Latent Tuberculosis Infection: A Guide for Primary Health Care Providers

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Appendix A

SAMPLE TB RISK ASSESSMENT TOOL

Persons with any of the following risk factors should be tested for TB infection unless there is written documentation of a previous positive TST or IGRA result.

Risk Factor	Yes	No
Recent close or prolonged contact with someone with infectious TB disease
Foreign-born person from or recent traveler to high-prevalence area
Chest radiographs with fibrotic changes suggesting inactive or past TB
HIV infection
Organ transplant recipient
Immunosuppression secondary to use of prednisone (equivalent of <15 mg/day for <1 month) or other immunosuppressive medication such as TNF-α antagonists
Injection drug user
Resident or employee of high-risk congregate setting (e.g., prison, long term care facility, hospital, homeless shelter)
Medical conditions associated with risk of progressing to TB disease if infected (e.g., diabetes mellitus, silicosis, cancer of head or neck, Hodgkin’s disease, leukemia, and end-stage renal disease, intestinal bypass or gastrectomy, chronic malabsorption syndrome, low body weight [10% or more below ideal for given population])
Signs and symptoms of TB

Adapted from a form developed by Minnesota Department of Health TB Prevention and Control Program