Tuberculosis (TB) Screening of Healthcare Workers (HCWs)

Tuberculin Shortage - April 30, 2013
MDH recommendations.

On this page:
Baseline TB Screening for HCWs
Serial TB Screening for HCWs
Special Situations:
HCW with a Newly-Identified Positive TST or TB Blood Test
HCWs with Written Documentation of a Previous Positive TST or TB Blood Test
HCWs with Verbal (Undocumented) History of a Previous Positive TST or TB Blood Test
HCWs with a Documented History of Previous Treatment for Latent TB Infection (LTBI) or Active TB Disease
HCWs with Signs or Symptoms of Active TB Disease
Pregnant HCWs
Conversions
HCWs with TST results between 5 and 9 mm of induration
Students
Volunteers
HCWs with previous history of severe adverse reaction to TST
HCWs who travel outside of the United States

Baseline TB Screening for HCWs

Baseline TB Screening Tool for HCWs (Word: 59KB/2 pages)

Baseline TB screening at the time of hire is required for all HCWs in Minnesota. Baseline TB screening consists of two components: (1) assessing for current symptoms of active TB disease, and (2) testing for the presence of infection with Mycobacterium tuberculosis by administering either a two-step TST or single TB blood test. An employee may begin working with patients after a negative TB symptom screen (i.e., no symptoms of active TB disease) and a negative TST (i.e., first step). The second TST may be performed after the HCW starts working with patients.

A HCW's history of BCG vaccination should be disregarded when administering and interpreting TST results.

All reports or copies of the TST or TB blood test and any chest radiographs and medical examinations conducted must be maintained in the employee's record.

Additional information about baseline TB screening can be found on pages 28-32 of "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005."

Serial TB Screening for HCWs

Serial TB testing, sometimes called annual or ongoing TB testing, refers to TB screening performed at regular intervals following baseline TB screening. Serial TB screening consists of two components: (1) assessing for current symptoms of active TB disease, and (2) testing for the presence of infection with Mycobacterium tuberculosis by administering either a TST or single TB blood test.

The need for and frequency of serial TB testing is based on the facility's TB risk classification:

Risk classification

Frequency

Low

Serial testing is not needed unless exposure occurs

Medium

Serial testing should be performed annually

Potential ongoing transmission

Consult with the Minnesota Department of Health TB Prevention and Control Program at 651-201-5414 regarding the frequency of testing under these circumstances

Special situations

HCW with a newly-identified positive TST or TB blood test result

These individuals should be assessed for current TB symptoms and risk factors for progression to active TB disease. In addition, they should receive a chest radiograph to exclude a diagnosis of active infectious TB disease before having direct patient contact. If the HCW is diagnosed with latent TB infection (LTBI), treatment to prevent the progression to active TB disease should be considered. After the baseline chest radiograph is performed and a negative result is documented, repeat chest radiographs are not needed unless the HCW develops symptoms or signs of active TB disease develop or a clinician recommends a repeat chest radiograph. These HCWs should be assessed for current TB symptoms on an annual basis and instructed to seek medical evaluation if TB symptoms develop at any time.

HCW with written documentation of a previous positive TST or TB blood test

If the date and result of the previous test are documented, these HCWs do not need a repeat TST or TB blood test. They should be assessed for current TB symptoms. If they have written documentation of the results of a chest radiograph indicating no active TB disease that is dated after the date of the positive TST or TB blood test result they do not need another chest radiograph at the time of hire. If they do not have written documentation, they must receive a chest radiograph to exclude a diagnosis of infectious TB disease before having direct patient contact. These HCWs should be assessed for current TB symptoms on an annual basis, and instructed to seek medical evaluation if TB symptoms develop at any time. After this baseline chest radiograph is performed and the result is documented, repeat radiographs are not needed unless symptoms or signs of TB disease develop or a clinician recommends a repeat chest radiograph.

HCW with a verbal (undocumented) history of a previous positive TST or TB blood test

These HCWs must undergo the same screening process as HCWs without previous positive results. HCWs should be encouraged to keep copies of the results of the TB screening, for future use.

HCW with a documented history of previous treatment for latent TB infection (LTBI) or active TB disease

These HCWs do not need a TST or TB blood test but do need to be assessed for current TB symptoms. HCWs with a history of treated LTBI also need to have written documentation on file of a chest radiograph indicating no active TB disease that is dated after the date of the initial diagnosis of LTBI or active TB disease. These HCWs should be assessed for current TB symptoms on an annual basis, and instructed to seek medical evaluation if TB symptoms develop at any time. Repeat chest radiographs are not needed unless symptoms or signs of active TB disease develop or a clinician recommends a repeat chest radiograph. Consultation is available from the MDH TB Prevention and Control Program (651-201-5414) regarding patients with a history of previous active TB disease.

