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View Full Version : Why do I have to get so many Tuberculosis skin tests?


Roland Deschain
05-20-2004, 03:49 AM
I'm a student nurse and it seems everytime I turn around someone wants me to get another Tuberculin skin test. Why Tuberculosis which is relatively rare in the United States (and really rare in Indiana with less than two hundred cases last year). Why not Hepatitus B, C or HIV, or MERSA tests (I have read reports that up to ten percent of healthcare workers harbor MERSA)? It would seem much more likely that I would have these diseases and yet nurses are not typically tested for these organisms (although we are required to have Hep B vaccinations).

How about if I got the BCG vaccine that they give overseas? Would they still make me take the test (I can't see why since this vaccine makes you test positive for Tuberculosis)? For that matter if Tuberculosis is a real threat why not just require the BCG vaccine? If this vaccine is not sufficiently effective why not develop an alternative? After all Tuberculosis is a relatively slow growing organism and should have less "antigenic drift" than bugs like influenza (viruses) which mutate much more rapidly (making effective vaccines very difficult).

Broomstick
05-20-2004, 06:05 AM
Tired of the skin tests?

Let's consider my dad.. he must have been exposed to TB at an early age, because his very first skin test showed a positive. He's never suffered from TB, apparently has antibodies to it anyway. All those times you get a skin test? He's gotten a LOT of chest x-rays over the years.

Some of these regs were put in place when TB actually WAS a major health concern, and just were never changed.

Boyo Jim
05-20-2004, 07:08 AM
Yeah, I work in a hospital and I don't even deal with patients, and I'm tested annually. So is every other employee, right fown to the janitors. Old rules that won'r go away, man. I've asked.

Smeghead
05-20-2004, 02:10 PM
They test for it a lot because it's very highly contagious, so they don't want people working around patients if they're harboring TB. Hepatitis and HIV and whatnot aren't going to spread as easily.

They don't require the vaccine because it's not very effective, and once you have the vaccine, you test positive with the skin test, so you lose the ability to screen with the skin test.

Last I heard, they're still working on a better vaccine.

Joe Mahma
05-20-2004, 04:19 PM
TB is a real health problem, a fact of which you will be made aware at some point in your nursing education.

Helen's Eidolon
05-20-2004, 05:04 PM
At my hospital, TB testing is not done because of old rules on the books. Tuberculosis is a real problem, especially with the new multi-drug resistant strains popping up. We do our best to keep our employees (and patients) healthy, and regular TB testing is part of that.

LaurAnge, who just spent all day mailing letters to remind employees to come in for their PPD.

TeaElle
05-20-2004, 06:01 PM
TB also poses a very real threat to patients who are immunosuppressed, and certain drugs, especially for rheumatoid arthritis, seem to heighten patient susceptability. Even though we have great drugs to treat TB nowadays, no one needs to suffer with the disease unnecessarily -- and catching it from an untested healthcare worker certain qualifies as unnecessarily.

Frank
05-20-2004, 06:16 PM
I don't know if it's still the case - in the early 80s in Maryland, I had to take a TB test to work in a restaurant.

My question for the first three posters here would be: Do you suppose the testing (and early treatment) has anything to do with the fact that TB is now a relatively rare disease in the US?

Qadgop the Mercotan
05-20-2004, 07:03 PM
Sadly, TB is not a rare disease anymore. Rates of TB infection (positive skin test, no evidence that the bacteria is not dormant) are rising, as are the rates of TB disease (active bacteria causing body damage, contagious).

So an annual skin test is recommended for people at risk, including health professionals. If the test turns positive, one gets a chest x-ray to rule out active pulmonary lesions, and answers a few questions to rule out active disease elsewhere in the body. If there's no sign of active disease, then its 9 months of daily INH to kill the TB (nasty, hardy bug) along with vitamin B6 to minimize some of the INH side-effects. Oh, and no more skin tests. Once positive, always positive. And subsequent skin reactions can be severe, so don't get one. Annual chest x-rays will suffice to assess whether TB disease is occuring.

If there is TB disease, then things get sticky. This generally requires localizing the disease (x-rays, CT scans) and treating the hell out of it with multi-drug regimens, as the active TB germ is even harder to kill. And getting more resistant.

And the CDC doesn't consider the TB vaccine real effective in preventing TB infections. But it is a great way to obscure whether one has a TB infection, as once you are vaccinated with it, your skin test will always be expected to be positive.

You want more effective alternatives to the TB vaccine? Come up with one and you'll probably win the Lasker Award, if not the Nobel prize. You'll be rich, for sure.

Why TB and not Hep B, C, HIV, etc? As Smeghead aptly pointed out, universal precautions (a standard medical procedure to be used on anyone who's bleeding or otherwise leaking bodily fluids) will reliably check those entities, but not TB.

