Updated Recommendations

Recommendations from the 2005 CDC guidelines that are outside the scope of health care personnel screening, testing, treatment, and education remain unchanged (Table); this includes continuing facility risk assessments for guiding infection control policies and procedures. Here, TB screening is defined as a process that includes a TB risk assessment, symptom evaluation, TB testing for M. tuberculosis infection (by either IGRA or TST) for health care personnel without documented evidence of prior LTBI or TB disease, and additional workup for TB disease for health care personnel with positive test results or symptoms compatible with TB disease. This update does not include recommendations for using an IGRA versus a TST for diagnosing LTBI, which have been published elsewhere (16).

Baseline (preplacement) screening and testing. All U.S. health care personnel should have baseline TB screening, including an individual risk assessment (Box), which is necessary for interpreting any test result. The 2005 guidelines state that baseline test results provide a basis for comparison in the event of a potential or known exposure to M. tuberculosis, facilitate detection and treatment of LTBI or TB disease in health care personnel before placement, and reduce the risk to patients and other health care personnel (1). The risk assessment and symptom evaluation help guide decisions when interpreting test results. For example, health care personnel with a positive test who are asymptomatic, unlikely to be infected with M. tuberculosis, and at low risk for progression on the basis of their risk assessment should have a second test (either an IGRA or a TST) as recommended in the 2017 TB diagnostic guidelines of the American Thoracic Society, Infectious Diseases Society of America, and CDC (16). In this example, the health care personnel should be considered infected with M. tuberculosis only if both the first and second tests are positive.

Postexposure screening and testing. After known exposure to a person with potentially infectious TB disease without use of adequate personal protection, health care personnel should have a timely symptom evaluation and additional testing, if indicated. Those without documented evidence of prior LTBI or TB disease should have an IGRA or a TST performed. Health care personnel with documented prior LTBI or TB disease do not need another test for infection after exposure. These persons should have further evaluation if a concern for TB disease exists. Those with an initial negative test should be retested 8–10 weeks after the last exposure, preferably by using the same test type as was used for the prior negative test.

Serial screening and testing for health care personnel without LTBI. In the absence of known exposure or evidence of ongoing TB transmission, U.S. health care personnel (as identified in the 2005 guidelines) without LTBI should not undergo routine serial TB screening or testing at any interval after baseline (e.g., annually). Health care facilities might consider using serial TB screening of certain groups who might be at increased occupational risk for TB exposure (e.g., pulmonologists or respiratory therapists) or in certain settings if transmission has occurred in the past (e.g., emergency departments). Such determinations should be individualized on the basis of factors that might include the number of patients with infectious pulmonary TB who are examined in these areas, whether delays in initiating airborne isolation occurred, or whether prior annual testing has revealed ongoing transmission. Consultation with the local or state health department is encouraged to assist in making these decisions.

Health care personnel might have risks for TB exposure that are not related to their work in the United States, or they might have risks for TB progression after baseline testing that necessitate special consideration. If these risks are unrecognized, these health care personnel might experience TB disease and transmit TB to patients, coworkers, or other contacts. Therefore, health care facilities should educate all health care personnel annually about TB, including risk factors, signs, and symptoms; facilities also should encourage health care personnel to discuss any potential occupational or nonoccupational TB exposure with their primary care provider and occupational health clinician. The decision to perform TB testing after baseline should be based on the person’s risk for TB exposure at work or elsewhere since that person’s last test.

Evaluation and treatment of health care personnel with positive test results. Health care personnel with a newly positive test result (with confirmation for those persons at low risk as described previously) should undergo a symptom evaluation and chest radiograph to assess for TB disease. Additional workup might be indicated on the basis of those results. Health care personnel with a prior positive TB test and documented normal chest radiograph do not require a repeat radiograph unless they are symptomatic or starting LTBI treatment (16). The local public health department should be notified immediately if TB disease is suspected.

Health care personnel with LTBI and no prior treatment should be offered, and strongly encouraged to complete, treatment with a recommended regimen, including short-course treatments, unless a contraindication exists (17,18). Health care personnel who do not complete LTBI treatment should be monitored with annual symptom evaluation to detect early evidence of TB disease and to reevaluate the risks and benefits of LTBI treatment. These health care personnel also should be educated about the signs and symptoms of TB disease that should prompt an immediate evaluation between screenings.

Health care facilities should aim to identify LTBI among health care personnel and encourage LTBI treatment. Health care facilities are urged to collaborate with public health agencies to assist in achieving this goal. Public health agencies can serve as a source for technical assistance, medical consultation regarding diagnosis and treatment of LTBI, and clarification of state or local regulations, surveillance requirements, and guidelines. Sharing information and experiences with public health agencies is necessary for understanding the impact of these recommendations on the overall incidence of TB and LTBI in the United States and the need to revise future recommendations for health care personnel.