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What are the rules for TB testing?


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Pt. from Thailand 5 years ago was seen 3 years ago here in USA and had a positive PPD.  CXR revals no active disese and the pt. was never symptomatic.  Since the initial testing and xray she has had a total of 3 additional xrays when applying to jobs or now, college.  Each one stated the negative CXR had to be less than 6 months old.  She never had TB prophy isoniazid for latent TB.  How many negative chest xray do you have to have before enough is enough?   Thanks in advance.

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http://www.cdc.gov/tb/topic/testing/

 

 

 

Testing for TB in BCG-Vaccinated Persons

Many people born outside of the United States have been BCG-vaccinated.

People who have had a previous BCG vaccine may receive a TB skin test. In some people, BCG may cause a positive skin test when they are not infected with TB bacteria. If a TB skin test is positive, additional tests are needed.

IGRAs, unlike the TB skin tests, are not affected by prior BCG vaccination and are not expected to give a false-positive result in people who have received BCG.

 

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cbrsmurf,  I am aware of what you say.  In this case , she did not have a BCG vaccine and after an initial negative CXR for any active disease, she has had to take additional CXR's for different positions and nursing school now.  My question is how many negative CXRs are needed.  Also, many of us have converted to positive due to exposure in our work place.  CXR neg.  Do we have to take a CXR every time we change a job?   She did not do any Isoniazid for 6-9 months.

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We have occasionally faced this issue with placing students on clinical rotations. Some students have had to get multiple films because a facility would not let them in the door without a "recent" film. 

 

I am hoping all the radiation will kill any mycobacteria present. 

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I've been ppd + since 1994 when I was a teenager.  I took 9 months of INH and have always had a negative CXR but still often have to get a repeat CXR for jobs, credentialing, schools, etc.   Some places are moving towards an initial negative CXR and then yearly symptom questionaires.  I'm hoping more places start to move towards this method. 

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+ PPD with out treatment should be treated

 

might try quant gold test to see

 

BUT last time I check insurances not paying for this

 

 

 

 

Think about this (here comes the logic )) 

 

They use TB vaccination in places where there is a good risk for being exposed to TB, if you have lived there years ago and now test positive - you were likely exposed to TB - A few years back I read an article that stated the false positive for vaccination only lasts a few years

 

So - I would agree with requiring a CXR prior to hire - if she has not been treated.  As stated TB can hang out just about anywhere in the body, BUT if it is in the lungs they could expose everyone they come in contact to......  Also, the digital CXR's these days have exceptionally low radiation so I would say 1) get treated or 2) get yearly CXR if needed for your job

 

There is a new drug that might well make most TB treatment 3 months.... so it might be wise to inquire.

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So - I would agree with requiring a CXR prior to hire - if she has not been treated.  As stated TB can hang out just about anywhere in the body, BUT if it is in the lungs they could expose everyone they come in contact to......  Also, the digital CXR's these days have exceptionally low radiation so I would say 1) get treated or 2) get yearly CXR if needed for your job

 

 

The risk of conversion to active TB even without treatment is pretty low.  Symptom questionnaires should be enough.  There is no reason to do yearly CXR.

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The risk of conversion to active TB even without treatment is pretty low.  Symptom questionnaires should be enough.  There is no reason to do yearly CXR.

 

Employers will want it. Also are you willing to stake your professional reputation on not getting it?

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Nevermind (back under rock).

 

 

not at all

 

it is great to kick things around here and see what others think.

 

In the past after having worked in ER and IR I am STRONGLY against unneeded rad exposure, but I just don't see any way around this one, cept for treatment that is.....

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Employers will want it. Also are you willing to stake your professional reputation on not getting it?

Where would one's professional reputation come into play for not wanting to get unnecessary yearly CXRs? What are you hoping to find in an asymptomatic person?

