Tuberculin Skin Testing: What Is It? Classification of The Tuberculin Skin Test Reaction

Tuberculin Skin Testing
What is it? Classification of the Tuberculin Skin

The Mantoux tuberculin skin test (TST) is one method
of determining whether a person is infected with
Test Reaction
Mycobacterium tuberculosis. Reliable administration • An induration of 5 or more millimeters is considered
and reading of the TST requires standardization of positive in
procedures, training, supervision, and practice. » People living with HIV
» A recent contact of a person with
How is the TST Administered? infectious TB disease
The TST is performed by injecting 0.1 ml of tuberculin » People with chest x-ray findings
purified protein derivative (PPD) into the inner surface suggestive of previous TB disease
of the forearm. The injection should be made with a
» People with organ transplants
tuberculin syringe, with the needle bevel facing upward.
The TST is an intradermal injection. When placed » Other immunosuppressed people (e.g., patients
correctly, the injection should produce a pale elevation of on prolonged therapy with corticosteroids
the skin (a wheal) 6 to 10 mm in diameter. equivalent to/greater than 15 mg per day of
prednisone or those taking TNF-α antagonists)
How is the TST Read? • An induration of 10 or more millimeters is considered

positive in
The skin test reaction should be read between 48 and 72
» People born in countries where TB disease is
hours after administration by a health care worker trained
common, including Mexico, the Philippines,
to read TST results. A patient who does not return within Vietnam, India, China, Haiti, and Guatemala,
72 hours will need to be rescheduled for another skin test. or other countries with high rates of TB
The reaction should be measured in millimeters of the » People who abuse drugs
induration (firm swelling). The reader should not measure
erythema (redness). The diameter of the indurated area » Mycobacteriology laboratory workers
should be measured across the forearm (perpendicular to » People who live or work in high-risk congregate
the long axis). settings (e.g., nursing homes, homeless
shelters, or correctional facilities)
How Are TST Reactions Interpreted? » People with certain medical conditions that place
them at high risk for TB (e.g., silicosis, diabetes
Skin test interpretation depends on two factors: mellitus, severe kidney disease, certain types
of cancer, and certain intestinal conditions)
• Measurement in millimeters of the induration
» People with a low body weight
• Person’s risk of TB infection or the risk of progression
(<90% of ideal body weight)
to TB disease if infected
» Children younger than 5 years of age
» Infants, children, and adolescents exposed
to adults in high-risk categories
• An induration of 15 or more millimeters is considered
positive in
» People with no known risk factors for TB
CS 320275-A September 2020

What Are False-Positive Reactions? How Often Can TSTs Be Repeated?
Some persons may react to the TST even though they In general, there is no risk associated with repeated
are not infected with M. tuberculosis. The causes of these tuberculin skin test placements. If a person does not return
false-positive reactions may include, but are not limited to, within 48-72 hours for a tuberculin skin test reading, a
the following: second test can be placed as soon as possible. There is
no contraindication to repeating the TST, unless a previous
• Previous TB vaccination with the bacille Calmette- TST was associated with a severe reaction.
Guérin (BCG) vaccine
• Infection with nontuberculosis mycobacteria
(mycobacteria other than M. tuberculosis) What is a Boosted Reaction?
• Incorrect measurement or interpretation of reaction A boosted reaction occurs mainly in previously infected,
older adults whose ability to react to tuberculin has
• Incorrect antigen used decreased over time. When given a TST years after
infection, these persons may have an initial negative
A TB blood test is the preferred method of testing for
reaction. However, the TST may stimulate the immune
people who have received the BCG vaccine in order to
system, causing a positive or boosted reaction to
prevent false-positive reactions. TB blood tests are also
subsequent tests. Giving a second TST after an initial
called interferon-gamma release assays or IGRAs.
negative TST reaction is called two-step testing.
What Are False-Negative Reactions? Why is Two-Step Testing Conducted?

Some persons may not react to the TST even though they
Two-step testing is useful for the initial skin testing of
are infected with M. tuberculosis. The reasons for these
adults who are going to be retested periodically, such
false-negative reactions may include, but are not limited to,
as some health care workers. This two-step approach
the following:
can reduce the likelihood that a boosted reaction will be
• Anergy misinterpreted as a recent infection.
• Recent TB infection (within the past 8 to 10 weeks)

