TB Skin Testing: a Practical Approach August 23, 2019 San Antonio, TX

Home , Tine test, Tuberculin

5/21/2020

Targeted Tuberculin Skin Testing Catalina Navarro, BSN, RN August 23, 2019

TB Skin Testing: A Practical Approach August 23, 2019 San Antonio, TX

EXCELLENCE EXPERTISE INNOVATION 1

Catalina Navarro, BSN, RN has the following disclosures to make:

•No conflict of interests

•No relevant financial relationships with any commercial companies pertaining to this educational activity

1 5/21/2020

Targeted Tuberculin Skin Test

San Antonio, Texas August 23rd, 2019

Catalina Navarro BSN, RN Heartland National TB Center

Tuberculosis Overview

Tuberculin Skin Test

2 5/21/2020

What is the difference between Active TB disease vs. TB Infection?

Active TB Disease

• Active infectious process involving the lungs ± other organs – CXR Abnormal in pulmonary TB in most persons • Symptoms (may be absent in those persons found during a CI) – Fever – Chills – Night Sweats – Weight Loss – Fatigue – Cough (dry or productive) – Hemoptysis

• When TB disease involves the lungs, the person is infectious

3 5/21/2020

Latent TB Infection • Persons are infected with Mycobacterium tuberculosis but: – No Active TB Symptoms

– Chest X‐ray may be normal, or show granuloma, stable pleural or parenchymal scarring

– Positive TST or IGRA

Latent TB Infection • Persons with LTBI are NOT infectious • 90 +% chance of never getting Active TB Disease

• But the TB organism is in your body!

“…a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens without evidence of clinically manifested active TB”

WHO Guidelines on the management of Latent Tuberculosis Infection 2015

4 5/21/2020

Latent TB Infection

• We used to think the bacteria were in a resting state or dormant but

• TB Bacteria are metabolically active and dividing, but infection is controlled by the immune system.

– Current methods of LTBI diagnosis are less than perfect

– Active TB Disease may develop if immunity wanes.

The Spectrum of Activity of MTB –One Could Think of Popcorn

5 5/21/2020

Persons at Risk for Developing TB Disease

Persons at high risk for developing TB disease fall into 2 categories

Those who have an Those with clinical increased likelihood of conditions that increase exposure to persons with their risk of progressing TB disease from LTBI to TB disease

Increase Likelihood of Exposure to Persons with TB Disease

. Recent Contacts

. Immigrants from TB endemic regions of the world

. Residents and employees of high‐risk congregate settings (e.g., correctional facilities homeless shelters, health care facilities)

6 5/21/2020

Progression of LTBI to Active TB Disease Increased By

• HIV infection • Chronic kidney disease • Silicosis • Recent exposure • Diabetes • Chest x‐ray abnormality c/w previous inadequately treated TB • Intravenous drug use • Smoking –active and passive • Underweight by >10% ATS‐CDC. Am J Respir Crit Care Med 2000;161:S221

Progression of LTBI to Active TB Disease Increased By • Pregnancy and first three months post partum

• Immunosuppression – Hematologic cancers and head and neck cancers – Medications • TNFα inhibitors • Prednisone >15 mg, > 4 weeks • Chemotherapy • Other immunosuppressive drugs

7 5/21/2020

Purpose of TB Testing

. Essential TB prevention and control strategy

. Detects persons with LTBI who would benefit from treatment

. De‐emphasizes testing of groups that are not at high risk for TB

. Can help reduce the waste of resources and prevent inappropriate treatment

ATS/IDSA/CDC Clinical Practice Guidelines: Diagnosis of TB in Adults and Children Guidelines recommend persons at low risk for MTB infection and disease progression NOT be tested. – If testing is performed in those unlikely to be infected despite guidelines to contrary: • We suggest performing an IGRA instead of a TST (conditional recommendation, very low‐quality evidence) • We suggest a 2nd diagnostic test if initial test positive – Confirmatory test may be either IGRA or TST – Person considered infected only if both tests positive (conditional recommendation, very low‐quality evidence) CID 2016

8 5/21/2020

ATS/IDSA/CDC Clinical Practice Guidelines: Diagnosis of TB in Adults and Children

• Recommend IGRA rather than TST for persons ≥ 5 – 1) likely to be infected with MTB – 2) low or intermediate risk of progression to disease – 3) decided testing is warranted and – 4) have either a history of BCG or are unlikely to return for reading • (Strong recommendation, moderate quality evidence) • TST acceptable if IGRA not available, too costly, too burdensome

CID 2016

IGRA ? TST ?