 

Sent from my Nexus 5 using Tapatalk

 

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Where would one's professional reputation come into play for not wanting to get unnecessary yearly CXRs? What are you hoping to find in an asymptomatic person? Sent from my Nexus 5 using Tapatalk

 

do you want to be the provider that cleared that patient, and did not get a CXR, only to find out that they do indeed have pulmonary TB and have been walking around exposing everyone to TB?  

 

 

To put this issue to rest

 

This is the statement from UpToDate (summary is + ppd = CXR and treatment based on results, and if from a place where they might have been vaccinated, order the blood tests for TB)

 

 

TST reactivity caused by BCG sensitization can be distinguished from latent TB infection by interferon-gamma release assays. (See "Interferon-gamma release assays for diagnosis of latent tuberculosis infection".)

 

Treating positive tests — Patients with positive tuberculin skin test or IGRA results must undergo clinical evaluation to rule out active tuberculosis prior to treatment for latent infection. This includes evaluation for symptoms (eg, fever, cough, weight loss), physical examination, and radiographic examination of the chest.

A chest radiograph is considered abnormal if it demonstrates parenchymal abnormalities, particularly upper lobe opacification. Radiographs demonstrating stable upper lobe fibro-nodular disease or calcified granulomas are considered to have evidence of previous tuberculosis and indicate the patient is at increased risk of reactivation (table 2). There is no role for routine radiography for patients with positive tuberculin skin test who do not complete treatment for LTBI [25-27].

Patients with symptoms or radiographic signs suggestive of active disease should undergo evaluation with sputum microscopy and culture and receive treatment as appropriate. Sputum induction should be performed if patients cannot expectorate spontaneously. Symptoms related to extrapulmonary sites should also be evaluated as appropriate. In addition, HIV testing should be considered in patients with LTBI. (See "Diagnosis of pulmonary tuberculosis in HIV-negative patients" and "Treatment of pulmonary tuberculosis in HIV-negative patients" and "Screening and diagnostic testing for HIV infection".).

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do you want to be the provider that cleared that patient, and did not get a CXR, only to find out that they do indeed have pulmonary TB and have been walking around exposing everyone to TB?

 

 

You are changing the context of the discussion. We are talking about policies for employers or schools on ppd positive individuals. The fact of the matter is that a yearly cxr is not needed and many places don't require it. I provided a recent negative cxr when I started PA school and from then on received a yearly questionnaire. At the start of my residency(at a very large hospital system) I had to provide the results of a previous negative cxr and was asked about recent symptoms. For the record, I did take 9 months of inh but have never been asked whether I had.

 

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You are changing the context of the discussion. We are talking about policies for employers or schools on ppd positive individuals. The fact of the matter is that a yearly cxr is not needed and many places don't require it. I provided a recent negative cxr when I started PA school and from then on received a yearly questionnaire. At the start of my residency(at a very large hospital system) I had to provide the results of a previous negative cxr and was asked about recent symptoms. For the record, I did take 9 months of inh but have never been asked whether I had.

 

Sent from my Nexus 5 using Tapatalk

 

 

Not sure I agree I am changing the dicussion - 

OP asked how many neg CXR is enough on +PPD

 

If you have not been treated, then yearly CXR if your employer requires a yearly PPD - as this will always be positive

 

you could test with Quant Gold if you wanted to know rather this is  LTBI or a + PPD from vaccination - and this will answer the question - if PPD + and neg Quant Gold - and they have been vaccinated in the past then the + PPD is from Vaccination - if they are both positive then the person has LTBI and should be treated.  If they have LTBI and have not been treated then I think it prudent, from a public and personal health perspective, to have yearly CXR

 

Remember typhoid mary??  

 

But this is just my read of the UpToDate and guidelines as I read them, but we are all free to do our own thing......  even if it is illogical.....

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Not sure I agree I am changing the dicussion - 

OP asked how many neg CXR is enough on +PPD

 

If you have not been treated, then yearly CXR if your employer requires a yearly PPD - as this will always be positive

 

you could test with Quant Gold if you wanted to know rather this is  LTBI or a + PPD from vaccination - and this will answer the question - if PPD + and neg Quant Gold - and they have been vaccinated in the past then the + PPD is from Vaccination - if they are both positive then the person has LTBI and should be treated.  If they have LTBI and have not been treated then I think it prudent, from a public and personal health perspective, to have yearly CXR

 

Remember typhoid mary??  

