Background: Baseline 2-step tuberculin skin testing (TST) is recommended for health care workers (HCWs) to identify cases of the "boosting phenomenon" (i.e., a negative initial TST result followed by a positive result) and to track the risk of acquiring occupational tuberculosis. However, the 2-step TST has been shown to be insufficient to identify all cases of the booster phenomenon in older adults and refugees. The objective of this study was to identify whether a history of bacille Calmette-Guérin (BCG) vaccination and foreign birth--variables that are known to be associated with the booster phenomenon--remain predictors of a positive TST result in a group of HCWs documented to have negative 2-step TST results (i.e., 2 TSTs done 7-28 days apart with indurations <10 mm in diameter).
Methods: We performed a retrospective analysis of an employee database in a tertiary care hospital in Winnipeg, Canada. The study population was comprised of 698 HCWs with negative 2-step TST results who underwent a TST 0-2 years after completion of the 2-step procedure.
Results: Forty-six HCWs (6.6%) had a positive TST result 0-2 years after the 2-step test. In a multiple logistic regression analysis controlling for age, BCG vaccination, foreign birth, sex, and work setting, only history of BCG vaccination (odds ratio [OR], 8.38; 95% confidence interval [CI], 4.04-17.4), foreign birth (OR, 3.19; 95% CI, 1.53-6.62), and high-risk work setting (OR, 2.93; 95% CI, 1.44-5.95) were associated with a positive TST result.
Conclusions: Even for HCWs with negative results of 2-step TST, foreign birth and history of BCG vaccination are associated with a positive result of a future TST. Some positive TST results in such HCWs are related to nonoccupational factors, including delayed boosting, rather than to conversion due to recent tuberculosis contact.