CDC Publishes New Guidelines for TB

by Olivia Wann, JD

Center for Disease Control and Prevention (CDC) published new guidelines, Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC on May 17, 2019.  These revised recommendations update those published in year 2005. 

The goal in healthcare is to provide early identification and prophylactic treatment of personnel who convert a TB skin test and prevent the spread of nosocomial TB within the facility. 

According to the CDC, health care personnel working in the U.S. are no longer considered at an increased risk for latent tuberculosis infection (LTBI) and TB disease from occupational exposures.  Based on these findings, routine serial TB testing at any interval after baseline in the absence of known exposure or ongoing transmission is no longer recommended.  

Prevalence of TB

TB rates in the U.S. have declined substantially.  The annual national TB rate in 2017 was 2.8 per 100,000 population representing a 73% decrease from the rate in 1991 (10.4).  TB incidence rates among health care personnel were similar to those in the general population.

According to CDC, one-fourth of the world’s population is infected with TB.  In 2017, 10.0 million people around the world became sick with TB disease. There were 1.3 million TB-related deaths worldwide.  TB is a leading killer of people who are HIV infected.

Risk Factors For Developing Active TB

CDC indicates that 5 to 10% of infected persons who do not receive treatment for latent TB infection will develop TB disease at some time in their lives.  Individuals whose immune systems are weak, especially those with HIV infection, have a much higher risk for developing TB disease than persons with normal immune systems.  CDC categorizes persons who have been recently infected with TB bacteria as well as those persons with medical conditions that weaken the immune system as having high risk for developing TB. 

Persons who have been recently infected with TB bacteria include:

• Close contacts of a person with infectious TB disease;
• Persons who have immigrated from areas of the world with high rates of TB;
• Children less than 5 years of age who have a positive TB test;
• Groups with high rates of TB transmission, such as homeless persons, injection drug users, and persons with HIV infection; and
• Persons who work or reside with people who are at high risk for TB in facilities or institutions, such as hospitals, homeless shelters, correctional facilities, nursing homes, and residential homes for those with HIV.

Persons with medical conditions that weaken the immune system include babies and young children who often have weak immune systems.  Individuals with the following conditions are also at increased risk: 

• HIV infection (the virus that causes AIDS)
• Substance abuse
• Silicosis
• Diabetes mellitus
• Severe kidney disease
• Low body weight
• Organ transplants
• Head and neck cancer
• Medical treatments such as corticosteroids or organ transplant
• Specialized treatment for rheumatoid arthritis or Crohn’s disease

Screening and early detection of TB in health care settings is important to prevent transmission.

Revised Guidelines and Protection of Health Care Workers

The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include the following: 

1. TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement).  This corresponds with CDC’s guidelines for dental offices whereby all workers are screened for TB upon hire regardless of the risk classification of the facility;
    
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 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.  

Individual Risk Assessment*

As part of the revised CDC’s recommendations, an individual risk assessment shall be performed to determine if health care personnel should be considered to be at increased risk for TB.  If the individual answers “yes” to any of the following statements, there is increased risk:

1. Temporary or permanent residence (for ≥1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe)

Or

1. Current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month), or other immunosuppressive medication

Or

1. Close contact with someone who has had infectious TB disease since the last TB test

Abbreviation: TNF = tumor necrosis factor.

* Individual risk assessment information can be useful in interpreting TB test results. Please refer to the Health Care Personnel (HCP) Baseline Individual TB Risk Assessment. 

Recommendations published in the 2005 CDC guidelines that were deemed to be outside the scope of health care personnel screening, testing, treatment and education, such as those addressing facility risk assessments and infection-control practices, remain unchanged. 

Risk Assessment for Transmission of Mycobacterium tuberculosis (M. tuberculosis) 

CDC specifies that every health care setting should conduct initial and ongoing evaluations of the risk for transmission of M. tuberculosis, regardless of whether or not patients with suspected or confirmed TB disease are encountered in the setting.  The TB risk assessment determines the type of administrative, environmental, and respiratory protection controls needed for a particular setting and serves as an ongoing evaluation tool of the quality of TB infection control and for the identification of needed improvements in infection control measures.  

A risk assessment is performed by utilizing the TB Risk Assessment available at  https://www.cdc.gov/tb/publications/guidelines/pdf/appendixb_092706.pdf. It is recommended that this assessment be completed the first quarter of every calendar year and reflect data from the year prior.  

TB Risk Classification 

Prior to the updates to the guidelines, the risk assessment and classification triggered determination for serial TB testing.  Continuing the risk assessment serves as a guide for infection control policies and procedures.   

To conduct the risk classification, the Safety Coordinator shall contact the local health department and ask for the number of TB patients in the community.  Place this number on the TB Risk Assessment form. Compare this to the number of TB patients seen in the practice the last year. If less than three patients were seen in the practice the year prior, the practice is considered “low” risk.  

Low Risk – Persons with TB disease not expected to be encountered, exposure unlikely (see criteria in Appendix B).    

Medium Risk – Health care workers who will or might be exposed to persons with TB disease (see criteria in Appendix B). 

Potential Ongoing Transmission – Temporary classification for any settings with evidence of person-to-person transmission of M. tuberculosis (see criteria in Appendix B). 

Patients Identified with Active TB

Patients with active TB are not treated in this facility.  A detailed initial medical history and periodic updates are obtained from each patient to include these symptoms:

• Active TB
• Unexplained Weight Loss
• Persistent Cough 2 – 3 weeks 
• Bloody Cough
• Night Sweats
• Prolonged Contact with Someone Diagnosed with TB 

If TB is suspected, the patient is provided with a mask and escorted to a treatment room.  The dentist/doctor will consult with the patient to determine if a referral is necessary for a medical evaluation, TB test, chest radiograph, and bacteriological exam. 

Elective treatment shall not be initiated until the patient is cleared by his/her medical provider.  For further information, please consult CDC Weekly/ May 17, 2019 / 68(19);439-443 and Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care Facilities, CDC Weekly/ December 30, 2005. 

Employees Exposed to TB

After a known exposure to a person with potentially infectious TB disease without adequate personal protection, the employee should have a timely symptom evaluation and additional testing, if indicated.  Those without documented evidence of prior LTBI or TB disease should have an IGRA or a TST performed. 

Health care personnel with documented prior LTBI or TB disease do not need another test for infection after exposure.  These persons should have further evaluation 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.

Update Your Policies

With this newly revised information, it’s time to update your TB Control Policy in your OSHA Manual.  If you are one of our subscribing clients, you will automatically receive the updates with your annual update.  If you are not a subscribing client but wish to update your materials, please contact us at [email protected].