Recommendations for Tuberculosis Screening of Post-secondary School Students

Rationale: The Minnesota Department of Health (MDH) has developed guidelines regarding tuberculosis (TB) screening of elementary and secondary school students. These guidelines emphasize several concepts, including: a) universal tuberculin skin testing of all students is not recommended; screening should be targeted to students at highest risk for TB, and b) school-based TB screening programs should be implemented only if they include complete plans for providing necessary clinical follow-up and treatment, as indicated, for students identified with latent TB infection or TB disease. These principles also apply to post-secondary education facilities (e.g., colleges, universities, vocational/technical schools).

However, due to the student demographics and health care infrastructure that are inherent to most post-secondary schools, this setting often provides an appropriate and convenient means to access and provide services to specific population subgroups for whom targeted TB screening is indicated. For example, most post-secondary students are 18 years of age or older. Data indicate that the prevalence of latent TB infection increases with age, and adults with pulmonary TB disease are significantly more likely than young children to be infectious.[1] Post-secondary school students often live in congregate living situations which may facilitate transmission of airborne diseases such as TB. Also, post-secondary students typically have access to student health services provided through the institution, thereby enabling them to obtain medical evaluation and treatment for TB, if indicated. Therefore, MDH has developed the following recommendations specific to TB screening of post-secondary school students:

1. Universal screening for TB (i.e., Mantoux tuberculin skin testing) among all students in the school setting is not recommended. National guidelines indicate that tuberculin skin testing programs should be targeted to persons at high-risk for TB.[2] In Minnesota, the most notable trend in the epidemiology of TB is the large and increasing number of cases of TB disease among foreign-born persons, with more than 80 percent of TB cases reported among persons born outside the U.S.
2. In post-secondary school settings, targeted tuberculin skin testing is recommended for all international students originating from (and other students traveling to) countries where TB is endemic. In this context, "international students" are defined as those persons who travel to the US for the purpose of studying at the given post-secondary institution. In addition, all students whose studies involve extensive international travel to areas where TB is endemic (e.g., Asia, Africa, Latin America, and Eastern Europe) also are candidates for tuberculin skin testing prior to travel and 10-12 weeks following their return to the U.S.
3. A decision to conduct TB screening is a decision to treat latent TB infection, if identified. Targeted screening of persons at high risk for TB infection or disease must be accompanied by a comprehensive plan for providing necessary follow-up. This plan must include resources for providing a follow-up chest x-ray, medical evaluation, and treatment of latent TB infection or disease, and clinical monitoring during such treatment. A plan to address each of these criteria should be developed before screening is initiated.
4. Systematic program evaluation is an integral part of any TB screening program. Programmatic indicators that should be evaluated include the number of students with history of prior TB disease or infection, the number of tuberculin skin tests administered, the number of skin tests that are read and the result of each in millimeters of induration, and rates of initiation and completion of treatment of latent TB infection (including reasons for discontinuation among those who fail to complete therapy). These data should be reviewed on an ongoing basis to determine the yield and effectiveness of the screening program. MDH is available, as needed, for consultation on implementing a program evaluation system and evaluating resulting data.

These recommendations are general public health guidelines intended for population-based application in post-secondary school settings. Health care providers should carefully assess each specific patient's individual risk factors for TB when making decisions regarding TB screening, evaluation, and treatment of latent TB infection or TB disease for a given patient. For example, TB screening may be indicated for other foreign-born students who arrived in the US as immigrants, refugees, or with some other status but who have not received a Mantoux tuberculin skin test previously. Also, post-secondary schools at which not all students have access to centralized health care services should consider and identify means to ensure appropriate follow-up services for students identified with latent TB infection or TB disease prior to implementing any targeted TB screening program.

References:

1. Henry PM, Mills WA, Holtan NR, et al. Screening for tuberculosis infection among secondary school students in Minneapolis-St. Paul: policy implications. Minnesota Medicine 1996;79:43-49.
2. Centers for Disease Control and Prevention. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49 (No. RR-6):1,7,22.

These guidelines are based on recommendations of the MDH Work Group on Screening of School Students, December 2000.