New TB testing guidelines from the CDC
Healthcare workers are at increased risk for TB, and the CDC will soon release updated tuberculosis testing guidelines that will change the way hospitals screen their patients and employees for TB.
On-demand webinar – new TB testing guidelines for healthcare workers
Join Dr. Masae Kawamura as she introduces the new 2019 national testing guidelines from the CDC and explores their implications for healthcare facilities.
Reduce onboarding time, increase patient time
Take the first step to streamlining your hiring with QuantiFERON-TB Gold Plus.
QuantiFERON-TB Gold Plus:
- Eliminates re-testing for no-shows
- Reduces overtime and temporary staffing costs
- Eliminates false-positive results from BCG vaccination
Unlike the TB skin test, QFT-Plus testing requires only a single patient visit.
The CDC further states that two-step testing is not required for IGRAs, like QFT-Plus, because IGRA testing does not boost subsequent test results (1).
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QFT-Plus streamlines healthcare worker TB control programs
Replacing the skin test with QFT-Plus provides reduced onboarding time and accurate exposure testing while improving surveillance quality and efficiency. IGRAs like QFT-Plus are preferred over the TST by the US CDC for patients who have received the Bacillus Calmette-Guérin (BCG) vaccination. Additionally, the CDC states that two-step testing is not required for IGRAs, because IGRA testing does not boost subsequent test results (1).
Healthcare workers are at increased risk of tuberculosis infection
Hospitals, clinics, and other congregate health settings are well recognized as areas of potential TB transmission. The transmission of TB of any kind (e.g., patient to worker, worker to worker, or worker to patient) within a healthcare setting can have significant consequences for healthcare operations, which is why many countries and institutions recommend or mandate regular surveillance of TB infection status among healthcare workers. Pre-employment and regular, ongoing screening for TB infection of doctors, nurses, custodial staff, and other health professionals help institutions monitor potential for occupational TB exposure and future infection. Implementation of targeted TB screening in groups with higher risk of exposure, such as healthcare workers, contributes significantly to effective TB control (2).
The tuberculin skin test may be insufficient in a healthcare setting
Besides the second appointment needed for test reading, the tuberculin skin test (PPD or TST) has several disadvantages. Cross-reactivity with non-tuberculous mycobacteria and – for healthcare workers even more important – the cross-reactivity with the Bacillus Calmette-Guérin (BCG) vaccine are responsible for the low specificity of the skin test. In some countries that have ceased BCG vaccination in the general population, healthcare workers are still vaccinated because they are considered a TB risk group. BCG vaccination has a profound impact on skin test results in healthcare worker population (2–5). In addition to the reductions in specificity caused by cross-reaction with BCG and non-tuberculous mycobacteria, repeated intradermal application of the tuberculin might result in an unwanted stimulation of the immune system of the healthcare worker, further lowering the specificity of the skin test in healthcare worker screening (2). Interpretation of the skin test can be complex, with three cut-offs commonly chosen based upon the patient’s background (≥ 5mm, ≥ 10mm, ≥ 15mm) (6).
QFT-Plus better identifies risk for TB infection in healthcare workers than the skin test
The use of Interferon Gamma Release Assays (IGRAs), like QFT-Plus, is more suited to the healthcare setting than the tuberculin skin test, particularly in countries of low TB burden, due to their high specificity and the potential for reducing costly unnecessary follow-up and treatment. Several studies have demonstrated that IGRAs, particularly QFT, have higher specificity over the skin test, principally in countries with low TB burden (7). In a metaanalysis, IGRA results were observed to be well correlated with TB infection risk factors, including occupational exposure, such as a healthcare worker's presence in a high-risk ward, TB clinic, or geriatric ward (8). Compared with the skin test, QFT demonstrates the highest specificity for TB infection (99.2%) in the general population in low TB prevalence settings (9). The use of QFT instead of the skin test would save between 25 to 98% of the chest x-rays needed to exclude active TB after a positive skin test.
To date, research indicates that the newest QuantiFERON TB test, QuantiFERON-TB Gold Plus (QFT-Plus), has shown good correlation and performance compared to its predecessor, QuantiFERON-TB Gold (QFT, 9), with publications on sensitivity (10–12), specificity (12, 13), utility in monitoring treatment (14), and importantly performance in healthcare workers (13). Like its predecessors, a positive QFT result correlates better to TB risk and is a better predictor of true infection from M. tuberculosis compared to the skin test (12).
Global migration increases the burden of latent TB infection
Tuberculosis is a truly global issue, especially in a healthcare setting. Migration from high TB burden countries to more developed, low TB burden countries can jeopardize infection control success. The prevalence of latent TB infection in migrants from high TB burden countries is high, and the risk of reactivation during the first years after migration is elevated (15). Therefore, TB risk in patients with a migration background is increased, yielding a potential source of infection for healthcare workers. Furthermore, migrating healthcare workers might import TB into the healthcare system of the host country. This stresses the need for pre-employment and ongoing or serial screening for latent TB infection of healthcare workers (16).
