[MCOH-EH] Question on Targeted Annual TB screenings in low risk hospital employees???

Thanassi, Wendy Wendy.Thanassi at va.gov
Thu Nov 15 15:11:26 PST 2018
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Hello David, To clarify. this is just an idea at this point – it doesn’t exist in practice. It doesn’t make sense to me that staff can carry such an easily treatable but highly contagious disease through the hospital, so I believe it’s a good idea.

Here at VA we can legally prevent illness (flu, hep a, shingles etc., but we are not supposed to treat non-work-related illness). So if I am to pull this off I would clarify that we are not treating LTBI, we are preventing active TB disease. Yes, we would treat here either in OH or in IM/ID. We would use a short-course of 3HP (12 days of abx) or 4 months of rif. Or perhaps we’d ask for verification of treatment from their PMD. Or for a signed waiver from the PMD. Either way, I think this is the direction the US should go if we want to get serious about eliminating TB disease.

Wendy

Wendy Thanassi MA, MD, MRO
Chief, Occupational Health Service
VA Palo Alto HCS
Stanford Associate Professor
Emergency Medicine

From: Cockrum, MD David S [mailto:dcockrum at frhs.org]
Sent: Thursday, November 15, 2018 11:36 AM
To: MCOH/EH <mcoh-eh at mylist.net>
Cc: Thanassi, Wendy <Wendy.Thanassi at va.gov>
Subject: [EXTERNAL] RE: Question on Targeted Annual TB screenings in low risk hospital employees???

Wendy-

I share your opinion – though I’m still battling to get our system to go with QFT only.

One question – if treatment for LTBI is mandatory for employment, is your system going to pay for it? Currently we defer treatment to the employee’s own expense since we aren’t mandating it, and we then put them on the list for annual symptom screening. But if there is a requirement for treatment, then I think the employer would be obligated to pay for it, right?

Thanks,

David

DAVID


COCKRUM

,

MD



Physician

Faith Regional Physician Services

Occupational Health



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From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Thanassi, Wendy via MCOH-EH
Sent: Wednesday, November 14, 2018 12:30 PM
To: MCOH/EH <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Cc: Thanassi, Wendy <Wendy.Thanassi at va.gov<mailto:Wendy.Thanassi at va.gov>>
Subject: Re: [MCOH-EH] Question on Targeted Annual TB screenings in low risk hospital employees???


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As you have listed in your table below, low-risk health care workers should not be getting annual testing. This goes back to 2005 and 2010 MMWR and will be emphasized and reiterated again in the 2018 MMWR. Recommendations from ATS/CDC/IDSA and NTCA are for HCW to get testing on hire and after exposure only.

We use QFT. We are STRONGLY encouraging workers who arrive with positive testing for LTBI to be treated, since the new short-course regimens are so safe and easy (12 doses of abx in the case of 3HP). I would like to make it a condition of hire and am exploring options for that for VA.

Wendy
Wendy Thanassi MD, MA, MRO
Chief, Occupational Health Service
Office of the Deputy Chief of Staff
Palo Alto, California 94304
650-493-5000 x 11-65214

Clinical Associate Professor, Stanford Hospital and Clinics
Emergency Medicine
1 Pasteur Drive
Stanford, CA 94305

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Shadowens, Lisa M
Sent: Wednesday, November 14, 2018 10:22 AM
To: MCOH/EH <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Subject: [EXTERNAL] Re: [MCOH-EH] Question on Targeted Annual TB screenings in low risk hospital employees???

Annually you do what for HCW employees? TSPOT? Or targeted testing for TB?

Lisa M. Shadowens, RN, CNOR.
St. Francis WorkWell Occupational Health
Employee Health Coordinator
135 Commonwealth Dr., Ste 120
Greenville, SC. 29615
Office 864.675.4681
Fax 864.675.4682
~Be the change you want to see~


From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of PRATER, DEANNA
Sent: Wednesday, November 14, 2018 1:07 PM
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Cc: Morehart, Tamara; Diaz, Denise
Subject: #ExtMail# Re: [MCOH-EH] Question on Targeted Annual TB screenings in low risk hospital employees???

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We do a TSPOT upon hire.  No more two step testing.

From: MCOH-EH <mcoh-eh-bounces at mylist.net<mailto:mcoh-eh-bounces at mylist.net>> On Behalf Of Shadowens, Lisa M
Sent: Wednesday, November 14, 2018 09:45
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Cc: Morehart, Tamara <TAMARA_MOREHART at bshsi.org<mailto:TAMARA_MOREHART at bshsi.org>>; Diaz, Denise <Denise_Diaz at bshsi.org<mailto:Denise_Diaz at bshsi.org>>
Subject: [MCOH-EH] Question on Targeted Annual TB screenings in low risk hospital employees???

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Hello,

Thank you in advance!! I would like to know your responses to my question on:


How do other hospitals do their ANNUAL LOW RISK Healthcare Workers TB screenings?  Is anyone using the CDC and DHEC recommended practice of TARGETED TESTING, only doing annual respiratory TB sign/symptoms questionnaire? I went to a recent TB DHEC 3 day conference and ALL the TALK WAS MOVING TO TARGETED TB TESTING BASED ON RISK LEVELS. Bon Secours St Francis is now/currently doing TSPOT TB IGRA test on our new hire on-boarding, and have stopped all two (2) step TST. We are moving forward with policy changes and I need input on annual practices and TB exposure for employees. I understand the Employee Health Reg. #601 to offer best practice CDC guidance and use Appendix B for calculating your risk. Attached doc to read.