• Very young age (younger than 6 months) Can TSTs Be Given To Persons
• Recent live-virus measles or smallpox vaccination Receiving Vaccinations?
• Incorrect method of giving the TST Vaccination with live viruses, including measles, mumps,
rubella, oral polio, varicella, yellow fever, BCG, and oral
• Incorrect measuring or interpretation of TST reaction typhoid, may interfere with TST reactions. For persons
scheduled to receive a TST, testing should be done as
Who Can Receive a TST? follows:
Most persons can receive a TST. TST is the recommended • Either on the same day as vaccination with live-virus
method of testing for children younger than 5 years of vaccine or
age. It should be noted that the American Academy of
• At least 1 month after the administration of the live-virus
Pediatrics (AAP) recommends that either a TST or TB
vaccine
blood test (interferon-gamma release assay [IGRA]), can be
used in children 2 years and older. In children previously
vaccinated with BCG, a TB blood test is preferred to
avoid a false-positive TST result caused by a previous
vaccination with BCG.
TST is contraindicated only for persons who have had a
severe reaction (e.g., necrosis, blistering, anaphylactic
shock, or ulcerations) to a previous TST. It is not
contraindicated for any other persons, including infants,
children, pregnant women, or persons living with HIV.
However, TB blood tests are the preferred method of testing
for people who have received the BCG TB vaccine.
Are there alternative tests to the TST? What are treatment options for latent
There are two kinds of tests that are used to determine if
a person has been infected with TB bacteria: the TB blood
TB infection?
test and the TB skin test. TB blood tests (sometimes called Treating latent TB infection is effective in preventing TB disease
IGRAs) use a blood sample to find TB infection. The tests and less costly than treating TB disease. There are several
measure the response of TB proteins when they are mixed treatment regimens for the treatment of latent TB infection.
with a small amount of blood. Only one visit is required to These regimens use the drugs isoniazid, rifapentine, or
draw blood for this test. Health care providers are encouraged rifampin.
to use newer TB blood tests to screen for TB infection. In CDC and the National Tuberculosis Controllers Association
order to prevent false-positive reactions, TB blood tests are (NTCA) preferentially recommend short-course, rifamycin-
also the preferred method of TB testing for people 5 years of based, 3- or 4-month latent TB infection treatment regimens
age and older who have received the BCG TB vaccine. over 6- or 9-month isoniazid monotherapy (6H or 9H,
respectively). Short-course regimens include: Three months
What does a positive TST mean for the of once-weekly isoniazid plus rifapentine (3HP), four months
of daily rifampin (4R), or three months of daily isoniazid plus
diagnosis of latent TB infection and TB rifampin (3HR). Short-course latent TB infection treatments
are effective, are safe, and have higher completion rates than
disease? longer treatments.
If a short-course treatment regimen is not an option, 6H or 9H
Diagnosis of Latent TB Infection is an effective alternative latent TB infection treatment regimen.
A diagnosis of latent TB infection is made if a person has
a positive TB test result and a medical evaluation does
not indicate TB disease. The decision about treatment for
latent TB infection will be based on a person’s chances of
developing TB disease by considering their risk factors.
Diagnosis of TB Disease
TB disease is diagnosed by medical history, physical
examination, chest x-ray, and other laboratory tests. TB
disease is treated by taking several drugs as recommended
by a health care provider.
Additional Information
• CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR
2005; 54 (No. RR-17). www.cdc.gov/tb/publications/guidelines/infectioncontrol.html
• CDC. Mantoux Tuberculin Skin Test: Training Materials Kit (2003).
• CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000; 49 (No. RR-6). www.cdc.
gov/MMWR/PDF/rr/rr4906.pdf
• Lewinsohn et al., Official American Thoracic Society/Infectious Diseases Society of America/CDC Clinical Practice
Guidelines: Diagnosis of Tuberculosis in Adults and Children, Clinical Infectious Diseases, 2017, Pages e1–e33. www.
academic.oup.com/cid/article/64/2/e1/2629583
• Latent TB Infection Testing and Treatment: Summary of U.S. Recommendations www.cdc.gov/tb/publications/ltbi/pdf/
CDC-USPSTF-LTBI-Testing-Treatment-Recommendations-508.pdf
• What You Need To Know About the Tuberculosis Skin Test www.cdc.gov/tb/publications/pamphlets/tb_skin_test.pdf
• Patient Education Materials Series www.cdc.gov/tb/education/patient_edmaterials.html
@CDC_TB CDCTB

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Tuberculin Skin Testing

What is it? Classification of the Tuberculin Skin

How is the TST Read? • An induration of 10 or more millimeters is considered

» People with no known risk factors for TB

CS 320275-A September 2020

What Are False-Negative Reactions? Why is Two-Step Testing Conducted?

• Recent TB infection (within the past 8 to 10 weeks)

• Patient Education Materials Series www.cdc.gov/tb/education/patient_edmaterials.html

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