HCWs with Signs or Symptoms of Active TB Disease

Persons with active TB disease may have 1 or more of the following symptoms:

  • Prolonged cough (≥ 3 weeks )
  • Hemoptysis
  • Weight loss
  • Night sweats
  • Fatigue
  • Fever, chills
  • Poor appetite
  • Chest pain
  • Other symptoms may be present, depending on the site of disease

Active TB disease most commonly affects the lungs (pulmonary), but approximately 40% of TB cases in Minnesota involve only an extrapulmonary site of disease.

Any HCW with symptoms of active TB disease, regardless of the results of the TST or TB blood test, should be promptly evaluated to exclude a diagnosis of active TB disease. The evaluation should include a medical examination and symptom screen, a chest radiograph, and collection of sputum specimens or additional testing if indicated. If active TB disease is confirmed or suspected, the diagnosing clinician should notify the Minnesota Department of Health within one working day.

HCWs with suspected or confirmed infectious TB or a draining TB skin lesion pose a risk to patients, HCWs, and others. Such HCWs should be excluded from the workplace and should be allowed to return to work only when the following criteria have been met: (1) three consecutive sputum samples collected in 8–24-hour intervals that are negative, with at least one sample from an early morning specimen (because respiratory secretions pool overnight); (2) the person has responded to antituberculosis treatment that will probably be effective (can be based on susceptibility results); and (3) the person is determined to be noninfectious by a physician knowledgeable and experienced in managing active TB disease.

HCWs with extrapulmonary TB disease usually do not need to be excluded from the workplace as long as no involvement of the respiratory track has occurred. They can be confirmed as noninfectious and can continue to work if documented evidence is available that indicates that concurrent pulmonary TB disease has been excluded.

The difference between latent TB infection (LTBI) and active TB disease Attention: Non-MDH links

Pregnant HCWs

Exemption Form for Tuberculin Skin Testing of a Pregnant HCW (Word: 31KB/1 page)

Pregnant and nursing women should be included in the same baseline and serial TB screening programs as other HCWs. Pregnancy is not a contraindication for TB skin testing. A pregnant HCW with a newly identified positive TST or TB blood test, or signs and symptoms of active TB disease is at increased risk for active TB disease and can receive a chest radiograph, using an abdominal shield.

Additional information is available on pages 49, 51, 60, and 81 of "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005."

Conversions

A conversion is when a person's TST or TB blood test result changes from negative initially to positive with subsequent testing. For surveillance purposes, an increase of >10 mm is defined as a TST conversion. Follow instructions for HCW with newly positive TST or TB blood test.

Additional information is available on pages 13 and 32-34 of "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005."

HCWs with TST results between 5 and 9 mm of induration

TST results between 5 and 9 mm of induration are negative for most HCWs but are positive for those with certain risk factors, including those who:

  • are HIV positive,
  • have had a recent close contact with someone with active TB disease of the lungs,
  • have had an organ transplant,
  • are immunosuppressed due to taking prednisone (greater than 15 mg a day for 1 month or longer) or TNF alpha inhibitor drugs such as Enbrel®, Humira®, or Remicade® for treatment of rheumatoid arthritis, Crohn's disease, or other autoimmune disorders, or
  • have a current chest x-ray that shows "scarring" or "fibrosis" or "old, healed TB."

MDH developed a suggested template form (Word: 35KB/1 page) to educate HCWs who have TST results between 5 and 9 mm. Employers cannot and should not collect information about these personal health TB risk factors. Employers are not required to follow-up with employees who have TST results between 5 and 9 mm unless the employee also has signs or symptoms of active TB disease.

Students

Students who will be performing healthcare-related activities should be included in HCW TB screening. Students who will be in the clinical setting for less than two weeks require a single TST (or single TB blood test) and TB symptom screen; all other students require a two-step TST (or single TB blood test) and TB symptom screen.

Volunteers

Volunteers who share airspace with patients for a significant amount of time (i.e., 5 to 10 hours a week) should receive the same TB screening as paid HCWs.

HCWs with previous history of severe adverse reaction to TST

Any HCW who provides a convincing verbal report of a severe adverse reaction to a TST, even if the reaction is not documented, should NOT receive a TST. Substitute a TB blood test for the TST if it is available in your area. If the TB blood test is not available in your area, document the severe reaction and conduct the TB symptom screen.

HCWs who travel outside of the United States

Any HCW who travels for more than four weeks to a country where TB is common and reports close contact with residents of that country (e.g., visiting family, medical volunteer work), may receive TB screening (i.e., single TST or TB blood test) 8 to 10 weeks after returning to the United States. The CDC Traveler's Health - Yellow Book can provide more information. Attention: Non-MDH link

Updated Thursday, 18-Apr-2013 14:59:40 CDT