If you're going to be a health professional, then be a professional! Don't figure out ways to get around public health and safety requirements, cooperate with them.

QtM, MD

Frank
05-20-2004, 07:08 PM
Sadly, TB is not a rare disease anymore. Rates of TB infection (positive skin test, no evidence that the bacteria is not dormant) are rising, as are the rates of TB disease (active bacteria causing body damage, contagious).
How much (if any) of that is due to people being diagnosed and not following the treatment regimen?

Derleth
05-20-2004, 07:09 PM
You're a nursing student and you don't know of multi-resistant TB? Just because it keeps me up nights doesn't mean anyone else has to care, I realize, but that's the first thing they talk about when it comes to discussions of superbugs and antibiotic misuse in general. Maybe because they can show all of those isolation wards and other places where you got wheeled off to die before antibiotics were invented.

(Oh, and as a nurse, get used to people misusing antibiotics and breeding diseases an al-Qaeda terrorist would salivate over. By gawd, them pills are spensive, so they better keep and they better work 'gainst the flu and the cold and the rheum... :smack: :smack: :smack: )

Qadgop the Mercotan
05-20-2004, 07:18 PM
How much (if any) of that is due to people being diagnosed and not following the treatment regimen?
After researching your question extensively, I believe I can answer it correctly and succinctly: Probably a lot. Some for sure.

Frank
05-21-2004, 12:04 AM
After researching your question extensively, I believe I can answer it correctly and succinctly: Probably a lot. Some for sure.
Gosh, you did all that in ten minutes? I'm seriously impressed. [insert joke smily face here]

The reason I asked is because it seems to me (as a layman) that various once defeated common and deadly diseases are making a comeback. Some of it is due to idiots resisting vaccination. I wondered if some of it was due to idiots resisting treatment.

mischievous
05-21-2004, 12:48 AM
I wondered if some of it was due to idiots resisting treatment.

Some, surely. There's also a lot of non-idiots who don't comply with treatment. There's been a big problem here in New York with homeless people harboring multi-drug resistant TB. Not only are the homeless a (oversimplification and stereotyping ahead) poorly organized and frequently mentally ill population, but they can't afford drugs. Frequently they can't get public assistance for drugs, because they have no fixed address to receive benefits. Thus, they get whatever the doctor who sees them gives them in temporary shelter, but fail to complete (often multi-month) treatments. There's been some discussion of the legality of incarcerating TB patients who are at "high risk" of "non-compliance".

Understandable from a public health perspective, but the idea of jailing someone for being sick gives me the heebee-jeebies.

mischievous

Roland Deschain
05-21-2004, 03:08 AM
Some, surely. There's also a lot of non-idiots who don't comply with treatment. There's been a big problem here in New York with homeless people harboring multi-drug resistant TB. Not only are the homeless a (oversimplification and stereotyping ahead) poorly organized and frequently mentally ill population, but they can't afford drugs. Frequently they can't get public assistance for drugs, because they have no fixed address to receive benefits. Thus, they get whatever the doctor who sees them gives them in temporary shelter, but fail to complete (often multi-month) treatments. There's been some discussion of the legality of incarcerating TB patients who are at "high risk" of "non-compliance".

Understandable from a public health perspective, but the idea of jailing someone for being sick gives me the heebee-jeebies.

mischievous

I'm not saying that TB is not an issue, but so are the other diseases such as MERSA, and Hep B which are not typically tested for. Also, between school, the volunteer fire dept, and my two part time jobs I've been tested four times in the last six months (no one would except anyone elses test). I'm starting to worry that the "test" might make me test positive in and off itself (through repeated antigenic sensitization). It just seems a little out of proportion for a disease that less than two hundred people in Indiana get each year. Also, it's my understanding that over seventy percent of newly diagnosed cases of TB (including multi drug resistant) are in those who are HIV positive. Thus, it can largely be thought of as an opportunistic infection. Furthermore, it is my understanding that it generally takes over six hours (actually I heard eight, but am giving myself a "factual cushion") in close contact to transmit the disease. My plan is to volunteer in Haiti next Summer for Nurses without Borders (arranged through school) so I suppose that I will need about a dozen more TB tests then.

I wonder if there has been any research on using high doses of garlic (allicin) to help combat TB. I remember reading a news report about a British Study (maybe at Sciencedaily.com) that showed high doses of garlic were effective in combatting MERSA (and even VERSA I think) especially when combined with more traditional antibiotics. How about old fashioned Sulfa drugs that were used before we had antibiotics? The fact that they have been "out of use" for so long should mean that organisms resistent to such drugs should have reverted to "wild type" at least with regard to these drugs (since modifications which provide a pathogen resistence to a drug usually comes at the expense of other traits which are positive for the organism). I seem to remember reading in a book written by Stanley Plotkin and or Walter Orenstein about new vaccines in the pipeline for TB and this was at least six years ago.