 

But this is just my read of the UpToDate and guidelines as I read them, but we are all free to do our own thing......  even if it is illogical.....

 

 

 

Yeah I hear ya...but you know how illogical the CDC can be with all of their facts and science and such hocus pocus.

 

 

Are periodic chest radiographs recommended for HCWs (or staff or residents of LTCFs) who have positive TST or BAMT results?

 

No, persons with positive TST or BAMT results should receive one baseline chest radiograph to exclude a diagnosis of TB disease. Further chest radiographs are not needed unless the patient has symptoms or signs of TB disease or unless ordered by a physician for a specific diagnostic examination. Instead of participating in serial skin testing, HCWs with positive TST results should receive a medical evaluation and a symptom screen. The frequency of this medical evaluation should be determined by the risk assessment for the setting. HCWs who have a previously positive TST result and who change jobs should carry documentation of the TST result and the results of the baseline chest radiograph (and documentation of treatment history for LTBI or TB disease, if applicable) to their new employers

 

http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

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The caveat is that I would be seeing this person to "clear them for work"  and I would want to know that they are not walking around with active TB.

 

You above underlined quote makes sense, to me, you can not exclude TB based on a negative CXR, and I am doing an exam for a specific reason.

 

No, persons with positive TST or BAMT results should receive one baseline chest radiograph to exclude a diagnosis of TB disease(yup CXR is only to R/O pulmonary TB - and it must be negative in order to be treated for LTBI). Further chest radiographs are not needed unless the patient has symptoms or signs of TB disease or unless ordered by a physician for a specific diagnostic examination - HUMM you are being asked to perform specific exam to exclude any evidence of a contagious chronic disease (that seems to be the verbiage I always see on these forms which I am signing to the effect/certifying)

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The caveat is that I would be seeing this person to "clear them for work"  and I would want to know that they are not walking around with active TB.

 

You above underlined quote makes sense, to me, you can not exclude TB based on a negative CXR, and I am doing an exam for a specific reason.

 

No, persons with positive TST or BAMT results should receive one baseline chest radiograph to exclude a diagnosis of TB disease(yup CXR is only to R/O pulmonary TB - and it must be negative in order to be treated for LTBI). Further chest radiographs are not needed unless the patient has symptoms or signs of TB disease or unless ordered by a physician for a specific diagnostic examination - HUMM you are being asked to perform specific exam to exclude any evidence of a contagious chronic disease (that seems to be the verbiage I always see on these forms which I am signing to the effect/certifying)

 

 

I spent a lot of time reading both the link you provided and the newest CDC TB health care worker education.

 

I see your point in the avoidance of repeat CXR for a HCW employed in the same facility with the same risk stratification setting - yes indeed could just use symptom screening.  However the HCW training does talk about about getting a CXR as part of initial + and if there is any clinical reason for exam.  

 

I guess it just comes down to the what we are comfortable with - I tended to be hired by a company to ensure that the new employee was disease free.  As they have a Hx of PPD + and the employer is looking for as much info on file as possible - I get CXR.

 

Just my style, but I see your point.  

 

good resource i found.....  http://www.cdc.gov/tb/webcourses/TB101/intro.html  

 

 

 

 

 

The bigger issue is why not get treatment and put the issue to rest??? 

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I spent a lot of time reading both the link you provided and the newest CDC TB health care worker education.

 

I see your point in the avoidance of repeat CXR for a HCW employed in the same facility with the same risk stratification setting - yes indeed could just use symptom screening.  However the HCW training does talk about about getting a CXR as part of initial + and if there is any clinical reason for exam.  

 

I guess it just comes down to the what we are comfortable with - I tended to be hired by a company to ensure that the new employee was disease free.  As they have a Hx of PPD + and the employer is looking for as much info on file as possible - I get CXR.

