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HCWs transferring from low-risk to low-risk settings. After a baseline result for infection with M. tuberculosis is established and documented, serial testing for M. tuberculosis infection is not necessary.

In dental health-care settings that routinely provide care to populations at high risk for TB disease, using engineering controls (e.g., portable HEPA units) similar to those used in waiting rooms or clinic areas of health-care settings with a comparable community-risk profile might be beneficial.

Baseline testing for M. tuberculosis infection is recommended for all newly hired HCWs, regardless of the risk classification of the setting and can be conducted with the TST or BAMT. Baseline testing is also recommended for persons who will receive serial TB screening (e.g., residents or staff of correctional facilities or LTCFs) (39,224). Certain settings, with the support of the infection-control committee, might choose not to perform baseline or serial TB screening for HCWs who will never be in contact with or have shared air space with patients who have TB disease (e.g., telephone operators who work in a separate building from patients) or who will never be in contact with clinical specimens that might contain M. tuberculosis.

The need for serial follow-up screening for groups of HCWs with negative test results for M. tuberculosis infection is an institutional decision that is based on the setting's risk classification. This decision and changes over time based on updated risk assessments should be official and documented. If a serial follow-up screening program is required, the risk assessment for the setting (Appendix B) will determine which HCWs should be included in the program and the frequency of screening. Two-step TST testing should not be performed for follow-up testing.

If TB disease is excluded, offer the HCW treatment for LTBI in accordance with published guidelines (see Supplements, Diagnostic Procedures for LTBI and TB Disease; and Treatment Procedures for LTBI and TB Disease [39,240]). If the HCW has already completed treatment for LTBI and is part of a TB screening program, instead of participating in serial skin testing, the HCW should be monitored for symptoms of TB disease and should receive any available training, which should include information on the symptoms of TB disease and instructing the HCW to report any such symptoms immediately to occupational health. In addition, annual symptom screens should be performed, which can be administered as part of other HCW screening and education efforts. Treatment for LTBI should be offered to HCWs who are eligible (39).

HCWs with a baseline positive or newly positive TST or BAMT result should receive one chest radiograph to exclude a diagnosis of TB disease (or an interpretable copy within a reasonable time frame, such as 6 months). After this baseline chest radiograph is performed and the result is documented, repeat radiographs are not needed unless symptoms or signs of TB disease develop or a clinician recommends a repeat chest radiograph (39,116). Instead of participating in serial testing for M. tuberculosis infection, HCWs with a positive test result for M. tuberculosis infection should receive a symptom screen. The frequency of this symptom screen should be determined by the risk classification for the setting.

Health-care settings should collaborate with the local or state health department to conduct an investigation. For settings in which HCWs are serially tested for M. tuberculosis infection, review HCW records to determine whether an increase in the number of conversions in test results for M. tuberculosis infection has occurred. Patient surveillance data and medical records should be reviewed for additional cases of TB disease. Settings should look for possible exposures from previous or current admissions that might have exposed patients with newly diagnosed TB disease to other patients with TB disease, determining if the patients were admitted to the same room or area, or if they received the same procedure or went to the same treatment area on the same day.

Operational policies, procedures, and practices at health-care settings can enhance HCW adherence to serial TST. In 2002, one focus group study identified potential barriers and facilitators to adherence with routine TST (319). HCWs identified structural factors (e.g., inconvenient TST screening schedules and locations and long waiting times) that negatively affected adherence. Facilitators to help HCWs adhere to routine TST included active follow-up by supervisors and occupational health staff and work-site visits for TST screening. Misinformation and stigma concerning TB also emerged in the discussions, indicating the need for additional training and education for HCWs.

Determining the need for treatment of LTBI is a subsequent and separate task. For infection-control and surveillance purposes, TST results should be interpreted and recorded under strict criteria, without considering setting-based or personal risk factors (see Supplement, Diagnostic Procedures for LTBI and TB Disease). Any HCW with a positive TST result from serial TB screening should be referred to a medical provider for an evaluation and to determine the need for treatment of LTBI based on individual risk (Box 3).

