Indiana State Department of Health

Guidelines for Tuberculin Skin Test Screening

and Treatment of Latent TB Infection

GUIDELINES FOR TUBERCULIN SKIN TEST SCREENING AND TREATMENT OF LATENT TB

INFECTION
Why screen for tuberculosis?
The goal of screening programs is to identify persons with latent TB infection (LTBI) who are at
high risk for progressing to active disease and would benefit from treatment, or to find persons
who have clinical TB disease and need treatment.
Who should be screened for TB?
The following groups should be screened with the tuberculin skin test:
Close contacts of persons known or suspected to have TB, i.e. those sharing the same
household or other enclosed environments
Persons infected with HIV
Persons who have certain clinical conditions known to increase the risk for disease if
infection occurs
Persons with a history of inadequately treated TB
Persons who inject illicit drugs
Residents and employees of high-risk congregate settings (i.e. nursing homes, correctional
facilities, mental institutions, other long-term care facilities, and homeless shelters)
Health-care workers who serve high-risk clients
Persons born outside the U.S. and Canada, including children. Prior vaccination with BCG is
not a contraindication for testing, nor does it affect the treatment protocol.
Some medically underserved, low-income populations, including high-risk racial and ethnic
groups
Infants, children, and adolescents exposed to adults in high-risk categories
Locally defined high prevalence groups (substance abusers, migrant workers, the homeless)
Who should not be routinely screened with the tuberculin skin test?
The following are examples of groups who do not need to be screened routinely for TB unless one
or more of the above risk factors are present:
School children and day care attendees
Foreign-born persons living in the U.S. for more than 5 years who have been screened
previously
Pregnant women
Food handlers
Why limit tuberculin screening to just high-risk individuals?
Targeted screening allows resources to be directed at the two top priorities of TB
control: treatment of active TB cases and conducting thorough contact investigations.
The tuberculin skin test is a better test when its use is restricted to high-risk
individuals. There are fewer false positives, which means less money is spent on

unnecessary diagnostic evaluation and treatment.

School-based screening for TB among children was started in the 1950s when infection and
disease rates were higher than at the present time.
Broad-based school testing involves screening large numbers of low-risk children and the
majority of children who have TB are preschool age.
Generalized screening of school children as a public health measure is not a cost-effective
method of detecting or preventing cases of childhood TB and should be discontinued.
Who should receive treatment for LTBI?
Regardless of age, persons who fall into one or more of the following high-risk categories with a
positive skin test, and who have not previously received treatment, should be treated unless
contraindicated (see below):
close contacts of a person with infectious TB (TST considered positive with 5mm
induration)
persons with HIV infection (TST considered positive with 5mm induration)
organ transplant patients, or patients with other immunosuppressive disorders (TST
considered positive with 5mm induration)
persons whose chest x-ray shows stable fibrotic lesions consistent with old, healed MTB and
a history of inadequately treated TB or no prior history of treatment for TB (TST considered
positive with 5mm induration)
injection drug users
persons with clinical conditions that make them high-risk, e.g. diabetes mellitus, certain
forms of cancer, silicosis, end-stage renal disease, substance abusers
recent tuberculin skin test converters (10mm increase within the past two years)
persons born in countries where TB is common
mycobacteriology laboratory personnel
residents and employees of high-risk congregate settings
children younger than 4 years of age
children and adolescents exposed to adults in high-risk groups
persons with recent travel to an area with high rates of TB
Some contacts to infectious TB cases have medical conditions that increase their risk of
progression to active disease if they are infected. Persons with high-risk medical conditions (e.g.,
HIV +, children < 4 years of age, immunosuppression) who have had active disease ruled out but
whose initial TST is < 5 mm of induration, should be placed on treatment for LTBI until LTBI is
ruled out. If a second TST placed 10 weeks after last contact with the source case is still < 5 mm,
treatment may be stopped. If it is 5 mm, continue the full course of treatment.
What is the recommended treatment regimen for LTBI?
Isoniazid for 9 months, regardless of age or HIV status, is the preferred regimen. Isoniazid may be
given to HIV-negative adults for 6 months if treatment for 9 months is not possible. PZA and
rifampin for 2 or 3 months for adults only is no longer recommended for general use due to an
unacceptably high risk of hepatitis. Consult with a TB expert before prescribing this regimen.
Rifampin for 4 months for adults or 6 months for children is an alternate regimen that may be
prescribed in certain circumstances, such as exposure to an isoniazid-resistant case. Dosages for
all regimens are the same as for active disease. The alternate short-course regimens are strictly
second-line recommendations and should not be used routinely in place of the isoniazid regimens.
persons with active hepatitis
persons with end-stage liver disease
pregnancy (therapy is usually delayed until after delivery)
major adverse medication reactions
previous adequate treatment for LTBI or active disease
What are the current standards for the evaluation and monitoring of treatment (LTBI)?
Baseline laboratory testing is not routinely indicated for all patients at the start of treatment
for LTBI.
Recent data indicate that baseline testing is no longer routinely indicated in persons older
than 35 years of age.

Once patients have been identified as requiring treatment for LTBI, they should receive an
initial clinical evaluation. This evaluation should include a detailed history for risk factors
that increase the likelihood of hepatotoxicity[1] and a brief physical assessment checking for
signs of hepatitis.
Patients whose initial evaluation suggests these risk factors should have baseline hepatic
measurements of serum AST (SGOT) or ALT (SGPT) and bilirubin.
Patients should be educated about the side effects associated with treatment of LTBI and
advised to promptly seek medical evaluation when they occur.
Patients being treated for LTBI should also receive follow-up evaluations at least
monthly. This evaluation should consist of questioning about side effects and a brief physical
assessment checking for signs of hepatitis.
What radiographic evaluations are indicated in the workup of patients with suspected
LTBI?
A chest radiograph is indicated for all persons being considered for treatment of LTBI to
exclude active pulmonary TB. Children younger than 5 yr of age should have both posterior
anterior and lateral radiographs. All other persons should receive posterioranterior
radiographs.
Patients with questionable findings on initial radiographs should be evaluated with
alternative x-ray views (lateral, apical lordotic, obliques).
If these views do not resolve visualization of any questionable areas on initial radiographs, a
CT scan can be considered. (Normally, there is little to no indication for the use of CT scans
of the chest. CT scans often are indicated for other purposes, but that would not be
considered part of the LTBI workup.)
For persons with LTBI who have had active disease ruled out and for asymptomatic
tuberculosis patients who have completed treatment, repeat chest x-ray examinations have
been shown to be of insufficient clinical value or productivity to justify their continued use
and are not recommended unless specific medical conditions exist.
In summary, efficient screening programs are limited to high-risk persons who would benefit from
treatment for latent TB infection.
This statement was approved by the Indiana State Department of Health TB Medical Advisory
Board on March 24, 1997, and revised October 25, 2000 and October 27, 2004.
previous adverse reactions to drugs contemplated for treatment of LTBI
current use of drugs which may interact with the drugs used for treatment
patients infected with HIV
pregnant women and those in the immediate postpartum period (i.e., within 3 months of
delivery)
persons with a history of liver disease (e.g., hepatitis B or C, alcoholic hepatitis or cirrhosis)
persons who use alcohol regularly
persons at risk for chronic liver disease
signs of hepatitis on physical assessment