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During the past year, the School Health Committee of the CT Chapter of the AAP asked DPH to review the then-current tuberculin skin testing guidelines for schools, issued in the year 2000. Notably, a collaborative AAP and CDC group had been meeting to review national recommendations, which culminated in the "October 2004 Recommendations of Pediatric Tuberculosis Collaborative Group: Targeted tuberculin skin testing and treatment of latent tuberculosis infection in children and adolescents" published in Pediatrics 2004;114:1175-1201.
While the 2000 DPH recommendations were similar to the October 2004 national recommendations, there were several features worth re-emphasizing. Most importantly, the national recommendations emphasize that routine tuberculin skin testing for daycare, school, camp and college entry is not necessary. Rather than automatically do a tuberculin skin test, each child should be screened using a questionnaire to assess risk of exposure, then test those with >1 risk factor. In addition, those found to have latent TB infection should receive treatment, with adherence promoted as feasible by the use of directly observed therapy in the school, home or clinic setting.
Based on the review, it was decided to update the Connecticut-specific guidelines to include a slightly modified list of risk factors and a specific screening questionnaire. This guidance has been finalized and is being sent to school superintendents, school medical advisors, school nurses and local health directors. Please further distribute it as needed.
If you have any questions, please feel free to call the DPH TB Control Program at 860-509-7722.
James L. Hadler, MD, MPH
State Epidemiologist
CT Department of Public Health
TUBERCULOSIS CONTROL SCREENING GUIDELINES FOR CONNECTICUT SCHOOLS
Connecticut Department of Public Health, Infectious Diseases Section
MAY 2005
These recommendations from the Connecticut Department of Public Health and the School
Health Committee of the Connecticut Chapter of the American Academy of Pediatrics replace those
issued May 2000 and are intended to guide school systems, health departments and pediatricians in
developing school district policies regarding tuberculin testing requirements for students and staff, and,
if applicable, administering a tuberculin skin testing program on-site.
The Connecticut General Statutes Sections 10-206 (b) and (c) mandate that each student have a
health assessment at three time periods during his/her primary and secondary school education: just
before school entry, during grade 6 or 7, and during grade 10 or 11. The Statute states that: "this
assessment shall include a test for tuberculosis when the local or regional Board of Education
determines, after consultation with the school medical adviser and local health department, that such a
test is necessary."
Recommended Testing Schedule
Routine tuberculin testing of all students at school entry or for any of the required examinations is not
recommended. The current low rates of transmission of tuberculosis in all parts of Connecticut do not
justify it.
It is recommended that at
each mandated examination, an assessment be made of the risk ofexposure to tuberculosis
. It is further recommended that all school districts mandate that any childdetermined to be at high risk be tested and that anyone found to be positive have an appropriate
management plan developed.
A model questionnaire is attached that can be used for screening.Students not already known to have a positive test should be tested if they have any of the following
risk factors for tuberculosis infection: a) were born in a high risk country of the world
1 and do not havea record of a tuberculin skin test performed in the U.S.; b) have traveled to a high risk country, stayed
for at least a week with substantial contact with the indigenous population since the previously required
examination; c) have had extensive contact with persons who have recently come to the US since the
previously required examination; d) had contact with person(s) suspected to have tuberculosis; or e) had
contact with anyone who has been in a homeless shelter, jail or prison, uses illegal drugs or has HIV
infection
. Schools should assure that all students originally from high risk countries1 who areentering school in Connecticut for the first time receive a tuberculin skin test.
A history of BCGvaccination is not a contraindication to testing nor should it be considered in interpretation of the
skin test result.
The results of the risk assessment and testing, when done, should be recorded on the state health
assessment record (HAR-3) or directly in the student's school health record (CHR-1).
Personnel
School personnel are not required by state statute or regulation to be tested. However, it is
recommended that all staff have baseline skin testing at the time of employment. Those with a clear
history of a previously positive test do not need to be tested. The result of the test should be recorded
1
All countries in Africa, Asia (including former Soviet Union), Eastern Europe, Central andSouth America, Dominican Republic and Haiti.
