Tuberculosis screening, testing, and treatment of U.S. health care personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019

Abstract

This article presents updated recommendations for screening health care workers for tuberculosis, including eliminating serial screening in the absence of exposure or ongoing transmission. This article presents updated recommendations for screening health care workers for tuberculosis, including eliminating serial screening in the absence of exposure or ongoing transmission. May 17, 2019/68(19);439-443 The 2005 CDC guidelines for preventing Mycobacterium tuberculosis transmission in health care settings include recommendations for baseline tuberculosis (TB) screening of all U.S. health care personnel and annual testing for health care personnel working in medium-risk settings or settings with potential for ongoing transmission.1Jensen PA Lambert LA Iademarco MF Ridzon R Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005.MMWR Recomm Rep. 2005; 54PubMed Google Scholar Using evidence from a systematic review conducted by a National Tuberculosis Controllers Association (NTCA)-CDC work group, and following methods adapted from the Guide to Community Preventive Services,2Briss PA Zaza S Pappaioanou M et al.Task Force on Community Preventive ServicesDeveloping an evidence-based Guide to Community Preventive Services—methods.Am J Prev Med. 2000; 18: 35-43Abstract Full Text Full Text PDF PubMed Scopus (490) Google Scholar,3Zaza S Wright-De Agüero LK Briss PA et al.Task Force on Community Preventive ServicesData collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services.Am J Prev Med. 2000; 18: 44-74Abstract Full Text Full Text PDF PubMed Scopus (385) Google Scholar the 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include (1) TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement); (2) 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); (3) no routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission; (4) encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated; (5) annual symptom screening for health care personnel with untreated LTBI; and (6) annual TB education of all health care personnel. Historically, U.S. health care personnel were at increased risk for LTBI and TB disease from occupational exposures; however, recent data suggest that this might no longer be the case. TB rates in the United States have declined substantially; the annual national TB rate in 2017 (2.8 per 100 000 population) represents a 73% decrease from the rate in 1991 (10.4) and a 42% decrease from the rate in 2005 (4.8).4CDCReported Tuberculosis in the United States, 2016. US Department of Health and Human Services, CDC, Atlanta, GA2017Google Scholar,5Stewart RJ Tsang CA Pratt RH Price SF Langer AJ Tuberculosis—United States, 2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 317-323Crossref PubMed Scopus (56) Google Scholar Surveillance data reported to CDC during 1995-2007 revealed that TB incidence rates among health care personnel were similar to those in the general population,6Lambert LA Pratt RH Armstrong LR Haddad MB Tuberculosis among healthcare workers, United States, 1995–2007.Infect Control Hosp Epidemiol. 2012; 33: 1126-1132Crossref PubMed Scopus (30) Google Scholar raising questions about the cost-effectiveness of routine serial occupational testing.7Mullie GA Schwartzman K Zwerling A N’Diaye DS Revisiting annual screening for latent tuberculosis infection in healthcare workers: a cost-effectiveness analysis.BMC Med. 2017; 15: 104Crossref PubMed Scopus (20) Google Scholar In addition, a recent retrospective cohort study of approximately 40 000 health care personnel at a tertiary U.S. medical center in a low TB-incidence state found an extremely low rate of TST conversion (0.3%) during 1998-2014, with a limited proportion attributable to occupational exposure.8Dobler CC Farah WH Alsawas M et al.Tuberculin skin test conversions and occupational exposure risk in US healthcare workers.Clin Infect Dis. 2018; 66: 706-711Crossref PubMed Scopus (14) Google Scholar Moreover, IGRAs and TSTs have well-documented limitations for serial testing of health care personnel at low risk for LTBI and TB disease.9Zwerling A van den Hof S Scholten J Cobelens F Menzies D Pai M Interferon-gamma release assays for tuberculosis screening of healthcare workers: a systematic review.Thorax. 2012; 67: 62-70Crossref PubMed Scopus (196) Google Scholar,10Dorman SE Belknap R Graviss EA et al.Tuberculosis Epidemiologic Studies ConsortiumInterferon-γ release assays and tuberculin skin testing for diagnosis of latent tuberculosis infection in healthcare workers in the United States.Am J Respir Crit Care Med. 2014; 189: 77-87Crossref PubMed Scopus (183) Google Scholar In 2015, an NTCA-CDC work group comprising experts in TB, infection control, and occupational health was formed to discuss potential updates to recommendations for health care personnel TB screening and testing. The work group included representation from CDC, state and local public health departments, academia, and occupational health associations. During 2015-2016, the work group met periodically to discuss where updates were needed to the 2005 CDC recommendations and to establish a plan for the review of evidence. In January 2017, the work group commenced a systematic literature review of the screening and testing of health care personnel for TB and discussed the findings during a web conference in September 2017. Updated recommendations were developed by the work group during a web conference in December 2017. A systematic review of evidence published after release of the 2005 guidelines was conducted using methodology developed for the Guide to Community Preventive Services.2Briss PA Zaza S Pappaioanou M et al.Task Force on Community