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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


AFL 19-28
August 16, 2019


TO:
All Facilities

SUBJECT:
Updated Centers for Disease Control Tuberculosis Screening Recommendations for Health Care Personnel (HCP) and Nationwide Shortage of Tuberculin Skin Test Antigens

AUTHORITY:    Title 22 California Code of Regulations (CCR) sections 70723, 7152372535, 73525, 74723, 75335, 76539, 76919, 78429, 79331, and 79795


All Facilities Letter (AFL) Summary

  • This AFL announces the Centers for Disease Control and Prevention’s (CDC) new guidelines for tuberculosis (TB) screening of U.S. health care personnel (HCP).
  • This AFL also announces that the CDC has declared a nationwide shortage of the tuberculin skin test (TST) antigen Aplisol.
    Additionally, this AFL reminds providers that an approved program flexibility is required for a facility to deviate from the requirements in the Title 22 CCR, including TB screening requirements.

2019 CDC TB Recommendations

On May 17th, 2019, the CDC issued Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, updating the 2005 CDC recommendations. The CDC's new recommendations for annual serial TB testing for HCPs has changed based on data that indicates that the risk of occupational exposure for HCP has dropped substantially.

Comparison of 2005 and 2019 CDC recommendations for tuberculosis screening and testing of U.S. health care personnel

Category

2005 CDC Recommendation

2019 CDC Recommendation

Baseline (preplacement) screening and testing

TB screening of all HCP, including a symptom evaluation and test interferon-gamma release assay (IGRA) or tuberculin skin test (TST) for those without documented prior TB disease or latent TB infection (LTBI.)

TB screening of all HCP, including a symptom evaluation and test (IGRA or TST) for those without documented prior TB disease or LTBI (unchanged); individual TB risk assessment (new).

Post-exposure screening and testing

Symptom evaluation for all HCP when an exposure is recognized. For HCP with a baseline negative TB test and no prior TB disease or LTBI, perform a test (IGRA or TST) when the exposure is identified. If that test is negative, do another test 8–10 weeks after the last exposure.

Symptom evaluation for all HCP when an exposure is recognized. For HCP with a baseline negative TB test and no prior TB disease or LTBI, perform a test (IGRA or TST) when the exposure is identified. If that test is negative, do another test 8–10 weeks after the last exposure (unchanged).

Serial screening and testing for HCP without LTBI

According to health care facility and setting risk assessment. Not recommended for HCP working in low-risk health care settings. Recommended for HCP working in medium-risk health care settings and settings with potential ongoing transmission.

Not routinely recommended (new); can consider for selected HCP groups (unchanged); recommend annual TB education for all HCP (unchanged), including information about TB exposure risks for all HCP (new emphasis).

 

Below is the 2019 CDC TB risk assessment:          

Indicators of risk for tuberculosis at baseline health care personnel CDC Assessment:

Health care personnel should be considered to be at increased risk for TB if they answer "yes" to any of the following statements.

  1. Temporary or permanent residence (for ≥1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe), or

  2. Current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month), or other immunosuppressive medication, or  

  3. Close contact with someone who has had infectious TB disease since the last TB test
     

Nationwide TST Shortage

On June 21, 2019, the CDC announced a Nationwide Shortage of Tuberculin Skin Test Antigens: CDC Recommendations for Patient Care and Public Health Practice. The CDC expects the shortage of the TB testing antigen Aplisol to last 3-10 months.

The CDC recommends the following three general approaches to mitigate a reduction in TB testing capability resulting from the expected shortage of Aplisol:

  1. Substitute IGRA blood tests for TSTs. Clinicians who use the IGRA blood tests should be aware that the criteria for test interpretation are different from the criteria for interpreting TSTs.
  2. Substitute Tubersol for Aplisol for skin testing. In studies, the two skin test products give similar results for most patients.
  3. Prioritize allocation of TSTs, in consultation with state and local public health authorities. Prioritization might require the deferment of testing some persons. CDC recommends testing only for persons who are at risk for TB. Groups at high risk for TB infection include:
    • Persons who are recent contacts exposed to persons with TB disease;
    • Those born in or who frequently travel to countries where TB disease is common;
    • Those who currently or previously lived in large group settings (such as homeless shelters or correctional facilities);
    • Persons with compromised immune systems, including those with health conditions or taking medications that might alter immunity; and
    • Children, especially those aged <5 years, if they are in one of the risk groups noted above.

 

Program Flexibility

Health care facilities must continue to comply with the requirements in Title 22 CCR regarding TB screening. Although the regulations allow the use of any TB test approved by the Food and Drug Administration and recommended by the CDC, most Title 22 regulations require annual retesting.

If your facility wants to follow the new CDC guidelines for HCP:

  • See Attachment A, California Tuberculosis (TB) Testing Regulations for Health Care Facilities to determine if a program flexibility is required for your health facility
  • Develop and submit a TB Program Flexibility request (refer to Attachment B for a sample TB Program Flexibility request, and see AFL 18-19 for program flexibility guidance and instructions.

Primary Care Clinic TB testing requirements are located within California statute, which CDPH cannot grant a program flexibility from, and do not require annual testing (Health and Safety Code 1226.1).

If you have any questions regarding the content of this AFL, please contact your respective L&C district office.

 

Sincerely,

Original signed by Heidi W. Steinecker 

Heidi W. Steinecker

Deputy Director

 

Attachments:

  1. California Tuberculosis (TB) Testing Regulations for Health Care Facilities
  2. Sample TB Program Flexibility Request (PDF)
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