CDC, in its recent May 17, 2019 issueof the Morbidity and Mortality Weekly Report (MMWR), published updated recommendations from the National Tuberculosis Controllers Association (NTCA) and CDC regarding Tuberculosis Screening, Testing and Treatment of U.S. Healthcare Personnel (HCP).
These updated recommendations (from prior 2005 CDC recommendations) now include the following:
Preplacement — TB screening with symptom evaluation (unchanged) and an individual risk assessment at baseline (new)
TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI) [for either baseline or post-exposure screening and testing situations] (unchanged)
No routine serial TB testing at any interval after baseline in absence of a known exposure or ongoing transmission (new)
Encouragement of treatment for all healthcare personnel with untreated LTBI, unless treatment is contraindicated (new)
Annual symptom screening for healthcare personnel with untreated LTBI (unchanged)
Annual TB education of all healthcare personnel (unchanged)
NOTE: this update does not include recommendations for using an IGRA versus a TST for diagnosing LTBI. This has been published here.
Why the changes to the previous CDC recommendations for HCP TB screening, testing and treatment?
Previous data showed U.S. healthcare personnel to be at increased risk for LTBI and TB disease from occupational exposures. However, more recent data indicated this may no longer be true, including the following:
TB rates in the U.S. have declined substantially — annual national TB rate in 2017 of 2.8 cases per 100,000 population has a 73% decrease from the rate in 1991 (10.4 cases per 100,000 population) and a 42% decrease from the rate in 2005 (4.8 cases per 100,000 population).
Surveillance data reported to CDC during 1995-2007 indicated that TB incidence rates among HCP were similar to those in the general population, prompting questions about the cost-effectiveness of routine serial occupational testing.
TB tests (IGRA and TST) have well-documented limitations for serial testing of HCP at low risk for LTBI and TB disease.
In 2015, the NTCA-CDC formed a work group of experts in TB, infection control, and occupational health to discuss potential updates to recommendations for HCP TB screening and testing. The work group initiated a systematic review and meta-analysis that found a low percentage of HCP test positive at baseline (IGRA-5% and TST-3%) and convert during serial testing (IGRA-4% and TST-0.7%). Based on these findings and expert opinion, draft NTCA-CDC work group recommendations were developed and then presented publicly for comment and feedback in meetings to both the Advisory Council on Elimination of Tuberculosis (ACET) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) in addition to NTCA’s 2018 National Tuberculosis Conference. The NTCA-CDC reconvened to address feedback received from these meetings and finalized the updated recommendations.
More to come…
Of note, the NTCA is expected, jointly with the American College of Occupational Medicine (ACOEM), to publish a supplemental implementation guidance document to aid healthcare facilities in implementing the updated recommendations. NTCA has noted in its press release (May 16, 2019) regarding the updated recommendations for TB screening and testing in healthcare settings that this supplemental document should be released within the next few weeks.
Healthcare personnel will welcome these long overdue changes to eliminate routine annual TB testing. Medical center employee health programs should see a significant reduction in TB testing conducted each year.
However, these changes do include a strengthening of management of HCP with LTBI and no prior treatment to strongly encourage a completed treatment with a recommended regimen, including short-course treatments, unless a contraindication exists. Note that these recommendations are consistent with the U.S. efforts to focus more on LTBI testing and treatment. LTBI treatment is what prevents later transmission of TB, not testing. Annual symptom evaluation to detect early evidence of TB disease and to reevaluate the risks and benefits of LTBI treatment should be done for all HCP diagnosed with LTBI that has not been treated previously. Hence, an annual HCP surveillance program to monitor individuals with untreated LTBI needs to remain in place along with annual TB education for all healthcare personnel.
These updated recommendations for TB screening and testing in healthcare settings have long been needed. However, these changes can’t be implemented immediately in many locations as there are local- and state-level challenges to be addressed before universal adoption and the movement away from annual testing. Healthcare facilities should reach out to their state TB program for assistance and guidance on addressing state and local TB screening and testing regulations. For a directory of TB programs, seehttp://www.tbcontrollers.org/community/statecityterritory.