The tests are not perfect

They provide one piece of your whole picture when assessing a patient, not the ‘answer’

9 5/21/2020

Mantoux Tuberculin Skin Test

TST Interpretation >5 mm is interpreted as positive in . HIV‐infected persons . Close contacts to an infectious TB case . Persons with chest radiographs consistent with prior untreated TB . Organ transplant recipients . Other immunosuppressed patients (e.g. , those taking the equivalent of > 15 mg/d of prednisone for 1 month or those taking TNF‐α antagonists)

10 5/21/2020

TST Interpretation >10 mm is interpreted as positive in . Recent immigrants . Injection drug users . Residents or employees of congregate settings . Mycobacteriology lab personnel . Persons with medical conditions that place them at high risk . Children <4 years, children and adolescents exposed to adults at high risk

TST Interpretation >15 mm is interpreted as positive in

• Persons with no known risk factors for TB.

. Although skin testing programs should be conducted only among high‐risk groups, certain individuals may require TST for employment or school attendance . Diagnosis and treatment of LTBI should always be tied to risk assessment

11 5/21/2020

“ the decision to test is a decision to treat…

Think!

12 5/21/2020

Myths and Misconceptions of TB Skin Testing

Heartland National TB Center

“A positive skin test A positive TB skin test only means I have TB.” confirms that you have been exposed to tuberculosis and are infected, but not necessarily that you have disease.

13 5/21/2020

“BCG vaccination does Vaccination with BCG may not affect the TST.” cause a false positive reaction to a TB skin test which may complicate decisions about prescribing treatment. Disregard BCG history when interpreting TST result

“My TST test result was A negative TST test result negative, so I do not may mean that the have tuberculosis.” individual is not infected with tuberculosis. However, more than 20 percent of people who are infected do not have a reaction to the test.

14 5/21/2020

Frequently Asked Questions (FAQs)

FAQs about Candidates Is placing a TST on a nursing mother safe?

Yes

Placing a TST on a nursing mother is safe.

15 5/21/2020

FAQs about Candidates Can pregnant women be tested? Yes Placing a TST on a pregnant woman is safe. No risk to the mother or the fetus. Pregnancy is often a good time to screen and test women who are at risk of TB.

FAQs about Candidates Can infants be tested? Yes However, infants may not react to a TST before 6 months of age, but should be tested if there is risk of exposure.

16 5/21/2020

FAQs About Candidates Can a person with a previous positive TST be retested? Yes However, retesting is not necessary if the previous result was documented. Also, repeated skin tests do not sensitize or make persons “allergic” to tuberculin.

FAQs About Administration

Does having more than one TST placed in 1 year pose any risk?

No risk exists for having TSTs placed multiple times per year.

17 5/21/2020

FAQs About Administration If a person does not return for a TST reading within 48 –72 hours, when can a TST be placed on them again?

A TST can be administered again as soon as possible.

FAQs about Administration Can a TST result be read 7 days after the TST was placed? Yes and No A positive TST result can be read up to 7 days after the original placement However, if the result is negative, another TST should be placed as soon as possible.

18 5/21/2020

FAQs about Administration

Should the TST site be covered with a bandage? NO Avoid covering the TST site with anything that interfere with reading it (e.g., bandages, cream, ointment, lotion, liquids, medication)

FAQs about Administration Can an insulin syringe be used to place a TST? No Insulin Syringes can not be used in place of a Tuberculin syringe because the units of measure are different and the needle of a TB syringe is shorter than that of an insulin syringe.