Tuberculosis Control Screen Guidelines for Connecticut Schools, May 2005
2in millimeters of induration in the employee health record. Repeat skin testing on persons with a
negative test is not routinely necessary, but should be done if exposure to a potentially infectious
tuberculosis case occurs in the school or if the employee develops symptoms of tuberculosis.
Type of Test and Recording Results
The intradermal injection test (Mantoux text) should be used. Multipuncture tests should not be used
since the amount and potency of antigen varies and testing techniques are not standardized,
compromising both sensitivity and specificity.
Interpretation and Management of Test Results
Negative Test Results
In general, an induration of 0-9 mm obtained by screening by the Mantoux test should be considered
negative.
If testing is being done as part of a contact investigation following discovery of apotentially infectious case, induration of 0-4 mm should be considered negative.
No furtherevaluation is indicated unless the child or employee has a chronic unexplained cough or is a contact to a
known infectious case of tuberculosis. In the latter instance, initiation of INH preventive therapy and
repeat skin testing in 2 months may be indicated.
Positive Test Results - Students
In most circumstances, induration of greater than or equal to 10 mm by the Mantoux test should be
considered positive.
If testing is conducted as part of a contact investigation, induration >5 mmshould be considered positive
. These criteria apply to all children, including those who have receivedBCG vaccination in the past. A symptom screen and chest x-ray should be performed to rule out active
TB disease on all students with a positive skin test.
If active TB disease is ruled out, the student's health care provider should initiate preventive therapy
with INH. To ensure adherence to the recommended 9-month course of daily therapy, arrangements
may need to be made for INH to be administered on school days by the school nurse or designee, as
authorized in Section 10-212a of the Connecticut General Statutes.
Although not required by law, it is recommended that any child with a positive test be reported to the
local health department and the Connecticut Department of Public Health Tuberculosis Control
Program. This is especially important for children who convert their skin test from negative to
positive. A follow-up contact investigation may be indicated.
Positive Test Results - Personnel
Positive results in personnel are defined in the same way as positive results in students. Similarly, each
employee with a positive skin test should have a symptom screen and chest X-ray to rule out active
disease. When indicated, employees should be offered preventive therapy with isoniazid by their
physicians. Repeat chest X-rays should be performed only if the employee develops symptoms
consistent with tuberculosis.
**********
For further information, please call the Connecticut Department of Public Health TB Control Program,
860-509-7722, or the Connecticut Department of Education, School Nurse Consultant, 860-807-2108.
Risk Assessment Questionnaire
for Tuberculosis Exposure
1. Was your child born outside the US?
If yes, where was your child born? If born in Africa, Asia (including the former Soviet
Union), Latin America (including Haiti and the Dominican Republic) or Eastern Europe, a
TST should be placed.
2. Has your child traveled outside the US?
If yes, where did the child travel, with whom did the child stay, and how long did the child
travel? If the child traveled to any of the above continental areas, stayed for >1 week and
interacted with the local people, including local friends or local family, then a TST should be
placed.
3. Has your child been exposed to anyone with TB disease?
If yes, determine whether the person had TB disease or LTBI, when the exposure occurred,
and what the nature of the contact was. If confirmed that contact was with a person with
known or suspected TB disease, a TST should be placed.
4. Does your child have close contact with someone with a positive TST?
If yes, see previous question for follow-up questions.
5. Does your child spend time with anyone who has been in jail (or prison) or a shelter,
injects illegal drugs, or has HIV?
If yes, then a TST should be placed.
6. Has your child drunk raw milk or eaten unpasteurized cheese since the last tuberculin
skin test?
If yes, then a TST should be placed.
7. Does your child have a household member who was born outside the US?
If yes, from what country? If country is one of the countries included in question 1, then a
TST should be placed.
8. Does your child have a household member who has traveled outside the US?
Included as a household member are persons who take care of the child in the home. If yes,
and the person is from one of the countries included in question 1, a TST should be placed.