As previously forecasted in Hospital Infection Control & Prevention, the CDC officially dropped routine annual tuberculosis testing of healthcare workers (HCWs) in recently published guidelines.1 (For more information, see the April 2019 issue of HIC.)

The agency is dropping routine screening in favor of testing on hire, and after TB exposure or ongoing transmission. In updating 2005 TB guidelines, the CDC screening change was expected as the disease continues to decline nationally and healthcare workers appear to be at no greater risk of transmission than the general public.

“In addition, a recent retrospective cohort study of approximately 40,000 healthcare personnel at a tertiary U.S. medical center in a low TB-incidence state found an extremely low rate of TST [tuberculin skin test] conversion (0.3%) during 1998-2014, with a limited proportion attributable to occupational exposure,” the CDC reported.1,2

Routine annual screening in low-risk populations has little epidemiological value, and could trigger false positives and unnecessary anxiety in healthcare workers.

“The recommendation is a lot more strongly stated that we really don’t need to be doing annual testing in almost every situation,” says lead author Lynn Sosa, MD, TB/STD Control Programs Coordinator at the Connecticut Department of Public Health. “This will save time because now you are not focused on tracking down people to get them tested every year.”

Oher CDC TB recommendations include:

  • Screening with an individual risk assessment and symptom evaluation at baseline;
  • Testing for TB using an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for employees without prior TB or latent TB infection (LTBI);
  • Encourage HCWs with untreated LTBI to seek treatment, unless treatment is contraindicated;
  • Annual screening for HCWs with untreated LTBI;
  • Annual TB education of all HCWs.1

There also is new emphasis on treating HCWs who test positive for LTBI. IPs played a large role in implementing TB infection control measures that made this possible. IPs must continue to emphasize rapid identification and isolation of TB patients.

“The 2005 recommendations3 still stand in terms of the infection control and the environmental control recommendations,” Sosa says. “Those are still really important. Just doing a test on healthcare workers does not prevent TB transmission.”

As part of the preplacement TB test for healthcare workers, the CDC recommends an individual risk assessment. “Instead of looking at the risk of a particular facility, we are focused on the risk of the individual person working in the healthcare setting,” Sosa says. “Because it really is important to understand what that individual’s risk of TB is to interpret and better understand the test results.”

HCWs should be considered at increased risk for TB if they answer yes to any one of the following statements:

  • Temporary or permanent residence in a country with a high TB rate;
  • Current or planned immunosuppression, including HIV, receipt of an organ transplant, treatment with a tumor necrosis factor-alpha antagonist, chronic steroids, or other immunosuppressive medication;
  • Close contact with someone who has had infectious TB disease since the last TB test.1

REFERENCES

  1. Sosa LE, Njie GJ, Lobato MN, et al. Tuberculosis screening, testing, and treatment of US health care personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR 2019;68:439-443.
  2. Dobler CC, Farah WH, Alsawas M, et al. Tuberculin skin test conversions and occupational exposure risk in US healthcare workers. Clin Infect Dis 2018;66:706-711.
  3. Jensen PA, Lambert LA, Lademarco MF, et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005;54:1-141.