 

Just my style, but I see your point.  

 

good resource i found.....  http://www.cdc.gov/tb/webcourses/TB101/intro.html  

 

 

 

 

 

The bigger issue is why not get treatment and put the issue to rest??? 

 

My point was not that repeat cxr aren't needed in the same facility.  It was that they aren't needed AT ALL and the CDC document that I linked says as much.  ONE initial cxr after becoming ppd positive is all that is needed unless a person is symptomatic(which is what is meant by a clinical reason for an exam). You keep approaching this as if you, personally, are going to be held responsible if someone has TB and you cleared them, which is ridiculous.  First off, most healthcare employers and schools have their own employee/student health departments that handle this issue.  Second, nobody is going to fault you if you're going by current guidelines and what a patient is telling you(document!).

 

Getting prophylactic treatment does not make someone less infectious as a person with LTBI is not infectious to begin with.  It only lowers the chance of reactivation.  Getting a cxr beyond the initial one does not provide any info unless the person is symptomatic and it exposes a patient to unnecessary radiation.  .

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My point was not that repeat cxr aren't needed in the same facility.  It was that they aren't needed AT ALL and the CDC document that I linked says as much.  ONE initial cxr after becoming ppd positive is all that is needed unless a person is symptomatic(which is what is meant by a clinical reason for an exam). You keep approaching this as if you, personally, are going to be held responsible if someone has TB and you cleared them, which is ridiculous.  First off, most healthcare employers and schools have their own employee/student health departments that handle this issue.  Second, nobody is going to fault you if you're going by current guidelines and what a patient is telling you(document!).

 

Getting prophylactic treatment does not make someone less infectious as a person with LTBI is not infectious to begin with.  It only lowers the chance of reactivation.  Getting a cxr beyond the initial one does not provide any info unless the person is symptomatic and it exposes a patient to unnecessary radiation.  .

 

I understand what you are saying and I will learn from this thread!

 

But I would be responsible for it as I was the Occ Health PA signing off for their employer.  We were a small Occ Health/PCP/Urgent care clinic and any + PPD would get a CXR and referral to the TB Clinic. If I did not do this the head of the clinic and the state infectious disease nurse would politely correct me (I would guess the nurse was notified for CXR taken for +PPD).    So I was held responsible, and there was a very specific process to handle + PPD's as directed by the state nurse who took her orders from the Pulm Doc. This is from the state Public health which I find a nice summary - and in reflecting on my own experience, I am not sure how many known +PPD I saw - most the time it was a new Dx.

 

 

 

Tuberculosis A health care worker must present evidence-based certification that he/she is free of active tuberculosis prior to employment. The following tests are acceptable:

 

1. A negative two-step tuberculin skin test using purified protein derivative (PPD). A two-step test is defined as the application and reading of two consecutive PPD tests. Optimally the second PPD should be administered 1-3 weeks after the first. The maximum allowable interval between the first and the second dose cannot be more than 365 days for it to qualify as a two step procedure.

 

2. The health care worker with a history of a positive PPD skin test result in the past is required to present proof that he/she is currently free of active disease. Such proof may include:

 

a) Physician documentation of a negative chest X-ray at the time the PPD was first read positive, accompanied by physician certification that the person is currently free of signs and symptoms of active TB. NOTE: Such a chest x-ray may be completed at any time prior to hire, provided that it is accompanied by a physician certification that the health care worker is currently free of signs and symptoms of active disease. OR  

 

b) In the absence of a negative chest X-ray at the time the PPD was first read as positive, a chest X-ray should be documented as negative before the person can start work. This X-ray must be done at any time prior to hire provided it is after the PPD was first noted to be positive and the person currently remains symptom free. OR

 

c) Physician certification of completion of a course of prophylactic therapy for latent TB infection, or completion of therapy for active disease in the past and the person currently remains symptom free. OR

 

d) Physician certification that the health care worker is currently free of active TB disease based on his/her clinical assessment. Because there can

be many complex clinical scenarios with TB infection and disease, the practitioner may exercise judgement in certifying a person free of infectious TB.

