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Updated School TB Screening Policy
Frank Alvarez, MD, MPH and Pamina Bagchi, MPHLos Angeles County Department of Public Health
Tuberculosis Control Program
Topics
• Background
• Data
• Myth-Busting
• New Approach
• Questions
Introduction
In 1980, amended California Administrative
Code, Title 22, Division 22, Chapter 9, Sections
41301-41329 to enable the Local Health Officer to
mandate tuberculosis (TB) testing of school children, if
deemed necessary, for that specific jurisdiction.
Introduction (2)
From 1985-2011, the TB Control Program has
required all kindergartners and students who have never
previously attended school in California to provide
written documentation of a TB skin test (or
IGRA) result.
Purpose of Previous Pre-K
TB Testing Requirement
• To collect County-wide data to assess
improvement in TB control and better
understand the presence of TB infection and
disease
• To determine the impact of immigration
patterns on local TB incidence
Purpose of Previous Pre-K
TB Testing Requirement (2)
• To identify children who are candidates for
treatment of latent TB infection (LTBI)
• To measure annual TB infection rates in the
school-aged population
7
TB Skin Test Results Among New School Entrants (K-12)
and TB Cases (4-18 year old) in Los Angeles County
1993-2009
53
47
34
39 2621
2025 27 27
15 28 20 1813 26
17
72
56
37
35 4740
3833 30 34
27 20 18 1315 11
10
0%
5%
10%
15%
20%
25%
30%
0
500
1000
1500
2000
2500
93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09
FB_Cases(4-18 Y.O.) US_Cases(4-18 Y.O.) Total_cases
US_TST(+) FB_TST(+)
Number of TB Cases % of TST (+)
Myth 1 About TB
•Myth: Being infected with TB (positive skin test or
blood test) means you have active TB disease.
•Fact: Infection does not necessarily mean disease.
TB Infection TB Disease Does not feel sick Usually feels sick Has no symptoms Has symptoms Cannot spread TB bacteria to others May spread TB bacteria to others Usually has a positive skin test or blood test
Usually has a positive skin test or blood test
Has a normal chest x-ray and a negative sputum smear
May have an abnormal chest x-ray, and/or positive sputum smear, and/or positive culture
Needs treatment for TB Infection to prevent developing active TB disease
Needs treatment for active TB disease
Myth 2 About TB
• Myth: TB testing is the same as TB screening.
• Fact: Testing for TB is not the same as screening.
TB Screening TB Testing
Risk assessment (series of
questions) performed by
clinician
Skin test (TST) or blood test
(QFT or T-Spot)
If deemed higher risk, test
for TB infection is done
If positive, then chest x-ray
is done
Myth 1 About Previous Testing
Requirement
• Myth: The Pre-K Testing Requirement was used as
a method of finding children with active TB disease.
• Fact: The requirement was designed to determine /
monitor TB infection rates, NOT to find and treat
active TB disease cases. TB Control utilizes contact
investigations to find active TB cases of all ages.
Myth 2 About Previous Testing
Requirement
• Myth: The Pre-K Testing Requirement was an
effective means of getting TB-infected children
treated.
• Fact: Monitoring was not in place to ensure that
children who tested positive for TB infection began
treatment. Evidence suggests that many who did
begin treatment did not complete the full treatment
regimen.
Myth 3 About Previous Testing
Requirement
• Myth: If the requirement were not in place, there
would be a rise in pediatric TB cases in LA County.
• Fact: Jurisdictions that either rescinded their Pre-K
Testing Requirement, like Riverside County, or that
never had a Pre-K Testing Requirement, like San
Diego County, have continued to see a steady
decline in pediatric TB cases.
New Requirement
• Rescind the testing requirement for children
entering kindergarten or a California school for
the first time.
• Incorporate universal TB screening and risk-
based testing in existing California State physical
examination requirement for children entering
first grade.
New Requirement (2)
• Health providers, as part of this routine health
assessment, will screen students and test them
for TB only if a risk factor is present.
New Requirement (3)
Old Policy New Policy
Screening for
High Risk None All Students
TB Testing All StudentsOnly those
at high risk
Additional Office
Visits Needed?Likely Not likely
(same as physical exam)
When?Entering
Kindergarten
Entering
First grade
5
Factors to Assess High Risk for
TB
If any of these is “Yes” TST or IGRA
• Birth outside US in high-prevalence region
• Travel to high-incidence country > 1 week
16
Factors to Assess High Risk for
TB (2)
If any of these is “Yes” TST or IGRA
• Contact with confirmed or suspected TB case
• Family member with positive TST
Why the Change?
• To promote evidence-based best practice, as
recommended by the CDC, AAP, USPSTF, etc.
• To avoid redundancy and prevent fragmented
care
• To prevent false positive children from receiving
treatments that may harm their livers
Why the Change? (2)
• To focus on placing children in medical homes
• To focus on more effective interventions (e.g.
CI)
• To focus on higher-risk populations (e.g.
homeless)
Partners
• Los Angeles County Office of Education (LACOE)
• Los Angeles Unified School District (LAUSD)
• American Academy of Pediatrics, Local Chapter
(AAP)
• American Academy of Family Practice, Local
Chapter (AAFP)
• Los Angeles County Medical Association (LACMA)
• American Lung Association in California (ALAC)
Partners (2)
• Child Health and Disability Prevention (CHDP)
• Maternal, Child and Adolescent Health (MCAH)
• Los Angeles County Department of Health
Services (DHS)
• CA Department of Public Health, TB Control
Branch (TBCB)
• Long Beach Department of Health, Human
Services (LBHHS)
• Long Beach Unified School District (LBUSD)
For Information on IGRAs• Cellestis, a Qiagen Company
(QuantiFERON Gold In-Tube)
Nancy Hyland
(661)289-2557
• Oxford Immunotec
(T-SPOT)
Deneen Jackson
(619)887-6109
TB Control Program Website
TB Control Program Website
Questions?
LA County TB Control Program Website
www.publichealth.lacounty.gov/tb/
Chhandasi Pamina Bagchi, MPH
Policy and Planning, TB Control Program
(213) 745-0836
