09-01 TB Screening

Letter to Chief Executive Officer
Number 09-01
Date January 8, 2009
Subject TB Screening

Dear Chief Executive Officer:

The purpose of this letter is to clarify changes in requirements for employee tuberculosis (TB) screening in hospitals and diagnostic and treatment centers in New York State. The New York State Department of Health (NYSDOH) requires a medical evaluation of all health care workers prior to employment in these facilities, which must include tuberculosis screening. TB screening may be done with any approved test to detect M. tuberculosis infection, such as the tuberculin skin test (TST), or one of the whole blood interferon-gamma release assays (IGRAs) approved by the Food and Drug Administration (FDA).

At this time, approved IGRAs include QuantiFERON-TB Gold, 2005; QuantiFERON-TB Gold In-Tube, 2007; and TSpot.TB, 2008. NYSDOH regulations, including 405.3(b)(10)(iv) for hospitals and 751.6(d)(4) for Diagnostic and Treatment Centers, will be amended to allow the use of these tests as an acceptable alternative to the tuberculin skin test, when used in accordance with the product insert. However, health care employers may incorporate these tests into employee screening protocols effective immediately.

Existing national guidelines include the December 30, 2005 Guidelines for preventing transmission of Mycobacterium tuberculosis in health care settings [MMWR 2005;54(NoRR-17) and the December 16, 2005 Guidelines for using the QuantiFERON-TB Gold Test for detecting Mycobacterium tuberculosis infection, United States [MMWR 2005;54 (NoRR-15). Further guidance on the use of these blood tests will be issued by the Centers for Disease Control and Prevention (CDC) and by the New York State Department of Health in 2009.

Employee TB Screening Prior to Employment

Baseline TB screening of all employees should be conducted with an approved test. The tuberculin skin test (TST) can be used to screen for tuberculosis infection, using the Mantoux method with 5 tuberculin units of purified protein derivative (PPD). Employees are not allowed to read or interpret their own TST results. When performing a TST, the manufacturer, lot number, date placed, results in millimeters of induration, date read and names of persons placing, reading and interpreting the test should be documented.

When the TST is used, two-step testing is recommended as a baseline for newly hired employees. For two-step testing, persons whose initial TST result is negative are given a second TST , administered 1-3 weeks after the first TST was placed. The two-step test is needed at baseline because in some persons with latent TB infection, the reaction to a TST wanes over time. The initial TST may "boost" responses to a subsequent test. In the absence of a known exposure, a positive reaction to the second-step of a two-step TST is considered to be due to boosting as opposed to recent infection with M. tuberculosis. A second TST is not needed if an employee has had a documented, negative TST during the previous 12 months. If an IGRA test is used for screening, there is no need to perform a two-step baseline. The TST reading(s) and/or the IGRA laboratory report should be documented in the employee health record.

Any employee found to be positive upon initial TB screening should undergo a clinical evaluation, including a baseline chest x-ray examination. Employees should not be allowed to work until active pulmonary or laryngeal TB disease has been ruled out.

At initial hire, employees with documentation of a previous positive TST or IGRA, or treatment for latent TB infection or TB disease do not need to undergo a TST or IGRA. These employees should be clinically evaluated for symptoms suggestive of TB including a cough for >3 weeks, loss of appetite, unexplained weight loss, night sweats, bloody sputum (hemoptysis), hoarseness, fever, fatigue, or chest pain. If symptomatic, a chest x-ray examination and further clinical evaluation are indicated prior to employment.

Annual TB Screening of Employees in New York State Hospitals and D&TCs

Annual TB screening of employees must be performed in hospitals and D&TCs in New York State. If previously negative, the TST or QFT should be performed. If previously positive, a screen for symptoms should be performed and the employee evaluated as appropriate. Routine, annual follow-up chest x-rays are not required. All screening activities should be documented in the employee health record.

An employee who is found to be a converter (defined as an individual with a >10 millimeter (mm) increase in the size of TST induration, or with a positive IGRA, after establishing a prior negative baseline TB screening test) must be assessed for active TB disease (clinical evaluation and chest x-ray examination). If active TB disease is suspected or diagnosed, the employee should not return to work until TB disease has been ruled out. If an employee is found to have active TB disease, the employee may not return to work until clinically determined to be non-infectious. Clusters of TST or IGRA conversions or active TB disease in an employee must be reported to the local and state health departments.

For employees who work in non-clinical, off site locations, annual TB screening is not required. However, in all cases in which staff is exempted from the requirement of an annual PPD test, the provider must document the specific settings and work titles that have been exempted in written occupational health protocols that must be maintained on file at the facility.

Additional Information

For additional information on TB screening issues, contact the Bureau of Tuberculosis Control, New York State Department of Health 518-474-7000, or e-mail the Bureau at tbcontrol@health.state.ny.us.


Margaret J. Oxtoby, M.D., Director
Bureau of Tuberculosis Control
Division of Epidemiology

Mary Ellen Hennessy
Division of Certification and Surveillance