SCREENING FOR TUBERCULOSIS

Effective Date: 
Thu, 09/01/2011
Reviewed: 
Thu, 09/01/2011
Revised: 
Mon, 04/03/2017
Policy: 

This procedure allows the RN to administer tuberculosis (TB) screening tests, interpret the results of these tests, educate the student about their results, and facilitate additional follow-up for students with positive screening test results. Students present for screening for tuberculosis for a number of reasons including the UC-wide policy of screening all new and incoming students for their risk of TB.  According to the CDC, it is appropriate to begin screening for tuberculosis by using a risk assessment questionnaire.  Students who answer no to the risk assessment questions do not need further testing unless they are specifically required to show documentation of a TST/IGRA blood test.   Any student who answers yes to any TB risk assessment question (other than past positive TST) should continue the process of screening with a Tuberculin Skin Test (TST) or an IGRA  (Interferon Gamma Release Assay:  Quantiferon Gold or T-spot) blood test.   Per the CDC, history of receiving BCG may contribute to a false positive skin test.  To minimize the possibility that BCG might cause a false positive TST, in consult with the Santa Cruz County Public Health Department, an IGRA blood test is recommended for those with history of BCG who are asymptomatic for symptoms of TB.  It is also the practice at UCSC Student Health Services to offer an IGRA blood test if the placed TST for asymptomatic students with history of BCG has an induration of 10-14mm.  Indurations larger than this, regardless of BCG history are considered positive.  The IGRA blood test has no possibility of cross-reactivity from BCG.

Procedure: 

 

  • Student presents for screening test.
  • Review student’s completed risk assessment form.
 
1. For all negative risk assessment answers:
 
Determine reason student has presented for testing.  If their form does not require a TB test and their TB risk assessment questionnaire is negative then complete and sign the EMR standard "Letter" indicating “TB Negative by Risk Assessment.”
 
Screening Test Process:
 
If a screening test is required and there is no indication of active disease, review and assist the student to choose one of the two screening tests, either the TST or IGRA blood test.  Explain the considerations in choice of test:
TST is low cost but carries a risk of a false positive.
IGRA costs more.  Has a very low risk of a false positive.
IGRA is a blood test.  TST is a needle/skin test.
IGRA will reduce the chance of a false positive from previous BCG vaccination.
If TST is placed, then explain the need for a second office visit and the process for TST reading 48 to 72 hours after placement.
 
For IGRA, blood test results will be given using the standard UCSC SHC lab result notification system (secure message or phone).
 
2. For positive risk assessment answers:
 
Conduct symptom review:
In each situation, first assess for any indication of active disease by asking about cough, hemoptysis, weight loss, anorexia, and/or night sweats.  With any indication of active disease: mandatory mask, order 1 view CXR, arrange same-day clinician evaluation.  Give copy of SHC handout “TB FAQs”.
 
A. Yes answers to any of the  TB Risk Assessment Questions other than "History of positive TST or IGRA":  if negative current symptoms, continue the screening process,  proceed to “Screening Test Process” as above.
 
B. Yes to “History of positive TST or IGRA” and documentation of treatment (keep copy to scan in to the EMR):  if negative current symptoms = complete the students required form to read “Negative TB Risk Assessment per symptoms review”, or generate a letter from the EMR "Latent TB Rx Completed".  Add to Problem List:  "A15.9 Latent TB Treated".
 
C. Yes to “History of positive TST or IGRA” and stated treatment without documentation:  if negative current symptoms, order 1 view CXR, arrange same-day clinician evaluation. (Encourage and/or assist the student to obtain documentation of treatment for future reference).  Add to Problem List "R76.11 TB Latent or Positive Test", and include the statement "Stated treatment but no documentation"
 
D. Yes to “History of positive TST or IGRA” and stated no treatment:  if negative current TB symptoms review, order 1 view CXR, arrange same-day clinician evaluation.  Clinician adds to Problem List: "R76.11 TB Latent or Positive Test".
 
E. Yes to “History of positive TST 10-14mm & Negative IGRA"  if negative current TB symptoms, complete EMR pre-written letter "TB Negative by Risk Assessment”.
 
F.  Yes to positive TST or IGRA with documentation of negative CXR post positive TST, but no treatment:  if negative current TB symptoms, complete EMR pre=written letter called  “TB Negative by Risk Assessment” and provide copy to patient.  Give patient two handouts:  Latent TB Disease and LTBI Treatment.   Offer an appointment with a Clinician to review optional latent TB treatment.  RN updates Problem List:  "R76.11 TB Latent or Positive Test".
 
Positive symptoms review at any step of the screen process:
 
Assess for any indication of active disease by asking about cough, hemoptysis, weight loss, anorexia, and/or night sweats. With any indication of active disease: mandatory mask, order 1 view CXR, arrange same-day clinician evaluation.  Give copy of SHC handout “TB FAQs”.
 