19 5/21/2020

FAQs about Administration Should gloves be worn when placing a TST?

Specific CDC recommendations do not exist regarding this topic. If your local area indicates that universal precautions should be practiced with skin testing, they should determine what precautions should be followed.

Pop Quiz! What is the correct amount of PPD antigen to use in a Tuberculin Skin Test?

(0.1 ml) (5 Units of Tuberculin)

20 5/21/2020

Pop Quiz!

After TB has been transmitted, how long does it take for the body’s immune system to be able to react to tuberculin?

A. 48‐72 hours B. 7‐10 days C. 2‐8 weeks D. 6 months or more

Pop Quiz!

After TB has been transmitted, how long does it take for the body’s immune system to be able to react to tuberculin?

A. 48‐72 hours B. 7‐10 days C. 2‐8 weeks D. 6 months or more

21 5/21/2020

What Do We Do with a Negative TST Result ?

 Provide documentation of result  No further evaluation necessary…

22 5/21/2020

What Do We Do with a Positive TST Result ?  Evaluate Further  Rule Out TB Disease  CXR  TB Symptom Screen/ Assessment  MD Evaluation  Sputum Collection  If disease is ruled out, consider for LTBI treatment  If patient not willing or able to take treatment, educate on TB signs and symptoms

FAQs about Interpretation

Can HCW’s read their own TST? No HCW’s should NEVER be allowed to read their own TST. Experience has shown that HCW’s do not measure their own TST results reliably.

23 5/21/2020

FAQs about Interpretation Do vaccinations interfere with TST results? Yes Vaccinations may cause false (‐) reactions. A TST should be administered either on the same day as vaccination with live virus or 4–6 weeks later. Vaccines that might cause a false‐negative TST result are:  measles  Smallpox  Rubella  live‐attenuated  Varicella  BCG  oral polio influenza.  yellow fever  Mumps  oral typhoid

Mantoux Tuberculin Skin Test DVD: 30 minutes – Introduction and Background (4 minutes) – Part One: Administering the Mantoux tuberculin skin Test (15 minutes) – Part Two: Reading the Mantoux tuberculin skin test (11 minutes)

24 5/21/2020

Questions regarding information on DVD?

25 5/21/2020

Practicum

ASIAN WHITE

HISPANIC BLACK

26 5/21/2020

• Break into Groups – Placing TST on each other – Reading TST mannequins • Hispanic •Asian •White •Black

• Answers will be posted once everyone has completed

Practice Placing and Reading TST

27 5/21/2020

Case Scenarios

Case Scenarios:

Interpreting TST

28 5/21/2020

Question # 1

• Bernie, 40 year‐old female tested because of job requirement to teach high school English; no known health problems and takes no medication.

– She has a 06 mm skin test reaction

– Is she is Positive/Negative?

Question # 1

• Bernie, 40 year‐old female tested because of job requirement to teach high school English; no known health problems and takes no medication. – She has a 06 mm skin test reaction – Is she is Positive/Negative? • Answer : Negative Induration of >15 mm is considered positive for this group * She is an employee who is at low risk for TB and who is tested as part of an infection control screening program at the start of employment.

29 5/21/2020

Question # 2

• Michael, 25 year‐old male admitted for injectable drug detoxification; found to be HIV seropositive.

– He has a 13 mm skin test reaction

– Is he is Positive/Negative?

Question # 2

• Michael, 25 year‐old male admitted for injectable drug detoxification; found to be HIV seropositive. – He has a 13 mm skin test reaction – Is he Positive/Negative?

• Answer: Positive

*Induration of >5 mm is considered positive in persons with HIV

30 5/21/2020

Question #3

• Richard, a 72 year old male resident of a nursing home has a:

– 00mm skin test reaction

– Is he is Positive/Negative?

Question #3

• Richard, a 72 year old male resident of a nursing home has a: – 00mm skin test reaction – Is he Positive/Negative?

• Answer: Negative

*Induration of >10 mm is considered positive in residents and employees of congregate settings such as nursing homes and other long‐term facilities for the elderly

31 5/21/2020

Question #4

• Rita, a 29 year old American born female tested as a work requirement for a day care center;

• Has a 12 mm skin test reaction.

