Tuberculosis (TB) Guidance for Health Care Providers

Marin County Public Health’s Tuberculosis (TB) Control Program works to prevent, identify, and manage TB in the community. The program partners with health care providers, laboratories, and community organizations to support timely diagnosis, treatment, and follow up. The program provides case management, consultation, and guidance to prevent TB transmission in the community.

• Health care providers diagnosing or treating TB or latent TB infection (LTBI)
• Hospitals and discharge planners
• Clinics conducting TB screening or evaluation
• Laboratories reporting TB results
• Providers who need to report a case should visit Report a Suspected Tuberculosis Case.

Report TB

Health care providers are required under California law (Title 17) to report:

• Suspected or confirmed active TB cases (report immediately; do not wait for lab confirmation)
• Positive TB tests in children under age 5
• TB test conversions within the past two years

Hospitals must complete a TB Discharge Treatment Plan before patient discharge.

For step-by-step instructions, visit Report a Suspected Tuberculosis Case.

TB Screening Requirements

TB screening is required in certain settings to reduce the risk of transmission.

• Health care facilities: On May 17, 2019, the CDC and the National Tuberculosis Controllers Association (NTCA) released updated recommendations for TB screening, testing, and treatment of health care personnel.
  • The three TB screening risk classifications are low risk, medium risk, and potential ongoing transmission. In medium risk facilities, health care personnel will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M. tuberculosis.
  • Health care facilities should offer annual TB testing if there is medium- or potential ongoing risk of TB transmission.
• Schools and child care facilities: California law requires that school staff and volunteers working with children and community college students be free of infectious tuberculosis (TB) disease.
  • Administer the California School Employee Tuberculosis (TB) Risk Assessment Questionnaire, and if risk factors are identified, a TB test and examination must be performed by a health care provider.
  • Routine testing is not required for all students, but may be recommended in certain situations.
• Other workplace settings: Use the CA TB Risk Assessment Form for Adults when mandatory TB testing is not required. The Marin County TB Control Program does not provide TB skin tests for work clearance.

Clinical Guidance

Visit TB Resources for Healthcare Providers (CDPH) for more information.

Who to test for TB

Approximately 80% of TB is due to the reactivation of LTBI. Routine assessment of TB risk followed by testing and treatment are crucial to preventing active, transmissible disease.

• Use a California TB Risk Assessment to determine if testing is needed
• Do not test low risk individuals, as this may lead to false positive results and unnecessary treatment

Risk assessment tools:

• CA Adults TB Risk Assessment & User Guide
• CA Pediatrics TB Risk Assessment & User Guide
• CA College and University Students TB Risk Assessment & User Guide
• CA Tuberculosis School Staff and Volunteer Risk Assessment

Selecting a test for latent TB infection (LTBI)

• Use a TB blood test (IGRA) for most patients
• IGRA is preferred over the tuberculin skin test (TST)
  • For TST, use Mantoux method for administration
• IGRA is especially recommended for patients who received BCG vaccine or were born outside the U.S.

BCG Vaccination & TB Testing

• BCG, or bacille Calmette-Guérin, is a vaccine for tuberculosis (TB) disease. Many foreign-born persons have been BCG-vaccinated. The TST and TB blood tests to detect TB infection are not contraindicated for persons who have been vaccinated with BCG. Blood tests to detect TB infection, unlike the TST, are not affected by prior BCG vaccination and are less likely to give a falsepositive result.
• Map on current & past BCG policies worldwide

Interpreting and evaluating a positive TB test

All patients with a positive TB test should receive a baseline evaluation:

• Conduct symptom review
• Obtain chest radiograph (Persons > 5 years of age should have a posterior-anterior view radiograph. Children under 5 years of age should have both posterior-anterior and lateral views)
  • Within 6 months if normal
  • Within 3 months if recent exposure, immunosuppression, or prior abnormal imaging
  • Obtain immediately if symptomatic
• Review medical history, including HIV status, history of liver disease, alcohol use, other medicines including those that are potentially hepatotoxic or have drug-drug interactions with rifamycins or isoniazid.

LTBI

If the known source of TB Infection has drug-resistant TB, consultation with Marin County Public Health is advised.

• Sample script to explain LTBI treatment
• Several treatment regimens are available. Providers should choose the appropriate regimen based on the following:
  • Drug-susceptibility results of the presumed source case (if known)
  • Coexisting medical illness
  • Potential for drug-drug interactions
• Use short-course regimens when possible, such as:
  • Three months of once-weekly isoniazid plus rifapentine (3HP) – for adults and children older than 2 years, including HIV-positive persons (as drug interactions allow), or
  • Four months of daily rifampin (4R) – for HIV-negative adults and children of all ages
  • Six to nine months of INH is now considered an alternative therapy.
  • Review the Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020
• Monitor a patient on LTBI treatment
  • Evaluate patients monthly for:
    • Signs of hepatitis
    • Adherence to medication regimen
    • Symptoms of possible adverse drug reactions or interactions
  • Patients who experience adverse reactions should be advised to stop medication and consult their health care provider immediately.
  • Assess patient understanding and provide education to support treatment adherence.
  • Consider directly observed therapy (DOT) for LTBI for persons who are at especially high risk for TB disease and are either suspected of nonadherence or are given an intermittent dosing regimen. Please contact the Marin County Public Health if you need assistance with DOT.
• Ater LTBI treatment completion, providers should:
  • Inform patients that future risk of developing active TB is low, but not zero
  • Review TB symptoms and advise seeking medical care if symptoms develop
  • Remind patients that their TB test will likely remain positive and to keep LTBI treatment completion documentation to avoid repeat TB testing
  • Provide a LTBI Treatment Completion Card/Letter (Samples)

For health care provider TB reporting, consultation, or general questions:

• Call Marin County Public Health, TB Control Program: 415-473-4163
• Email: ZnevaPQ@znevapbhagl.tbi

If you think you may have TB, contact your health care provider.

Drop-In TB Testing

Marin Community Clinics (MCC) offers drop-in TB screening on Tuesdays & Fridays from 1:30 pm-4:00 pm at 3260 Kerner Blvd., San Rafael, CA 94901. For more information call 415-448-1500.