Pregnancy. Tens of thousands of pregnant women have received TST since the test was developed, and no documented episodes of TST-related fetal harm have been reported (341). No evidence exists that the TST has adverse effects on the pregnant mother or fetus (39). Pregnant HCWs should be included in serial skin testing as part of an infection-control program or a contact investigation because no contraindication for skin testing exists (342). Guidelines issued by the American College of Obstetricians and Gynecologists (ACOG) emphasize that postponement of the diagnosis of infection with M. tuberculosis during pregnancy is unacceptable (343).

Booster phenomenon and two-step testing. In certain persons with LTBI, the DTH responsible for TST reactions wanes over time. Repeated TST can elicit a reaction called boosting in which an initial TST result is negative, but a subsequent TST result is positive. For example, a TST administered years after infection with M. tuberculosis can produce a false-negative result. This TST might stimulate (or boost) the person's ability to react to tuberculin, resulting in a positive result to a subsequent test (including the second step of a two-step procedure) (36,74,316,342,343). With serial testing, a boosted reaction on a subsequent TST might be misinterpreted as a newly acquired infection, compared with the false-negative result from the initial TST. Misinterpretation of a boosted reaction as a new infection with M. tuberculosis or TST conversion might prompt unnecessary investigations to find the source case, unnecessary treatment for the person tested, and unnecessary testing of other HCWs. The booster phenomenon can occur in anyone, but it is more likely to occur in older persons, persons with remote infection with M. tuberculosis (i.e., infected years ago), persons infected with NTM, and persons with previous BCG vaccination (39,229,234,344,345).

BCG vaccination. In the United States, vaccination with BCG is not recommended routinely for anyone, including HCWs or children (227). Previous BCG vaccination is not a contraindication to having a TST or two-step skin testing administered. HCWs with previous BCG vaccination should receive baseline and serial skin testing in the same manner as those without BCG vaccination (233) (Box 1).

Chest radiographic abnormalities can suggest pulmonary TB disease. Radiographic abnormalities that are consistent with pulmonary TB disease include upper-lobe infiltration, cavitation, and effusion. Infiltrates can be patchy or nodular and observed in the apical (in the top part of the lungs) or subapical posterior upper lobes or superior segment of the lower lobes in the lungs. HCWs who have positive test results for M. tuberculosis infection or symptoms or signs of TB disease, regardless of test results for M. tuberculosis infection, should have a chest radiograph performed to exclude a diagnosis of TB disease. However, a chest radiograph is not a substitute for tests for M. tuberculosis infection in a serial TB screening program for HCWs.

HCWs should receive serial screening for infection with M. tuberculosis (either TST or BAMT), as determined by the health-care setting's risk classification (Appendix B). For infection-control purposes, the results of the testing should be recorded and interpreted as part of the TB infection-control program as either a 1) negative TST result, 2) previously documented positive TST or BAMT result, or 3) TST or BAMT conversion. All recordings of TST results should also document the size of the induration in millimeters, not simply as negative or positive. BAMT results should be recorded in detail. The details should include date of blood draw, result in specific units, and the laboratory interpretation (positive, negative, or indeterminate) and the concentration of cytokine measured (e.g., IFN-γ).

The interpretation of TST results is more complicated in a contact investigation among HCWs who have negative baseline TST results from two-step testing but where the induration was >0 mm on the baseline TST or subsequent serial testing. Differences in the TST results between the contact investigation and previous baseline and serial TST could be a result of 1) inter-test variability in reaction size; 2) intervening exposure to NTM, BCG, or M. tuberculosis; and 3) reversion. In practice, for TST, only inter-test variability and exposure to or infection with NTM or M. tuberculosis are likely.

When using BAMT for serial testing, a conversion for administrative purposes is a change from a negative to a positive result (Box 3). For HCWs who have indeterminate test results, providers should consult the responsible laboratorian for advice on interpreting the result and making additional decisions (383). Persons with indeterminate results should not be counted for administrative calculations of conversion rates. 2b1af7f3a8