In the Journals

Health care personnel should not be screened yearly for TB, guidelines say

In updated guidance, the CDC and National Tuberculosis Controllers Association recommended against screening U.S. health care personnel, or HCP, for latent tuberculosis every year, reflecting an overall decrease in TB cases and incidence among HCP.

“A systematic review found a low percentage of HCP have a positive TB test at baseline and upon serial testing,” Lynn E. Sosa, MD, of the Connecticut Department of Public Health and National Tuberculosis Controllers Association, and colleagues wrote in MMWR.

The updated recommendation reads: “In the absence of known exposure or evidence of ongoing TB transmission, U.S. health care personnel ... without [latent TB infection] should not undergo routine serial TB screening or testing at any interval after baseline (e.g., annually).”

The updated guidelines come after a steady decline in U.S. TB cases since 1991, including among HCP, Sosa and colleagues explained. According to the report, the annual national TB rate in 2017 was 2.8 cases per 100,000 population, representing a 42% decrease from 2005, when the most recent guidelines were drafted. With the CDC reporting similar rates of TB among HCP and the general population, questions were raised about the cost-effectiveness of yearly screening.

The updated guidelines recommend that all U.S. HCP be screened for TB at baseline, including an individual risk assessment and symptom evaluation, which is necessary for interpreting test results later.

“The risk assessment and symptom evaluation help guide decisions when interpreting test results. For example, health care personnel with a positive test who are asymptomatic, unlikely to be infected with [Mycobacterium] tuberculosis, and at low risk for progression on the basis of their risk assessment should have a second test” — either an interferon-gamma release assay or a tuberculin skin test, Sosa and colleagues wrote. “In this example, the health care personnel should be considered infected with M. tuberculosis only if both the first and second tests are positive.”

Additionally, the guidelines recommend that HCP receive a timely symptom evaluation and additional testing after a known exposure to a person with potentially infectious TB without the use of adequate personal protection. HCP without documented evidence of prior latent TB infection or TB should receive an interferon-gamma release assay or a tuberculin skin test, whereas those with documented prior latent TB infection or TB disease do not need another test for infection after exposure but should instead be further evaluated if a concern for TB disease exists.

“Those with an initial negative test should be retested 8-10 weeks after the last exposure, preferably by using the same test type as was used for the prior negative test,” Sosa and colleagues wrote.

They said facilities should consider serial TB screening of certain personnel at an increased risk for TB exposure — for example, pulmonologists or respiratory therapists — or in certain settings, such as EDs, if transmission has occurred there before.

“Such determinations should be individualized on the basis of factors that might include the number of patients with infectious pulmonary TB who are examined in these areas, whether delays in initiating airborne isolation occurred, or whether prior annual testing has revealed ongoing transmission,” they wrote. “Consultation with the local or state health department is encouraged to assist in making these decisions.”

If someone newly tests positive, the guidelines recommend they undergo a symptom evaluation and chest radiograph to assess for TB. HCP with latent TB and no past treatment “should be offered, and strongly encouraged to complete, treatment with a recommended regimen, including short-course treatments, unless a contraindication exists,” Sosa and colleagues said. Those who do not complete treatment should be evaluated for symptoms annually to detect early evidence of TB disease and to re-evaluate the risks and benefits of latent TB infection treatment and should be educated about signs and symptoms of TB disease that should prompt an immediate evaluation between screenings, they said. – by Caitlyn Stulpin

Disclosures: The authors report no relevant financial disclosures.

In updated guidance, the CDC and National Tuberculosis Controllers Association recommended against screening U.S. health care personnel, or HCP, for latent tuberculosis every year, reflecting an overall decrease in TB cases and incidence among HCP.

“A systematic review found a low percentage of HCP have a positive TB test at baseline and upon serial testing,” Lynn E. Sosa, MD, of the Connecticut Department of Public Health and National Tuberculosis Controllers Association, and colleagues wrote in MMWR.

The updated recommendation reads: “In the absence of known exposure or evidence of ongoing TB transmission, U.S. health care personnel ... without [latent TB infection] should not undergo routine serial TB screening or testing at any interval after baseline (e.g., annually).”

The updated guidelines come after a steady decline in U.S. TB cases since 1991, including among HCP, Sosa and colleagues explained. According to the report, the annual national TB rate in 2017 was 2.8 cases per 100,000 population, representing a 42% decrease from 2005, when the most recent guidelines were drafted. With the CDC reporting similar rates of TB among HCP and the general population, questions were raised about the cost-effectiveness of yearly screening.

The updated guidelines recommend that all U.S. HCP be screened for TB at baseline, including an individual risk assessment and symptom evaluation, which is necessary for interpreting test results later.

“The risk assessment and symptom evaluation help guide decisions when interpreting test results. For example, health care personnel with a positive test who are asymptomatic, unlikely to be infected with [Mycobacterium] tuberculosis, and at low risk for progression on the basis of their risk assessment should have a second test” — either an interferon-gamma release assay or a tuberculin skin test, Sosa and colleagues wrote. “In this example, the health care personnel should be considered infected with M. tuberculosis only if both the first and second tests are positive.”

Additionally, the guidelines recommend that HCP receive a timely symptom evaluation and additional testing after a known exposure to a person with potentially infectious TB without the use of adequate personal protection. HCP without documented evidence of prior latent TB infection or TB should receive an interferon-gamma release assay or a tuberculin skin test, whereas those with documented prior latent TB infection or TB disease do not need another test for infection after exposure but should instead be further evaluated if a concern for TB disease exists.

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“Those with an initial negative test should be retested 8-10 weeks after the last exposure, preferably by using the same test type as was used for the prior negative test,” Sosa and colleagues wrote.

They said facilities should consider serial TB screening of certain personnel at an increased risk for TB exposure — for example, pulmonologists or respiratory therapists — or in certain settings, such as EDs, if transmission has occurred there before.

“Such determinations should be individualized on the basis of factors that might include the number of patients with infectious pulmonary TB who are examined in these areas, whether delays in initiating airborne isolation occurred, or whether prior annual testing has revealed ongoing transmission,” they wrote. “Consultation with the local or state health department is encouraged to assist in making these decisions.”

If someone newly tests positive, the guidelines recommend they undergo a symptom evaluation and chest radiograph to assess for TB. HCP with latent TB and no past treatment “should be offered, and strongly encouraged to complete, treatment with a recommended regimen, including short-course treatments, unless a contraindication exists,” Sosa and colleagues said. Those who do not complete treatment should be evaluated for symptoms annually to detect early evidence of TB disease and to re-evaluate the risks and benefits of latent TB infection treatment and should be educated about signs and symptoms of TB disease that should prompt an immediate evaluation between screenings, they said. – by Caitlyn Stulpin

Disclosures: The authors report no relevant financial disclosures.