The Shortage Of Tuberculin Antigens; Can Anything Be Done?

For as long as most of us can remember, we have been subject to regulatory oversight regarding testing for tuberculosis in our residents. For most of us, this equates to a “mandatory” skin test upon admission (as well as mandatory tests for our employees!) to check for possible “exposure” to TB. The efficacy of these tests, or even the accuracy of chest x-rays, in diagnosis of the disease is tenuous at best, but we still must comply with the regulation.

There has been recent news about a nationwide shortage of Aplisol, one of two purified-protein derivatives (PPD) used in performing tuberculin skin tests (TST). Since it is recommended on the CDC website that Tubersol be used as a possible substitute, I recently checked with one of the pharmacy providers who serves my facilities; turns out that Tubersol is on national back-order status as well! Another possible “solution”promulgated by CDC is the substitution of interferon-gamma release assay (IGRA) blood tests. These tests are subject to the same limitations of the TST, i.e. they are not sufficient for diagnosis. And, they are more expensive for our facilities as well.

These are financial and regulatory burdens that face our homes. Some questions to consider:

  1. Have you contacted your local department of health to determine when these shortages might directly impact your area?

  2. Do you have a plan if these shortages continue for a period of months?

  3. If you are corporately owned, does the corporate hierarchy have any guidance about this issue?

Finally, it should be noted that, in many areas of California, it is very common that our residents will test positive on a TST; many have been in a nursing facility in the past, or were born abroad in countries where exposure to the disease is more common, or myriad other factors that would lead to an active test. When this occurs, we have become accustomed to immediately ordering a chest x-ray. Some health-care systems have (rightly) questioned this practice, as it (again) is expensive. We should be careful to recognize that our residents have the option to decline these x-rays, and perhaps not order them without “informed consent.”

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