 

 

 

 

 

 

 

 

Just a different way of dealing with it - and I see your point and will learn from it.

 

 

 

For those with a + PPD and ZERO signs of TB, no CXR, just offer treatment and document no signs of TB.....

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  • 1 year later...

Sorry to bring up an old topic, but I was doing some reading on this subject tonight.

 

I am curious to know what the protocol is for a patient who has a positive PPD for the first time, has a chest x-ray which then returns as negative.  They are completely asymptomatic for tuberculosis.  Then what...

 

Based on the reading I have done it seems to suggest a 9 month course of INH for latent tuberculosis.  Is this the correct interpretation?

 

Does it matter if they had the BCG Vaccine?  I assume not?  Is there any instance in which you would not treat a patient with a positive PPD for latent tuberculosis?

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I understand what you are saying and I will learn from this thread!

 

But I would be responsible for it as I was the Occ Health PA signing off for their employer.  We were a small Occ Health/PCP/Urgent care clinic and any + PPD would get a CXR and referral to the TB Clinic. If I did not do this the head of the clinic and the state infectious disease nurse would politely correct me (I would guess the nurse was notified for CXR taken for +PPD).    So I was held responsible, and there was a very specific process to handle + PPD's as directed by the state nurse who took her orders from the Pulm Doc. This is from the state Public health which I find a nice summary - and in reflecting on my own experience, I am not sure how many known +PPD I saw - most the time it was a new Dx.

 

 

 

Tuberculosis A health care worker must present evidence-based certification that he/she is free of active tuberculosis prior to employment. The following tests are acceptable:

 

1. A negative two-step tuberculin skin test using purified protein derivative (PPD). A two-step test is defined as the application and reading of two consecutive PPD tests. Optimally the second PPD should be administered 1-3 weeks after the first. The maximum allowable interval between the first and the second dose cannot be more than 365 days for it to qualify as a two step procedure.

 

2. The health care worker with a history of a positive PPD skin test result in the past is required to present proof that he/she is currently free of active disease. Such proof may include:

 

a) Physician documentation of a negative chest X-ray at the time the PPD was first read positive, accompanied by physician certification that the person is currently free of signs and symptoms of active TB. NOTE: Such a chest x-ray may be completed at any time prior to hire, provided that it is accompanied by a physician certification that the health care worker is currently free of signs and symptoms of active disease. OR  

 

b) In the absence of a negative chest X-ray at the time the PPD was first read as positive, a chest X-ray should be documented as negative before the person can start work. This X-ray must be done at any time prior to hire provided it is after the PPD was first noted to be positive and the person currently remains symptom free. OR

 

c) Physician certification of completion of a course of prophylactic therapy for latent TB infection, or completion of therapy for active disease in the past and the person currently remains symptom free. OR

 

d) Physician certification that the health care worker is currently free of active TB disease based on his/her clinical assessment. Because there can

be many complex clinical scenarios with TB infection and disease, the practitioner may exercise judgement in certifying a person free of infectious TB.

 

 

 

 

 

 

 

 

Just a different way of dealing with it - and I see your point and will learn from it.

 

 

 

For those with a + PPD and ZERO signs of TB, no CXR, just offer treatment and document no signs of TB.....

Under circumstances A/B... The patient does not have active tuberculosis.  How can you know that they don't have latent disease?  I have read that as many as 10% of people with latent TB will develop active TB at some point during their lifetime.... 

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I had two negative quantiferon gold tests, over 20 negative chest x rays, a negative sputum and 4 chest CT's in less than 4 months related to a pleural effusion. Some how it wasn't enough for my PA program to prove I didn't have TB.  They required me to pay out of pocket for the PPD since my insurance company refused to pay, amazingly it was negative too.  For once the insurance company was right to refuse unnecessary diagnostics.  

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