• Is she Positive/Negative?

Question #4

• Rita, a 29 year old American born female tested as a work requirement for a day care center – Has a 12 mm skin test reaction. – Is she Positive/Negative?

• Answer: Positive

* Induration of > 10mm is considered positive in residents and employees of high risk congregate settings such as jail, prison, shelter, workplace, school, child care center, nursing home, social club, rehabilitation facility, residential living or treatment facility

32 5/21/2020

Question #5

• Martin, a 25 year old male tested as a job requirement at the state correctional institution; health history good; no known medications;

– He has a 7mm skin test reaction

– Is he Positive/Negative?

Question #5 • Martin, a 25 year old male tested as a job requirement at the state correctional institution; health history good; no known medications; – He has a 7mm skin test reaction. – Is he Positive/Negative? • Answer: Negative

• Induration of > 10mm is considered positive in residents and employees of high risk congregate settings such as prisons and jails.

33 5/21/2020

Question #6

• Stephanie, a 55 year old female who just received a liver transplant and has been placed on immunosuppressive medications.

– She has a 20 mm skin test reaction

– Is she is Positive/Negative?

Question #6

• Stephanie, a 55 year old female who just received a liver transplant and has been placed on immunosuppressive medications. – She has a 20 mm skin test reaction. – Is she Positive/Negative? • Answer: Positive

* Induration of >5 mm is considered positive in patients with organ transplants and other immunosuppressed patients

34 5/21/2020

Question #7

• Tony, a 19 year‐old American born male enrolling in a private college; testing was an admission requirement

– He has a 13 mm skin test reaction

– Is he Positive/Negative?

Question #7

• Tony, a 19 year‐old American born male enrolling in a private college; testing was an admission requirement – He has a 13 mm skin test reaction – Is he Positive/Negative?

• Answer: Negative

*Induration of >15 mm is considered positive in persons with no known risk factors for TB.

35 5/21/2020

Question #8

• Margarita, a 21 year‐old female on work visa employed as a migrant farm worker; tested at the county’s prenatal clinic as a part of her physical

– She has a 17 mm skin test reaction

– Is she Positive/Negative?

Question #8

• Margarita, a 21 year‐old female on work visa employed as a migrant farm worker; tested at the county’s prenatal clinic as a part of her physical. – She has a 17mm skin test reaction. – Is she Positive/Negative?

• Answer: Positive

*Induration of >10 mm is considered positive in recent immigrants (i.e., within the last 5 years) from countries with a high prevalence of TB

36 5/21/2020

Question #9

• Miyamoto, a 20 year‐old Japanese male with a history of BCG vaccine at age 6 years; tested as a requirement for citizenship application.

– He has a 7mm skin test reaction.

– Is he Positive/Negative?

Question #9

• Miyamoto, a 20 year‐old Japanese male with a history of BCG vaccine at age 6 years; tested as a requirement for citizenship application – He has 7 mm skin test reaction. – Is he Positive/Negative? Answer: Negative

*Induration of >10mm is considered positive in recent immigrants (i.e., within the last 5 years) from countries with a high prevalence of TB

37 5/21/2020

Question #10

• Naomi, a 5 year‐old American‐born female whose parents were Southeast Asian refugees; test was done prior to starting public school

– She has a 17 mm skin test reaction.

– Is she Positive/Negative?

Question #10

• Naomi, a 5 year‐old American‐born female whose parents were Southeast Asian refugees; test was done prior to starting public school. – She has a 17mm skin test reaction. – Is she Positive/ Negative? • Answer: Positive

*Induration of >10 mm is considered positive in children less than 5 years of age.