Preventive ServicesDeveloping an evidence-based Guide to Community Preventive Services—methods.Am J Prev Med. 2000; 18: 35-43Abstract Full Text Full Text PDF PubMed Scopus (490) Google Scholar,3Zaza S Wright-De Agüero LK Briss PA et al.Task Force on Community Preventive ServicesData collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services.Am J Prev Med. 2000; 18: 44-74Abstract Full Text Full Text PDF PubMed Scopus (385) Google Scholar The search included articles indexed in MEDLINE, EMBASE, and Scopus. The medical subject headings used for the search were “latent tuberculosis” and “tuberculosis”; search terms included “healthcare worker,” “healthcare personnel,” “health worker,” “occupational exposure,” and “occupational diseases.” English language articles were included that (1) were published during January 2006–November 2017; (2) described TB screening and testing in low-incidence,11World Health OrganizationFramework Towards Tuberculosis Elimination in Low-incidence Countries: Methods. World Health Organization, Geneva, Switzerland2014Google Scholar high-income countries12The World BankWorld Bank Country and Lending Groups. The World Bank, Washington, DC2019Google Scholar; (3) employed study designs that were randomized controlled trials, prospective cohort, retrospective cohort, or cross-sectional studies; and (4) reported LTBI prevalence, test conversion or reversion, or TB transmission rates. Each study was independently abstracted and assessed for suitability of study design by two reviewers using a data abstraction form adapted from the Guide to Community Preventive Services.3Zaza S Wright-De Agüero LK Briss PA et al.Task Force on Community Preventive ServicesData collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services.Am J Prev Med. 2000; 18: 44-74Abstract Full Text Full Text PDF PubMed Scopus (385) Google Scholar This search identified 1147 citations, of which 39 studies focused on TB screening and testing among health care personnel; three studies (one that was an economic evaluation, one that focused only on test performance, and one of limited execution quality) were excluded, leaving 36 studies in the analysis (Supplementary Box, https://stacks.cdc.gov/view/cdc/77668). Sixteen (44%) of these had been conducted in the United States, with the remaining studies from Australia (one), Europe,17CDCTreatment regimens for latent TB infection (LTBI). US Department of Health and Human Services, CDC, Atlanta, GA2017Google Scholar Israel (one), and New Zealand (one). Thirty-four (94%) studies had been conducted in a hospital setting; most used either a retrospective cohort or cross-sectional design.14CDCHealth Infection Control Practices Advisory Committee record of the proceedings: May 17-18, 2018. US Department of Health and Human Services, CDC, Atlanta, GA2018Google Scholar Substantial unexplained heterogeneity existed for all outcomes examined, even when stratified by location or study design. An examination of the patterns of results did not indicate publication bias.SummaryWhat is already known about this topic?Since 1991, U.S. tuberculosis (TB) rates have declined, including among health care personnel (HCP). Serial TB testing has limitations in populations at low risk.What is added by this report?A systematic review found a low percentage of HCP have a positive TB test at baseline and upon serial testing. Updated recommendations for screening and testing HCP include an individual baseline (preplacement) risk assessment, symptom evaluation and testing of persons without prior TB or latent TB infection (LTBI), no routine serial testing in the absence of exposure or ongoing transmission, treatment for HCP diagnosed with LTBI, annual symptom screening for persons with untreated LTBI, and annual TB education of all HCP.What are the implications for public health practice?Increasing LTBI treatment among HCP might further decrease TB transmission in health care settings. What is already known about this topic? Since 1991, U.S. tuberculosis (TB) rates have declined, including among health care personnel (HCP). Serial TB testing has limitations in populations at low risk. What is added by this report? A systematic review found a low percentage of HCP have a positive TB test at baseline and upon serial testing. Updated recommendations for screening and testing HCP include an individual baseline (preplacement) risk assessment, symptom evaluation and testing of persons without prior TB or latent TB infection (LTBI), no routine serial testing in the absence of exposure or ongoing transmission, treatment for HCP diagnosed with LTBI, annual symptom screening for persons with untreated LTBI, and annual TB education of all HCP. What are the implications for public health practice? Increasing LTBI treatment among HCP might further decrease TB transmission in health care settings. Five U.S. studies reported prior bacillus Calmette-Guérin vaccination by health care personnel (median percentage = 7%; range = 2.3%-93%). Eight of the 16 U.S. studies reported two-step TST testing at baseline. The remaining studies reported IGRA (six) or a combination of IGRA and TST (two) at baseline. Findings from the metaanalyses indicated that 5% and 3% of U.S. health care personnel tested positive at baseline by IGRA and TST, respectively, and that 4% and 0.7% converted from a negative to a positive during serial testing by IGRA and TST, respectively. Among U.S. health care personnel who had a baseline positive test and were retested by the same method during serial testing, the second test was negative in 48% of cases by IGRA and 62% by TST. No U.S. studies were found that evaluated the clinical implications of these discordant results. Among 63 975 U.S. health care personnel from eight studies reporting disease occurrence, none