointment cannot be arranged in a timely manner and delays would preclude school entry. Approval will be based on a review of existing practice and protocol for testing.
Uninsured individuals at high risk for TB infection and disease: Community health centers and other primary care providers may identify uninsured patients at high risk for TB infection and for whom an appropriate plan for treatment is established. DPH will provide PPD for testing uninsured high-risk individuals, should product availability be adequate. Approval will be based on a review of epidemiology and protocol for testing and treatment.
Local health departments and other sites that receive PPD from DPH will be required to follow DPH standards and reporting associated with PPD ordering, inventory management, distribution, and usage. Manufacturing or distribution interruptions may further limit distribution of DPH-supplied PPD.
For more information about ordering PPD, contact the Division of Global Populations and Infectious Disease Prevention at firstname.lastname@example.org
Two formulations of PPD are available for skin testing: Tubersol (Sanofi Pasteur), which is the preferred product used by MDPH, and Aplisol (JHP Pharmaceuticals). PPD can be ordered through medical suppliers.
Two IGRA tests are FDA-approved for use in the United States: QuantiFERON-TB® Gold In-Tube (QFT-G) and T-SPOT.TB®.
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