38 5/21/2020

39 5/21/2020

Review TST Pre‐Post Test Answers

TST Pre-Post Test: Question #1

The standard recommended tuberculin skin test is the: a. Tine test b. Mantoux c. BCG d. Quantiferon‐Gold

Answer: b. Mantoux

40 5/21/2020

TST Pre-Post Test: Question #2

• The administration of the TB skin test is just beneath the surface of the skin. This is identified as a/an ______injection. a. p.o. b. IM c. Subcutaneous d. Intradermal

Answer: d. Intradermal

TST Pre-Post Test: Question #3

• The correct dose for the TB skin test is: a. 0.5 ml b. 0.1 ml c. 1.0 ml d. 10 ml

Answer: 0.1 ml

41 5/21/2020

TST Pre-Post Test: Question #4

• When placing a TB skin test, the needle bevel should be facing: a. Downward to prevent leakage b. In any direction c. Upward d. The subcutaneous tissue

• Answer: Upward

TST Pre-Post Test: Question #5

• When administered correctly, a TB skin test should produce a wheal measuring ______in diameter. a. 1 mm to 3 mm b. 3 mm to 5 mm c. 6 mm to 10 mm d. 10 mm to 12 mm

Answer: 6mm to 10 mm

42 5/21/2020

TST Pre-Post Test: Question #6

• After administering the TB skin test you should: a. Read reaction 48‐72 hours after placement b. Measure the erythema and induration c. Record results in millimeters d. A and C e. All of the above

Answer: d. A and C

TST Pre-Post Test: Question #7

• The diameter of the indurated area should be measured: a. Vertically b. Across the forearm (perpendicular to the long axis) c. By adding the measurements of A and B d. None of the above

Answer: Across the forearm (perpendicular to the long axis)

43 5/21/2020

TST Pre-Post Test: Question #8

• PPD should be stored at: a. 35‐46 degree Fahrenheit b. 46‐65 degree Fahrenheit c. Room temperature d. None of the above

Answer: 35‐ 46 degrees Fahrenheit

TST Pre-Post Test: Question #9

• Once a vial of PPD has been opened for use you should: a. Date and initial b. Discard after 30 days of being opened c. Keep out of light d. Not use it beyond the expiration date e. All of the above

Answer: e. all of the above

44 5/21/2020

TST Pre-Post Test: Question #10

• A TST incorrectly placed may be replaced: a. 48 hours after initial attempt b. 72 hours after initial attempt c. 8‐10 weeks after initial attempt d. Immediately after initial attempt

Answer: d. Immediately after initial attempt

TST Pre-Post Test: Question #11 True/ False

• TB skin testing is contraindicated if an individual has a history of having received vaccination with BCG (Bacille Calmette Guerin).

Answer: FALSE

45 5/21/2020

TST Pre-Post Test: Question#12 True/False • It is safe to do a TB skin test on someone who is pregnant if the test is indicated?

Answer: True

TST Pre‐Post Test: Question #13 True/False

• A negative tuberculin skin test always means that the individual does not have TB infection.

Answer: FALSE

46 5/21/2020

TST Pre-Post Test: Answer #14 True/False

Targeted skin testing programs should be conducted among the general population.

Answer: FALSE

TST Pre-Post Test: Question #15 True/False

A tuberculin reaction greater than 10 mm of induration is classified as positive in persons with no known risk factors for TB.

Answer: FALSE

47 5/21/2020

Medical Consultation • 1‐800‐TEX‐LUNG (1‐800‐839‐5864) • Warm line – Monday –Friday – 8:00am‐5:00pm CST

• Response with in 24 business hours – Call Tuesday at 9:00am; returned call Wednesday by 9:00am – Call Friday at 3:00pm; returned call by Monday 3:00pm

References

• CDC Guidelines, Targeted Tuberculin Testing and Treatment of LTBI; MMWR June 9, 2000/Vol.49/No. RR‐6

• CDC Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis; MMWR December 16, 2005/Vol. 54/ No. RR‐15

• CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Settings, 2005. MMWR December 30, 2005/ Vol.54/ No. RR‐17.

48 5/21/2020

Practicum Agenda • Pre‐Test • Folders and booklet with CDC handouts • Mantoux TST CDC‐ DVD (30 Minutes) • TST PowerPoint (case scenarios & FAQ’s) • Practice placing and reading TST • Post Test • Certificate of Completion