Is it possible to get a Hawai'i TB clearance without a PPD skin test?
November 4, 2016 3:32 AM   Subscribe

I need to get a TB clearance from the state of Hawai'i, but they won't give me a chest X-ray without documentation of my past positive PPD, which I don't have. Every other medical professional I've ever asked about this has told me not to get another PPD, but that seems to be the only thing I can do here, right?

I had a positive PPD skin text about 20 years ago, and have gotten intermittent chest x-rays since then when I needed to prove to school, job, etc, that I was TB-free.

Now I live in Hawai'i and I need to provide my university and the casual food service/baby-sitting type jobs I'm applying for with a state TB clearance card. My university would accept a chest x-ray, but my doctor here refers everything TB-related to the state TB clinic. The state TB clinic won't give me a chest x-ray without a more complete record of my positive PPD than I have and told me that I could take another PPD if I wanted to, or find a private radiologist to give me a chest x-ray.

Doctors, etc, have always told me not to take the PPD again, mostly because we know it will just be positive, but also partially because of the increased risk of an adverse reaction. I assume that risk is still pretty small, but I can't figure it out from googling and I will feel stupid if I get arm necrosis because I wanted a job at Arby's.

My questions:
-Is there a way to get my Hawai'i TB clearance without taking the PPD again, short of finding a private radiologist to x-ray me?
-If there isn't and knowing that YANMD, can anyone give me a sense of the actual risk of getting another PPD, on a scale of "only a bit higher than with any injection" to "definite arm necrosis"? So I can assess whether to do it or pay private radiologist money to avoid. Thanks.
posted by Snarl Furillo to Health & Fitness (11 answers total)
AFAIK it is not recommended to get a PPD/TST/Mantoux (all the same) when suspecting a currently fully active TB infection.

I learned that repeat testing is not a problem though - if you didn't have an overly strong reaction to the first test - it will be just like that first exposure. The antibodies are in your body after all.

Here's a source I found by the CDC on repeat testing..
posted by mathiu at 6:00 AM on November 4, 2016

If you've had a positive PPD in the past, you shouldn't have another one. You should request a blood test instead, called Quantiferon Gold. This will show whether you have active TB infection. This test is both more sensitive and more specific for detecting TB infection. It is more expensive than PPD, so you may have to pay extra depending on your insurance.
posted by stillmoving at 6:39 AM on November 4, 2016 [3 favorites]

If the reason for testing is only legal purposes money is a consideration take the cheapest available option. It sounds like this is a new PPD from the state TB clinic as they suggest. Save any documentation you receive with the results.

Repeated PPD isn´t dangerous, merely unnecessary and in some cases uncomfortable (see mathiu´s link). If you have a reason to do it again then do so. Your arm will not fall off.
posted by abx1-se at 6:54 AM on November 4, 2016

Another option is interferon testing, which I assume hasn't been offered because it's a more expensive test. I had a positive PPD years ago (with no known exposure) and had been getting chest x-rays. Finally, I asked for an interferon test, which was negative.
posted by i_am_a_fiesta at 6:59 AM on November 4, 2016

does your doctor (the one who referred you to the state TB testing lab) not believe that you would be at increased risk of complications if you got another PPD? if so, then maybe s/he would approve the chest x-ray outside of the TB clinic because you are certainly right that your medical decisions should not be dictated by bureaucracy when that path contravenes medical advice.

If you current doc doesn't have a problem with you getting another ppd then its a question of why s/he thinks that and why others have different opinions.
posted by Exceptional_Hubris at 10:15 AM on November 4, 2016

It's dumb that they don't just believe you about the previous positive PPD but I think its fine to get another one if they're unwilling to pay for Quantifiron or Chest X Ray without it.
posted by latkes at 10:23 AM on November 4, 2016

The state health department only gives the PPD and then an x-ray. I don't think they have the facilities to give the interferon blood test. My current dr (busy low-cost public clinic) can give the skin test, but doesn't have the facilities for the subsequent x-rays, and they won't give the skin test to me now that I've told them I had a positive result in the past. So it's not that they think I should take the skin test again, they just didn't have any ideas about what I should do instead.

I just left a message with my current doctors asking if they can give me the interferon blood test, that seems like a good avenue. They seem to do better when I ask them for a specific thing rather than general advice.

People who have taken the interferon test, if your result was negative, did you then stop getting the chest x-ray? So it basically acts like a negative skin test for bureaucratic purposes?
posted by Snarl Furillo at 2:48 PM on November 4, 2016

Everything depends on the bureaucrat who ends up processing your stuff. Some will accept whatever, some won't. But they'd be wrong not to accept a quantifiron.

It's really standard that a significant percentage of the population (military veterans, foreign born residents) will have positive PPDs due to immunizations. Doing an x-ray when you have a history of positive PPD is the norm. This is a weird situation you're in.
posted by latkes at 2:54 PM on November 4, 2016

I agree with latkes. Routine screening for TB includes a questionnaire that asks about a history of TB and a history of reactions to PPD. If anyone has had a positive PPD in the past, you skip it because it will usually show positive again, and move on to a chest x-ray. In the past few years (in my practice on the mainland), we've switched from PPD and chest x-ray to the Quantiferon (same as interferon) test because it shows whether you actually have TB or not, rather than if you've been exposed to TB in the past or have suspicious lung lesions. So it acts as a definitive TB test for clinical and bureaucratic purposes.

Anither thing you might try is to call one of the doc in the box places and request just the QFG test. They should have someone who can order the test for you (again, you might have to pay more?) Or try calling your university's occupational health department or student health office. You could also try calling a lab like Quest to see if they do the test. Finally, you can just start the process to get the PPD done. Once you are being screened, they'll either punt you to the chest x-ray stage or place the PPD. Some people wil actually have negative PPDs if many years have passed since the original. It won't hurt you, you'll just have a big spot on your arm. I've seen lots of patients who didn't remember having had a positive PPD in the past and have another one placed--they usually just get a larger reaction than a first-time positive. (TINMA, just my experience in the past ten years).
posted by stillmoving at 1:04 AM on November 5, 2016

Having another PPD will not be harmful to you, and that is what I would recommend.

I do need to correct a misconception stated above about the blood test for TB. The primary indication for that would be if you had previously been vaccinated with the BCG vaccine ( or if you are the rare person who does in fact have a positive PPD test without prior exposure for some other reason). It does not in fact show whether or not you have active disease, but, like the PPD test is intended simply to show if you have had prior exposure to TB. The chest x-ray is intended to detect the presence of active lung disease; with latent tuberculosis you have a lifetime potential for conversion to active disease.
posted by noonday at 11:05 AM on November 5, 2016 [1 favorite]

Update: The current Hawai'i administrative rules don't recognize the Quantiferon blood test as a valid TB test, so the Health Department won't accept it to get you to the chest x-ray, and my university won't accept it in lieu of a skin test or cxr. (The nurse who answered the nurse advice line at my doctor's office told me no such blood test existed, but that's a whole other thing.)

So I got the skin test at the Health Dept. They did not care that I reported a past positive and there was no questionnaire/interview process, aside from asking if I had the documentation for the past positive and then shrugging when I said no. And it is...completely negative. 0 mm. ¯\_(ツ)_/¯ Good thing I took all that Isoniazid!

Thanks everyone for suggesting possible avenues, it made me feel more confident to pin people down and get everything resolved.
posted by Snarl Furillo at 7:42 PM on November 10, 2016

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