 Regulation 61-16

Minimum Standards for Licensing Hospitals and Institutional General Infirmaries



My state, city, and hospital is and has been in the LOW RISK category for MTB for over 10 years. The CDC Targeted testing information sheet for HCWs is as follows:


[Testing Health Care Workers]
Tuberculosis (TB) transmission has been documented in health care settings where workers and patients come in contact with people who have TB disease.  Periodic testing of health care workers is recommended as part of a TB Infection Control Plan and may be required by state regulations.
TB testing programs should include anyone working or volunteering in health-care settings.  Persons (health care workers and non- health care workers) who have face to face contact or potential exposure to TB through shared air or space with infectious patient(s) should be part of a TB testing program.
There are two types of testing for TB in health care workers.
•         Initial baseline testing upon hire: Two-step testing with a TB skin test or a TB blood test
•         Annual or serial screening: determined by state regulations or risk assessment outcomes.
•         Frequency of TB Testing<https://na01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cdc.gov%2Ftb%2Ftopic%2Ftesting%2Fhealthcareworkers.htm%23tabs-2-1&data=02%7C01%7Cdcockrum%40frhs.org%7Ca8116e1658ae4c924b6508d64b1656f8%7Ca5250d802de049728b97184a3c848efa%7C1%7C1%7C636778956670969647&sdata=fmONxAd462N%2B63x%2FAOXmOrIAMo7jEeqJU8PtlKAPoco%3D&reserved=0>
•         TB Skin Test: Two-Step Testing<https://na01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cdc.gov%2Ftb%2Ftopic%2Ftesting%2Fhealthcareworkers.htm%23tabs-2-2&data=02%7C01%7Cdcockrum%40frhs.org%7Ca8116e1658ae4c924b6508d64b1656f8%7Ca5250d802de049728b97184a3c848efa%7C1%7C1%7C636778956670969647&sdata=gXtlyPzeeMCyXJDDW9A7%2FtB%2F4ykBwCZRtbFRYWKfxZQ%3D&reserved=0>
•         TB Blood Test<https://na01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cdc.gov%2Ftb%2Ftopic%2Ftesting%2Fhealthcareworkers.htm%23tabs-2-3&data=02%7C01%7Cdcockrum%40frhs.org%7Ca8116e1658ae4c924b6508d64b1656f8%7Ca5250d802de049728b97184a3c848efa%7C1%7C1%7C636778956670979655&sdata=DsBNzqN1E5qskwclPciPhjRHMYaOo2WyhBOBCSkmzVE%3D&reserved=0>
Frequency of TB Testing
Health care facilities have different TB testing requirements.  Facilities should conduct staff TB testing based on risk classification.
Risk classification

Frequency of testing

Low

Baseline; then test if TB exposure occurs

Medium

Baseline, then annually

Potential ongoing transmission

Baseline, then every 8–10 weeks until evidence of transmission has ceased

To determine the risk classification for your facility, review the infection control guidelines and complete the Appendix B. Tuberculosis (TB) Risk Assessment Worksheet(https://www.cdc.gov/tb/publications/guidelines/pdf/appendixb_092706.pdf)<https://na01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cdc.gov%2Ftb%2Fpublications%2Fguidelines%2Fpdf%2Fappendixb_092706.pdf&data=02%7C01%7Cdcockrum%40frhs.org%7Ca8116e1658ae4c924b6508d64b1656f8%7Ca5250d802de049728b97184a3c848efa%7C1%7C1%7C636778956670989663&sdata=RSD3gW3%2FM7%2FX1wI%2BwQqCPi3lfGTQjyG7p4FPDsuGewU%3D&reserved=0> (PDF – 195k).
Contact your State TB Control Program(https://www.cdc.gov/tb/links/tboffices.htm)<https://na01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cdc.gov%2Ftb%2Flinks%2Ftboffices.htm&data=02%7C01%7Cdcockrum%40frhs.org%7Ca8116e1658ae4c924b6508d64b1656f8%7Ca5250d802de049728b97184a3c848efa%7C1%7C1%7C636778956670989663&sdata=9SbbJXHQSfzMaqQ0%2B670tlnspTdDv%2BRIj80zLFO0lAE%3D&reserved=0> for information about health care worker TB testing requirements in your state.
Baseline Testing
A baseline test should be given prior to employment.  The result of this test can be compared with later tests (due to potential exposure or as part of annual testing) to help determine if recent TB transmission has occurred in the facility.
Annual or Serial Testing
You may need to test for TB on a regular basis.  To standardize the interpretation of results, the same test should be used for the baseline and the later tests.


Please share your policies and ideas with me as this is an Infection Prevention and Employee Health policy change that is meeting a bit of resistance….. I appreciate all your professional help!!!

Blessed,
Lisa


Lisa M. Shadowens, RN, CNOR.
St. Francis WorkWell Occupational Health
Employee Health Coordinator
135 Commonwealth Dr., Ste 120
Greenville, SC. 29615
Office 864.675.4681
Fax 864.675.4682
~Be the change you want to see~



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