experienced TB disease. Based on expert opinion from the NTCA-CDC work group and findings from the systematic review indicating that a limited proportion of health care personnel test positive at baseline and convert during serial testing, recommendations were drafted for presentation to the Advisory Council on the Elimination of Tuberculosis (ACET) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The draft NTCA-CDC recommendations were presented publicly at the April 2018 ACET meeting13CDCAdvisory Committee for the Elimination of Tuberculosis Record of the Proceedings: April 17, 2018. US Department of Health and Human Services, CDC, Atlanta, GA2018Google Scholar and the May 2018 HICPAC meeting.14CDCHealth Infection Control Practices Advisory Committee record of the proceedings: May 17-18, 2018. US Department of Health and Human Services, CDC, Atlanta, GA2018Google Scholar Members of ACET and HICPAC were asked to provide feedback to CDC regarding the recommendations and their accuracy, practicability, clarity, and usefulness. Commenters during the ACET meeting noted that the recommendation encouraging treatment of health care personnel with LTBI could potentially generate cost savings and play an important role in the elimination of active TB disease in the United States. Commenters during the HICPAC meeting were supportive of the need to reduce TB testing for health care personnel; questions were raised about the evidence for, and feasibility of, implementing some of the proposed changes. Commenters during both meetings also encouraged the work group’s plan for a supplemental document to aid health care facilities in implementing the updated recommendations. In addition, the recommendations were presented by NTCA at the National Tuberculosis Conference in May 201815National Tuberculosis Controllers Association; California Tuberculosis Controllers Association. National Tuberculosis Conference Agenda. Palm Springs, CA; May 21-24, 2018. http://www.tbcontrollers.org/docs/conference/2018/NTC_Conference2018_Agenda_final.pdfGoogle Scholar for comment and feedback. Conference attendees supported the need for updated guidelines and the content of the recommendations that were presented. In July 2018, the NTCA-CDC work group held another web conference to address feedback received from the ACET, HICPAC, and National Tuberculosis Conference meetings and finalized the updated recommendations. The work group requested that NTCA convene a new work group to develop the supplemental implementation guidance document supported by ACET and HICPAC. The supplemental document is expected to be completed by NTCA in 2019. Recommendations from the 2005 CDC guidelines that are outside the scope of health care personnel screening, testing, treatment, and education remain unchanged (Table 1); this includes continuing facility risk assessments for guiding infection control policies and procedures. Here, TB screening is defined as a process that includes a TB risk assessment, symptom evaluation, TB testing for M. tuberculosis infection (by either IGRA or TST) for health care personnel without documented evidence of prior LTBI or TB disease, and additional workup for TB disease for health care personnel with positive test results or symptoms compatible with TB disease. This update does not include recommendations for using an IGRA versus a TST for diagnosing LTBI, which have been published elsewhere.16Lewinsohn DM Leonard MK LoBue PA et al.Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children.Clin Infect Dis. 2017; 64: 111-115Crossref PubMed Scopus (391) Google ScholarTABLE 1Comparison of 2005aJensen PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005;54(No. RR-17). https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm. and 2019bAll other aspects of the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 remain in effect, including facility risk assessments to help guide infection control policies and procedures. recommendations for tuberculosis (TB) screening and testing of U.S. health care personnel (HCP)Category2005 Recommendation2019 RecommendationBaseline (preplacement) screening and testingTB screening of all HCP, including a symptom evaluation and test (IGRA or TST) for those without documented prior TB disease or LTBI.TB screening of all HCP, including a symptom evaluation and test (IGRA or TST) for those without documented prior TB disease or LTBI (unchanged); individual TB risk assessment (new).Postexposure screening and testingSymptom evaluation for all HCP when an exposure is recognized. For HCP with a baseline negative TB test and no prior TB disease or LTBI, perform a test (IGRA or TST) when the exposure is identified. If that test is negative, do another test 8–10 weeks after the last exposure.Symptom evaluation for all HCP when an exposure is recognized. For HCP with a baseline negative TB test and no prior TB disease or LTBI, perform a test (IGRA or TST) when the exposure is identified. If that test is negative, do another test 8–10 weeks after the last exposure (unchanged).Serial screening and testing for HCP without LTBIAccording to health care facility and setting risk assessment. Not recommended for HCP working in low-risk health care settings. Recommended for HCP working in medium-risk health care settings and settings with potential ongoing transmission.Not routinely recommended (new); can consider for selected HCP groups (unchanged); recommend annual TB education for all HCP (unchanged), including information about TB exposure risks for all HCP (new emphasis).Evaluation and treatment of positive test resultsReferral to determine whether LTBI treatment is indicated.Treatment is encouraged for all HCP with untreated LTBI, unless medically contraindicated (new).Abbreviations: IGRA, interferon-gamma release