Helen's Eidolon
05-21-2004, 07:42 AM
People generally get vaccinated for Hep B, which is why we don't test them all the time. Also, it's not transmitted through air.

I've never heard of anyone converting to TB+ because of skin tests.

duffer
05-21-2004, 08:41 AM
People generally get vaccinated for Hep B, which is why we don't test them all the time. Also, it's not transmitted through air.

I've never heard of anyone converting to TB+ because of skin tests.

Including this cuz it was easier to hit reply than parse another post. Thanks.

Roland, are you really studying to be a nurse? My mom was an RN for 30 years, and I learned long ago why she had to have the test so often. You see, TB can be passed by air!. Comparing it to Hep or AIDS shows you have a LOT to learn about health care. If you are in fact in that field. I'm a layman and know this.

To spread Hep to a patient, or AIDS, you'd have to pass on bodily fluids. Not likely if you're passing meds, give I.V.'s, chart vitals, etc. But if you're breathing the same air they do, especially considering they are likely to be in less than optimal health, well you should study why that could be a problem when it comes to an airborne disease.

If you didn't already know this, then your instructors are a major reason TB is making a hard comeback.
I shudder to think of how many other nurses are of this mindset.

Qadgop the Mercotan
05-21-2004, 11:12 AM
Roland, you certainly shouldn't be expected to be tested more often than yearly if your last test was negative and you've had no significant exposures or symptoms. Not accepting another agency's certification of a negative TB skin test is really not appropriate in most circumstances.

But TB is still a much more problematic communicable disease for the health care providers than either Hep B, C, MRSA, or HIV. The basic screening protocols do make sense. And it is not an opportunistic infection; there is no requirement for immune system impairment for the disease to take root.

Sorry those protocols are not being adhered to regarding skin testing among your employers/trainers.

Kalhoun
05-21-2004, 11:24 AM
My ex's father lived in a TB sanitarium for a decade back in the 50s. It's hard to get rid of. You can get it from jobs that have people in close quarters, i.e., restaurant workers, hospital workers, schools, etc.

Quitchyerbitchin and get tested. You don't want this bug.

Helen's Eidolon
05-21-2004, 04:21 PM
Roland, you certainly shouldn't be expected to be tested more often than yearly if your last test was negative and you've had no significant exposures or symptoms. At our hospital, there are groups tested every 6 months, inhalation therapists and people working with AIDS patients. Everyone else is either yearly or every two years.

Ferret Herder
05-21-2004, 05:17 PM
I'm not saying that TB is not an issue, but so are the other diseases such as MERSA, and Hep B which are not typically tested for. Also, between school, the volunteer fire dept, and my two part time jobs I've been tested four times in the last six months (no one would except anyone elses test). I'm starting to worry that the "test" might make me test positive in and off itself (through repeated antigenic sensitization). It just seems a little out of proportion for a disease that less than two hundred people in Indiana get each year.
Fine, let me explain it this way then: You cannot get HepB, HepC, HIV, etc. by sitting in the same room with an infected person. You potentially can with tuberculosis. I would wager that many, many more people would get TB in Indiana (and elsewhere) if hospital staff were not regularly tested for TB.

As for testing staff for HepB, HepC, HIV, etc., you should know that you're supposed to always treat all blood as being potentially infectious. If possible contamination occurs (whether patient to staff, or staff to patient), that's when you test. These incidents happen far less frequently than just being in the room with someone else, naturally.

Qadgop the Mercotan
05-21-2004, 08:28 PM
At our hospital, there are groups tested every 6 months, inhalation therapists and people working with AIDS patients. Everyone else is either yearly or every two years.
I don't believe all areas in the US require that frequency of testing in those circumstances, but I certainly can understand it if TB is becoming even more common in that area.

Roland Deschain
06-11-2004, 06:36 PM
I don't believe all areas in the US require that frequency of testing in those circumstances, but I certainly can understand it if TB is becoming even more common in that area.

By the way I just started working at an additional home health care agency that is requiring that I have yet another Tuberculin Skin Test. I actually, the Harrison's articles on TB skin tests last week and came up with the following questions:

1. Is it possible to develop a positive reaction from having too many skin tests (thus sensitizing your immune system to the TB antigens)?

2. I actually, read an opinion that stated that mortality was higher for "all causes of death" in people who tested negative on TB skin tests. How could this be? Are they perhaps referencing studies conducted in areas of the world where most people have been exposed (and thus testing negative reflects a decreased immune system?) .

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