Wisconsin Tuberculosis (TB) Program Information Update

January, 2021

Recommendations for TB Testing with COVID-19 Vaccination for Health Care Personnel and Patients Entering Care Facilities

Background

The COVID-19 vaccination is an important tool to help stop the pandemic, and Centers for Disease Control and Prevention (CDC) recommends health care personnel be among those offered the first doses of COVID-19 vaccines.  As the U.S. COVID-19 vaccination program continues, some may have questions about the interaction between new COVID-19 mRNA vaccines and tests used for tuberculosis (TB) infection.

There are no data on the impact of the COVID-19 mRNA vaccines on either the tuberculin skin test (TST), (administered by intradermal placement of 0.1 cc of purified protein derivative) or the interferon gamma release assay (IGRA). There is no immunologic reason to believe that a TST or blood draw for IGRA will impact the effectiveness of COVID-19 mRNA vaccines.

According to the Vaccine Recommendations and Guidelines of the Advisory Committee on Immunization Practices (ACIP), inactive vaccines do not interfere with TB test results. Vaccination with live viruses (such as the MMR vaccine) can cause mild immune system suppression, and may reduce the reactivity of the TST, possibly causing a false-negative reaction.

Although the COVID-19 mRNA vaccine is not a live virus vaccine, not enough is yet known of the potential impact of mRNA vaccines on immune responses to say conclusively whether the COVID-19 mRNA vaccine could have a potential effect on TST or IGRA test results during the first four weeks after COVID-19 vaccination.

Wisconsin Recommendations

Until more is known, Wisconsin recommends following the CDC Dear Colleague Letter regarding timing for TB testing (TST/IGRA) with the COVID-19 vaccine.

For health care personnel (HCP) or patients who require baseline TB testing (at onboarding or for entry/preplacement into facilities) at the same time they are to receive a COVID-19 vaccine:

• Perform TB risk assessment and symptom evaluation (includes obtaining medical history) on all HCP or patients.
  • Evaluate for risk of TB infection, see TB Risk Assessment form F-02314 with detailed instructions on the second page.
  • Evaluate for TB symptoms: persistent cough lasting three or more weeks and one or more of the following symptoms: coughing up blood, fever, night sweats, unexplained weight loss or fatigue. 
  • Clinical judgement should be accompanied by careful evaluation of medical history including residence or travel (≥ 1 month) in a country with high TB incidence, history of previous treatment for TB or latent TB infection (LTBI) and history of TB in the family.
  • Per previous Wisconsin TB Program recommendations (see Publications P-02382 and P-02382A), previous documented negative TB tests (TST/IGRA) less than a year old may be used for clearance in the absence of new risk or symptoms. 

• If using the interferon gamma release assay (IGRA), draw blood prior to COVID-19 vaccination.
• If using the tuberculin skin test (TST), place prior to COVID-19 vaccination.

• If a two-step TST is needed (see Publications P-02382 and P-02382A), place the first TST prior to COVID-19 vaccination and the second TST four weeks after the full COVID-19 vaccination series is complete.
  1. A clinical decision on direct patient care duties (for HCP) or admission (for patient admission to care settings) should be made based on TB risk assessment, symptom evaluation, first-step TST results and medical history.

For HCP or patients who require baseline TB testing (at onboarding or for entry/preplacement into facilities) and COVID-19 vaccination has already occurred:

• Perform TB risk assessment and symptom evaluation (includes obtaining medical history) on all HCP or patients.
  • Evaluate for risk of TB infection, see TB Risk Assessment form F-02314 with detailed instructions on the second page.
  • Evaluate for TB symptoms: persistent cough lasting three or more weeks and one or more of the following symptoms: coughing up blood, fever, night sweats, unexplained weight loss or fatigue. 
  • Clinical judgement should be accompanied by careful evaluation of medical history including residence or travel (≥ 1 month) in a country with high TB incidence, history of previous treatment for TB or latent TB infection (LTBI) and history of TB in the family.
  • Per previous Wisconsin TB Program recommendations (see Publications P-02382 and P-02382A), previous documented negative TB tests (TST/IGRA) less than a year old may be used for clearance in the absence of new risk or symptoms.
• For HCP or patients with no risk/history of TB infection and no TB symptoms:
  1. Defer TST or IGRA until four weeks after completion of full COVID-19 mRNA vaccination series. TB testing should occur as soon as possible after this time.
  2. HCP can be cleared for direct patient care and patients can be admitted to care settings.
• For Asymptomatic HCP or patients with risk /history of TB infection:
  1. Defer TST or IGRA until four weeks after completion of full COVID-19 mRNA vaccination series. TB testing should occur as soon as possible after this time.
  2. Perform chest radiography (CXR) and symptom evaluation for clearance. A clinical decision on direct patient care duties (for HCP) or admission (for patient admission to care settings) should be made based on TB risk assessment, symptom evaluation, CXR and medical history.
     1. Per CDC Guidance, a previous CXR less than 6 months old may be used for clearance for asymptomatic HCP/patients.

Resources

F-02314: Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation

P-02382: Tuberculosis Screening and Testing: Health Care Personnel and Caregivers

P-02382A: Tuberculosis Screening and Testing: Residents of Adult Long Term Care Facilities

P-02529: Decision Tree: Tuberculosis Screening of Patients/Residents upon Admission to Care Facilities

P-02530: Decision Tree: Tuberculosis Screening of Health Care Personnel and Caregivers upon Hire

References

AOEM (2020) Tuberculosis Screening, Testing, and Treatment of US Health Care Personnel. JOEM vol. 62, No. 7.

CDC (2005) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR Vol. 54, No. RR-17.

CDC (2019) Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Vol 68, No. 19.

Chorba, T. (2020) Dear Colleague Letter from CDC Chief, Field Services Branch, January 7, 2021 E-mail communication to State TB Programs and also available On-line: TB Tests and mRNA COVID-19 Vaccines. https://www.cdc.gov/tb/publications/letters/covid19-mrna.html

Wisconsin Tuberculosis (TB) Program Contact Information

Main WTBP phone number: 608-261-6319

WTBP fax: 608-266-0049

WTBP group email: DHSWITBProgram@dhs.wisconsin.gov

Please do not reply directly to this email message. If you have a question, please contact the Wisconsin Tuberculosis Program at (608) 261-6319.