assay; LTBI, latent tuberculosis infection; TST, tuberculin skin PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005;54(No. RR-17). other aspects of the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 remain in effect, including facility risk assessments to help guide infection control policies and procedures. in a new IGRA, interferon-gamma release assay; LTBI, latent tuberculosis infection; TST, tuberculin skin U.S. health care personnel have baseline TB screening, including an individual risk assessment which is for any test The 2005 guidelines state that baseline test results provide a for in the of a potential or known exposure to M. tuberculosis, and treatment of LTBI or TB disease in health care personnel and reduce the risk to and other health care PA Lambert LA Iademarco MF Ridzon R Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005.MMWR Recomm Rep. 2005; 54PubMed Google Scholar The risk assessment and symptom evaluation help guide when test results. For health care personnel with a positive test who are to be with M. tuberculosis, and at low risk for on the of their risk assessment have a second test an IGRA or a TST) as recommended in the 2017 TB guidelines of the American Thoracic Diseases Society of and DM Leonard MK LoBue PA et al.Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children.Clin Infect Dis. 2017; 64: 111-115Crossref PubMed Scopus (391) Google Scholar In this the health care personnel be with M. tuberculosis only both the and second are of for tuberculosis (TB) at baseline health care personnel care personnel be to be at increased risk for TB to any of the following or in a with a TB rate any other New the United States, and those in or or including of an treatment with a or of for or other with who has had TB disease the last TB risk assessment information can be in TB test results. Leonard LoBue PA, et American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and from a tuberculosis risk assessment form developed by the California Department of Health care personnel be to be at increased risk for TB to any of the following or in a with a TB rate any other New the United States, and those in or or including of an treatment with a or of for or other with who has had TB disease the last TB risk assessment information can be in TB test results. Leonard LoBue PA, et American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and from a tuberculosis risk assessment form developed by the California Department of known exposure to a with potentially TB disease without of health care personnel have a symptom evaluation and additional testing, without documented evidence of prior LTBI or TB disease have an IGRA or a TST Health care personnel with documented prior LTBI or TB disease do not need another test for infection after persons have further evaluation a for TB disease with an negative test be retested weeks after the last by using the same test as was used for the prior negative In the absence of known exposure or evidence of ongoing TB transmission, U.S. health care personnel identified in the 2005 without LTBI not routine serial TB screening or testing at any interval after baseline Health care facilities might consider using serial TB screening of groups who might be at increased occupational risk for TB exposure or or in settings transmission has in the be on the of that might include the of with TB who are in these whether in or whether prior annual testing has revealed ongoing transmission. with the local or state health is encouraged to in these Health care personnel might have risks for TB exposure that are not to their work in the United States, or might have risks for TB after baseline testing that If these risks are these health care personnel might TB disease and TB to or other health care facilities all health care personnel about TB, including risk and facilities also health care personnel to discuss any potential occupational or TB exposure with their care and occupational health The to perform TB testing after baseline be on the risk for TB exposure at work or that last Health care personnel with a positive test for those persons at low risk as described a symptom evaluation and to for TB disease. workup might be indicated on the of those results. Health care personnel with a prior positive TB test and documented do not a unless are or LTBI DM Leonard MK LoBue PA et al.Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children.Clin Infect Dis. 2017; 64: 111-115Crossref PubMed Scopus (391) Google Scholar The local public health be TB disease is Health care personnel with LTBI and no prior treatment be and encouraged to treatment with a recommended including unless a regimens for latent TB infection (LTBI). US Department of Health and Human Services, CDC, Atlanta, GA2017Google PA tuberculosis the of tuberculosis elimination in the Infect Dis. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar Health care personnel who do not LTBI treatment be with annual symptom evaluation to evidence of TB disease and to the risks and of LTBI health care personnel also be about the and symptoms of TB disease that an evaluation Health care facilities to LTBI among health care personnel and LTBI Health care facilities are to with public health to in this health can as a for medical regarding diagnosis and treatment of LTBI, and of state or local and information and with public health is for the of these recommendations on the incidence of TB and LTBI in the United States and the need to recommendations for health care personnel. have completed and the form for of potential of a from outside the from the National Tuberculosis Controllers Association during the of the from the Health Association of Health in and National for and Health of outside the No other potential of were