[MCOH-EH] [EXTERNAL] Re: Re: TB screening question

[Sally Foster-Chang]

There is clearly a burning need for more research on when and when not to
re-test.  When we initiated an IGRA based program, we re-tested a number of
our prior positive PPDs employees. Most did test positive, but a few did
not.  One employee had worked in a Leprosy clinic and had a history of a
positive PPD and a reaction to prophylactic treatment for latent TB  (which
meant the treatment was never finished).  Leprosy is one of those diseases
that can cause a false positive PPD and may also cross-react with an IGRA.
Apparently, Leprosy can be cleared by the immune system and not result in
symptoms.  This employee's IGRA was negative, but the employee was still
placed in the "group to watch".

Some of the current research suggests PPDs might be better at identifying
remote TB infections, while IGRAs might be better at picking up more recent
infections (if you need references, let me know). There are also cases
where individuals appear to spontaneously clear TB or revert to negative
after treatment.  Sometimes doing more testing can just blur the picture.
It is indeed a delicate balance. As several of my esteemed colleagues have
very appropriately advised, documentation, risk assessment,
symptom screening and annual TB education are essential!






On Thu, Feb 9, 2023 at 12:36 PM Swift, Melanie D., M.D., M.P.H. via MCOH-EH
<mcoh-eh at mylist.net> wrote:

> Agree these specific questions can pose quandaries, if asked on an annual
> symptom questionnaire. The immunosuppression question is helpful if you
> have tested them and they have a positive test, declined LTBI treatment,
> and are now immunocompromised which might change their decision to accept
> treatment. We incorporate this concept in an annual reinvitation to get
> treatment for everyone with untreated LTBI.
>
>
>
> The travel question on hire can be informative if their baseline test is
> positive. On an annual basis, it just serves to prompt them to consider
> testing, if you are surveying people without a prior positive test who are
> not required to get annual testing for their job role. But you may just be
> surveying people with known untreated LTBI in which case it is not useful.
>
>
>
> We use all these questions in the baseline screening, but we actually
> adapted our annual questionnaire to remove these questions *except* in
> states where public health depts require either symptom survey for everyone
> or require these questions specifically for annual surveys. Do check with
> your state TB control program before adapting the survey.
>
>
>
> Melanie
>
>
>
> *From:* Enass Awad <umhaneen at gmail.com>
> *Sent:* Thursday, February 09, 2023 11:14 AM
> *To:* MCOH-EH <mcoh-eh at mylist.net>
> *Cc:* Swift, Melanie D., M.D., M.P.H. <Swift.Melanie at mayo.edu>
> *Subject:* [EXTERNAL] Re: [MCOH-EH] Re: TB screening question
>
>
>
> Hi everyone:
>
> Tagging along on the TB topic but about symptom screening questionnaires
> for annual TB surveillance.
>
>   When employees answer “ yes” for history of travel to a TB prevalent
> country for one month or more , do you require them to do a test if they
> are asymptomatic?
>
>
>
> Same inquiry about what do you do if the employee answers yes to the “ do
> you have current or planned immunosuppression !
>
>
>
> Our hospital currently tests employees if they said yes to the travel
> question whether or not they are symptomatic which am not sure is necessary
> ? Any one aware  of what data supports  this ? With the immune suppression
> we are testing only those who are symptomatic !!
>
>
>
> Thanks much ,
>
> Enass Arahman, MD, MPH,FACOEM
>
>
>
> Medical Director Employee Health Services
>
> UC Davis Health
>
> Sacramento, CA
>
>
>
> On Wed, Feb 8, 2023 at 12:10 Swift, Melanie D., M.D., M.P.H. via MCOH-EH <
> mcoh-eh at mylist.net> wrote:
>
> Dr. Thrasher, attached is the NTCA-ACOEM collaborative guidance document
> on TB testing and treatment in healthcare personnel. The preplacement
> evaluation recommendations for HCP with a prior positive TB test begin at
> the bottom of page e358.
>
>
>
> Recommendations are essentially the same for prior treated LTBI and prior
> treated active TB. Document the dates and confirmation of completed
> treatment. For active TB they should have a clearance document from their
> public health department at the completion of therapy. A symptom screen
> would be recommended, but as long as she is asymptomatic and you have
> documentation of her prior positive IGRA and/or TST at the time of her
> original diagnosis, documentation of complete treatment and clearance of
> the active infection, then there really is no testing or imaging
> recommended. The key will be obtaining that documentation. If she has none,
> then as Sally recommends you could get an IGRA now (likely would be
> positive) and follow your usual clearance process. You can do a single view
> CXR with abdominal shielding, should records be unavailable and you need to
> exclude active TB. If you have the records though, no need to image her
> unless she is symptomatic or her treatment wasn’t complete.
>
>
>
> Melanie
>
>
>
> *Melanie Swift, MD, MPH*
>
> (she/her)
> Vice Chair, Division of Public Health, Infectious Diseases and
> Occupational Medicine
>
> Medical Director, Mayo Clinic Physician Health Center
> <https://www.mayoclinic.org/departments-centers/preventive-occupational-aerospace-medicine/physician-health-center/referrals>
>
> Associate Medical Director, Occupational Health Service
>
> _______________________________
> *Mayo Clinic*
> 200 First Street SW
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>
> *From:* MCOH-EH <mcoh-eh-bounces+swift.melanie=mayo.edu at mylist.net> *On
> Behalf Of *Sally Foster-Chang
> *Sent:* Wednesday, February 8, 2023 11:20 AM
> *To:* MCOH-EH <mcoh-eh at mylist.net>
> *Subject:* [EXTERNAL] Re: [MCOH-EH] TB screening question
>
>
>
> I’d do an IGRA. At least you would have a baseline.
>
>
>
> On Wed, Feb 8, 2023 at 12:02 PM dennis thrasher via MCOH-EH <
> mcoh-eh at mylist.net> wrote:
>
> Any recommendations for a new-hire nurse applicant? She is pregnant and
> has previously been treated for active TB.
> Thanks.
> Dennis Thrasher, MD, MPH
> sunnyside at dakotacom.net
> 520 247 1397
>
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> --
>
> Enass Awad A/Rahman,MD,MPH
> Department of Occupational Medicine
> Mercy Medical Group
> 3000 Q Street
> Sacramento,CA,95816
> Tel: 916-733-3390
>
>
> "We can enrich the world if we choose to embrace our similarities; we can
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> The MCOH-EH List has always been moderated by members of the ACOEM Medical
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> MediTrax / Occupational Health Systems, Inc. provides financial support to
> ensure the list remains a free resource for the occupational health
> community.
> ---------------------------------------
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