Notification of results:
 
Negative results TST:  skin test results are read 48-72 hours after placement.  The nurse completes the students form or provide a copy of results using EMR generated form.  If form requires a two-step TB test, schedule next TST for 7 - 21 days after the initial test.  Two step testing is indicated for people who will be TB tested annually.   The two step tuberculosis test can find the small number of people who were exposed to tuberculosis a long time ago and need to have their immunity boosted with a first TB test in order to show this prior exposure on their second TB test.
 
If the results are needed for UC-wide TB Risk Screening Compliance, the nurse will "Add Event" to the Immunization Section of the EMR and update compliance manually. Students with positive results should forwarded to the Nursing Supervisor after "Add Event" is completed.
 
Positive TST:  
A positive reaction is measured in millimeters of induration, measured in one direction only,  perpendicular to the long access of the arm.  If a positive test is suspected, the nurse will have a second nurse or clinician confirm the result.  A positive reaction is defined by a combination of the millimeters of induration plus the circumstances of a patient’s condition and risk or exposure:
 
The UCSC SHC uses the CA Tuberculosis Controllers Association guideline as follows:
 
Reaction 0-4mm of induration are considered negative.
 
Reaction 5 mm - 9mm of induration are considered negative unless student has:
 
• Human immunodeficiency virus (HIV)-positive persons
• Recent contacts of tuberculosis (TB) case patients
• Fibrotic changes on chest radiograph consistent with prior TB
• Patients with organ transplants and other immunosuppressed patients (receiving the equivalent of > 15 mg/d of prednisone for 1 month or more)
 
With any of the above  conditions present and a TST of 5-9mm, the student is considered positive for LATB
 
Reaction 10mm - 14mm of induration is considered positive.  Except students with a history of BCG.   With history of BCG and TST 10mm-14mm, offer IGRA. Provide the Quantiferon Fact Sheet.   A negative IGRA in this case is considered negative for LATB.
 
Reaction of 15mm or >, regardless of BCG history or negative IGRA, are considered positive for LATB.
 
Negative results IGRA:  Provide results using the UCSC SHC standard lab notification system; stress the importance of:   keeping a copy of the results for future proof of negative screening.  For patients with a history of previous positive TST and now a negative IGRA, instruct for future to avoid future TST testing, symptoms review only.
 
Positive or Equivocal IGRA:
Students with a positive or equivocal IGRA are to be contacted by phone with their
results.  Then follow the procedure for positive or equivocal IGRA below.
 
Follow-up on Positive results:
 
For students with a positive screening test, either TST or IGRA:
 
Assess again for any indication of active disease by asking about cough, hemoptysis, weight loss,
anorexia, and/or night sweats.  With any indication of active disease: mandatory mask, order 1
view CXR, arrange same-day clinician evaluation.
 
With no indication of active TB: order a 1-view PA chest x-ray and arrange a clinician
appointment on the same day as the x-ray to discuss treatment latent tuberculosis (LATB).   Give and review two handouts with patient:  Latent TB Disease and LTBI Treatment.  Clinician updates Problem List to indicate "R76.11 TB Latent or Positive Test"
 
Any positive results for students needing to meet UC-wide TB Risk Screening with or without symptoms should have chart note  forwarded to the Nursing Supervisor.
 
 
 
Equivocal IGRA:
Arrange a non-same day clinician appointment to review the results.
 
Additional Considerations:
If a student indicates that they have a history of (LATB) with treatment, assist them to obtain documentation of this.    If they have a negative review of symptoms for active TB, then determine if they will need a chest x-ray to satisfy the requirements of their program.
 
Students who are traveling to a high risk area should be reminded to be tested upon their return.
Patients referred by a clinician for testing are to be referred back to that clinician.
 
Experience, Training and/or Education
Current California RN License
Completion of UCSC orientation specific to Tuberculosis screening
 
Evaluation of Competency
Initial Competency:
Observes experienced RN implementing this procedure
Demonstrates successful use of this procedure under direct RN supervision at least three times
Submits a minimum of 5 chart notes demonstrating use of the procedure to the Clinic Director for review
 
On-going Competency:
Chart reviews of this procedure occur as part of the on-going Quality Assurance program of the UCSC Health Center.
 
Scope of Supervision 
No direct supervision required. Clinicians available on site for consultation and evaluation as needed.
 
Criteria for Provider Consultation and Referral
 
RN is to arrange same-day appointment with a clinician consult for any students with any indication of active disease on review of risk assessment form or after questioning.
RN is to consult with DOC or Patient Care Coordinator for any question about disposition of a particular case.
 
Documentation
RN documents according to the standards delineated in the UCSC Policy on Documentation of Care.