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USPSTF latent TB screening recommendations
   Who to screen   
  • Group 1 - Patients from countries with high prevalence of TB

    • In the U.S, more than half the foreign-born patients with active TB come from 5 countries - Mexico, the Philippines, Vietnam, India, and China. Haiti and Guatemala are also important contributors.

    • World Health Organization list of top 30 countries with highest prevalence of TB (2016 - 2020)
      • MDR - countries with a high prevalence of multidrug resistant TB
      • Angola (MDR)
      • Bangladesh (MDR)
      • Brazil
      • Cambodia
      • China (MDR)
      • Congo
      • Central African Republic
      • DPR Korea (MDR)
      • DR Congo (MDR)
      • Ethiopia (MDR)
      • India (MDR)
      • Indonesia (MDR)
      • Kenya (MDR)
      • Lesotho
      • Liberia
      • Mozambique (MDR)
      • Myanmar (MDR)
      • Namibia
      • Nigeria (MDR)
      • Pakistan
      • Papua New Guinea (MDR)
      • Philippines (MDR)
      • Russian Federation (MDR)
      • Sierra Leone
      • South Africa (MDR)
      • Thailand (MDR)
      • The United Republic of Tanzania
      • Vietnam (MDR)
      • Zambia
      • Zimbabwe (MDR)

  • Group 2 - Persons who live in, or have lived in, high-risk congregate settings
    • Homeless
    • Prison/correctional facilities
    • Long-term care facility residents

  • Group 3 - Immunosuppressed patients
    • HIV
    • Patients on immunosuppressive medications (e.g. chemotherapy or tumor necrosis factor-alpha inhibitors)
    • Organ transplant recipients
    • Patients with silicosis
   How to screen   
  • The USPSTF recommends screening with one of the following:

    • Tuberculin Skin testing (PPD)
      • Procedure: Intradermal placement of purified protein derivative (PPD) with reading of induration in 48 - 72 hours. For screening purposes, ≥ 10 mm of induration is considered a positive test. In patients with known exposure, ≥ 5 mm of induration is considered a positive test. PPD contains > 200 M tuberculosis proteins.
      • Advantages: may be less expensive
      • Disadvantages: requires return visit; crossreacts with BCG vaccine; crossreacts with nontuberculous mycobacteria; may have booster effect with repeated dosing; readings are subjective
      • Sensitivity (10 mm threshold): 80%
      • Specificity (10 mm threshold): >95%
      • Known exposure: patients should be tested 8 - 10 weeks after their most recent known exposure [12,13]

    • Interferon-Gamma Release Assays (IGRAs)
      • Two tests available in the U.S. - QuantiFERON®-TB Gold and T-SPOT®.TB
      • Procedure: Test is run on venous blood draw. The QuantiFERON®-TB Gold test measures the amount of interferon-gamma release and the T-SPOT®.TB test measures the amount of interferon-gamma producing cells.

        • The following values are measured on the blood:
          • nil result - amount of interferon-gamma activity in blood that has not been exposed to an antigen (control)
          • TB antigen result - amount of interferon-gamma activity in blood that has been exposed to TB antigen. The assays contain 2 - 3 antigens that are fairly specific for M tuberculosis.
          • Mitogen result - amount of interferon-gamma activity in blood that has been exposed to a nonspecific T-cell stimulator
          • TB antigen minus nil - this value is used to determine if the test is positive. A significant rise in interferon-gamma from baseline means a TB infection is likely.
          • Mitogen minus nil - this value is used to detect anergy or immune suppression

      • Advantages: does not crossreact with BCG vaccine or most nontuberculous mycobacteria (exceptions M kansasii, M szulgai, and M marinum); objective result; no booster effect with repeat testing; one visit
      • Disadvantages: more expensive; low positive or indeterminate values may occur and there is no consensus on how to manage these results; active TB may suppress interferon-gamma release
      • T-SPOT®.TB: Sensitivity - 90%; Specificity - >95%
      • QuantiFERON®-TB Gold: Sensitivity - 80%; Specificity - >95%
      • Known exposure: patients should be tested 8 - 10 weeks after their most recent known exposure [12,13,14]

    • The USPSTF makes no recommendation on repeat screening. Patients at continued risk should be rescreened, but no optimal interval has been defined