QFT-Plus can provide a more cost-effective approach than the skin test in healthcare settings
Although traditionally perceived as low-cost and simple, several factors drive inefficiency of the tuberculin skin test in the healthcare setting, including: Increased labor costs due to requirement for 2 visits, variable specificity of the skin test, particularly in BCG vaccinated individuals, requirement for specially trained personnel to administer the skin test, high inter- and intra-reader variability. In addition to these programmatic inefficiencies, due to its low specificity particularly in low prevalence populations with a mixed BCG vaccination status, the skin test is associated with other potential costs such as follow-up physician visits, unrequired antibiotic treatments, and chest x-rays. Several studies demonstrated that introducing interferon-gamma release assays, like QFT-Plus, to support TB screening of healthcare workers will improve the cost-effectiveness of the screening program (17–20).
1. US CDC. (2010) Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection — United States.
MMWRRecomm. Rep. 59 (RR-5), 1.
2. Costa, J.T., et al. (2009) Tuberculosis screening in Portuguese healthcare workers using the tuberculin skin test and the interferon-gamma release assay. Eur. Respir. J. 34, 1423.
3. Nienhaus, A., Schablon, A., Le Bacle, C., Siano, B., and Diel, R. (2008) Evaluation of the interferon-γ release assay in healthcare workers. Int. Arch. Occup. Environ. Health 81, 295.
4. Tripodi, D. et al. (2009) Evaluation of the tuberculin skin test and the interferon-gamma release assay for TB screening in French healthcare workers. J. Occ. Med. Tox. 4, 30.
5. Harada, N., Nakajima, Y., Higuchi, K., Sekiya, Y., Rothel, J., and Mori, T. (2006) Screening for tuberculosis infection using whole-blood interferon-gamma and Mantoux testing among Japanese healthcare workers. Infect.Control Hosp. Epidemiol. 27, 442.
6. US CDC (2005) Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR 54, RR-17.
7. ECDC European Centre for Disease Prevention and Control (2011) Guidance for the Use of interferon-gamma release assays in support of TB diagnosis. Stockholm. doi: 10.2900/38588.
8. Zwerling, A., van den Hof, S., Scholten, J., Cobelens, F., Menzies, D., and Pai, M. (2012) Interferon-gamma release assays for tuberculosis screening of healthcare workers: a systematic review. Thorax 67, 62.
9. QuantiFERON-TB Gold Plus (QFT-Plus) Package Insert, Rev. 04. February 2016.
10. Hoffmann, H., et al. (2016) Equal sensitivity of the new generation QuantiFERON-TB Gold plus in direct comparison with the previous test version QuantiFERON-TB Gold IT. Clin. Microbiol. Infect. 22, 701.
11. Yi , L., et al. (2016) Evaluation of QuantiFERON-TB Gold Plus for detection of Mycobacterium tuberculosis infection in Japan. Sci. Rep. 6, 30617.
12. Barcellini, L., et al. (2016) First Independent Evaluation of QuantiFERON-TB Plus Performance. Eur. Respir. J. 47,1587.
13. Moon, H et al. (2016) Evaluation of QuantiFERON-TB Gold Plus in Healthcare Workers in a Low-Incidence Setting, J. Clin. Microbiol. 55,1650.
14. Kamada, A., Amishima, M. (2017) QuantiFERON-TB® Gold Plus as a potential tuberculosis treatment monitoring tool. Eur. Respir. J. 49, 1601976.
15. Liu, Y. et al. (2012) Estimating the Impact of Newly Arrived Foreign-Born Persons on Tuberculosis in the United States. PLoS ONE 7, e32158.
16. Horsburgh C.R., and Rubin E.J. (2011) Clinical practice. Latent tuberculosis infection in the United States. N. Engl. J. Med. 364, 1441
17. Eralp, M.N., Scholtes, S., Martell, G., Winter, R., and Exley, A.R. (2012) Screening of healthcare workers for tuberculosis: development and validation of a new health economic model to inform practice. BMJ Open 2, e000630
18. de Perio, M., Tsevat, J., Roselle, G.A., Kralovic, S.M., and Eckman, M.H. (2009) Cost-effectiveness of Interferon Gamma Release Assays vs Tuberculin Skin Tests in Health Care Workers. Arch. Intern. Med 169, 179.
19. Nienhaus, A., Schablon, A., Costa, J.T., and Diel, R. (2011) Systematic review of cost and cost-effectiveness of different TB-screening strategies. BMC Health Serv. Res. 11, 247.
20. Pareek, M. et al. (2011) Screening of immigrants in the UK for imported latent tuberculosis: a multicentre cohort study and cost-effectiveness analysis. Lancet Infect. Dis. 11, 435.