New Recommendations Released for TB Screening and Testing of Health Care Personnel

Health workers in the United States have historically been at an increased risk for latent tuberculosis infection (LTBI) and tuberculosis (TB) disease. However, recent data suggest that TB rates have dropped substantially, with the annual national TB rate declining by 73% from 1991 to 2017, and 42% alone since 2005.

The 2005 guidelines for preventing Mycobacterium tuberculosis transmission in health care personnel (HCP) include recommendations for annual testing for those working in medium-risk settings or settings with a risk for transmission.

Surveillance data reported to the US Centers for Disease Control and Prevention (CDC) between 1995-2007 indicate that HCP have a similar TB incidence rate as the general population, spurring questions about the cost-effectiveness of annual occupational testing. With the updated data, a team of investigators from the CDC and National Tuberculosis Controllers Association created a work group to conduct a systematic review and update the 2005 recommendations.

The 2005 guidelines recommended that all US HCPs without documented TB disease or LTBI should have baseline TB screening, including testing with interferon-gamma release assay, or tuberculin skin test. The new update also advises that an individual risk assessment should be included to guide decisions when interpreting test results and evaluating symptoms. For the risk assessment, HCPs should indicate whether they have been a resident of a country with a high TB rate, whether they are currently immunosuppressed, and whether they have had close contact with an individual with infectious TB disease since their previous TB test.

The post-exposure screening and testing recommendations remain the same in the updated guidelines. In the event of an exposure, HCPs with baseline negative results and no prior TB disease or LTBI should undergo testing with interferon-gamma release assay, or tuberculin skin test. HCPs with previously documented LTBI or TB do not need to undergo an additional test for infection after exposure but should be further evaluated if a concern for TB disease exists.

In the event that the test for an individual with no prior documentation is negative, a second test should be conducted 8-10 weeks after the last exposure.

For HCPs without LTBI, annual screening and testing is no longer routinely recommended. However, the recommendation that facilities might consider using annual screening of certain groups at increased exposures including pulmonologists or respiratory therapists, or in settings where transmission has occurred in the past such as the emergency department, remains unchanged.

The new guidelines also continue to recommend annual TB education for all HCPs, including risk factors, signs, and symptoms, with a new emphasis on providing education about TB exposure risks for all HCPs.

HCPs with a newly positive test should undergo a symptom evaluation and chest radiograph to assess for TB disease, with an additional workup potentially requested on the basis of those results. However, HCPs with a prior positive TB test and documented normal chest radiograph do not require a repeat radiograph unless symptomatic or initiation LTBI treatment.

The 2019 recommendations also include that personnel with LTBI and no prior treatment should be offered and encouraged to receive treatment unless a contraindication exists. Those who do not complete treatment should be monitored with annual symptom evaluation.

“Health care facilities should aim to identify LTBI among health care personnel and encourage LTBI treatment. Health care facilities are urged to collaborate with public health agencies to assist in achieving this goal,” the authors of the guidelines conclude.