The Centers for Disease Control and Prevention (CDC) dropped annual tuberculosis (TB) screening recommendations for healthcare workers last year, saying the disease continues to decline nationwide and healthcare workers appear to be at no greater risk 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 last year.1

However, there are workers who could be exposed at work or in the community, including those from countries with endemic TB who can be offered new treatments for latent infection. Thus, TB experts recently issued a companion document to the CDC recommendations that emphasizes education and treatment in the absence of routine testing.

“Educational programs should address the range of TB-related issues with which all staff should be familiar: exposure risks (both within and outside of the workplace), what to expect if a workplace TB exposure is identified, signs and symptoms of active disease, and which workplace-based and non-workplace-based medical resources to access if symptoms develop,” according to the report. “Since more than 80% of active TB cases in the U.S. arise from previously untreated [latent TB infection], (LTBI) represents a unique opportunity to prevent a potentially devastating infectious disease via early treatment. For this reason, treatment of LTBI is now a cornerstone of the nation’s TB elimination strategy.”2

Staff should be reminded of the option for voluntary TB testing if it is offered, the authors added. “Additional attention should be given to specific knowledge required by healthcare personnel who have untreated LTBI and to those who may be at increased TB risk due to work-related or non-work-related factors such as immune suppression,” they noted.

Q&A

Hospital Employee Health spoke to the lead author of the paper, Wendy Thanassi, MD, MA, MRO, a professor at Stanford University and chief of Occupational Health Services at the VA Palo Alto Health Care System in California.

HEH: How is this paper designed to complement and augment the 2019 CDC report?

Thanassi: The companion document is sort of a user guide and an operational assistant on how to implement those guidelines and considerations to take into account what couldn’t be included in the [2019] document. One sentence in the MMWR [Morbidity and Mortality Weekly Report] can pack a whole lot of implications for policy, direction, and operations downstream. The companion document is written largely by occupational health physicians with many years of experience in the field who are offering their colleagues other thoughts, considerations, examples, and insights into ways to turn these policies into practice in your own facility.

HEH: Routine TB screening has been dropped, but it puts more emphasis on healthcare worker education. Can you comment on that shift in emphasis?

Thanassi: With the absence of annual testing, we will rely more on our educated healthcare worker staff to self-report incidents where they may have been exposed. We tested millions of healthcare workers a year with a negligible-to-negative return on that investment. The idea is to continue to test, but only those people at highest risk of having been exposed. In occupational health, we don’t necessarily know that because we aren’t in people’s private lives.

We can educate people on the risk factors to being exposed to TB. Then, if they recognize that they could be at risk, they need to notify occupational health. Those risks could be a prolonged stay in a high-burden [of TB] country, incarceration, a second job working in a homeless shelter. There are plenty of places where a healthcare worker could easily run into TB, but it has been clearly shown that testing all of them [was not necessary]. The education focuses on how do you recognize if you were exposed and can you recognize the symptoms of TB should you develop them?

HEH: You note that there is a concerning finding that healthcare workers with LTBI are less likely than non-healthcare personnel to pursue treatment.

Thanassi: It is a critical issue. When you have a patient with TB in a hospital that is a very low-volume impact, the patient may expose a few people in the ER [emergency room] and on the floor and you take care of them. When a healthcare worker develops active TB, they can [expose] 300 people in a day. They may be in and out of waiting rooms, surgery clinics, or may be a housekeeper walking throughout the hospital.

To get healthcare workers to accept treatment for their latent TB on the day of their hire is one of the most important aspects of this document. It is a shift from looking at all these 97% who are negative and those 3% who are positive and have been positive every year. It is taking all that energy, focus, and money and switching it to the date of hire when people are positive from previous exposures. [Employee health] can offer them 12 days of treatment and in doing so prevent a massive exposure situation down the line, with potentially millions of dollars in costs and lots of harm done if their tuberculosis becomes active.

HEH: The document emphasizes how much shorter treatment for latent TB is now, with far fewer side effects.

Thanassi: Yes, a huge part of the education component is how easy and safe treatment is now. It is no longer the nine months — the 270 days of isoniazid, which has been associated with toxicity risks. It is now 12 days of antibiotics, and most people tolerate that quite well. It is a big bang for the buck to take a few days of antibiotics and be in a situation where tuberculosis will never reactivate.

HEH: You note something that is not often mentioned in a medical article: preventing the environmental harm associated with millions of negative TB tests annually. Why did you feel that was important to emphasize?

Thanassi: I think the healthcare industry has been largely immune from looking at the incredible impact that its waste has on the world. It struck me that one can try to drive an electric vehicle or use reusables, but then I go to work and get hundreds of negative tests a day using alcohol swabs, a butterfly with plastic tubing that draws into more tubing — it all gets thrown into medical waste. The tubes go off to the laboratory, that goes on plastic plate, gloves get thrown out, all these tests get run, and they are all negative. The tubes for the [interferon-gamma release] test are made in Austria, and at four tubes per test, there is the production, the flying, and shipping to different locations. I started to calculate in the back of my head what is the burden and impact of all of this on the planet. This is something that healthcare does all of the time, and there has been essentially no accountability for the price the world pays for that.

REFERENCES

  1. Sosa LE, Njie GJ, Lobato MN, et al. Tuberculosis screening, testing, and treatment of U.S. health care personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morb Mortal Wkly Rep 2019;68:439-443.
  2. Thanassi W, Behrman AJ, Reves R, et al. Tuberculosis screening, testing, and treatment of US health care personnel: ACOEM and NTCA Joint Task Force on Implementation of the 2019 MMWR Recommendations. J Occup Environ Med 2020;62:e355-e369.