TUBERCULOSIS SKIN TEST

The tuberculosis skin test is a test used to determine if someone has developed an immune
response to the bacterium that causes tuberculosis (TB). This response can occur if someone
currently has TB, if they were exposed to it in the past, or if they received the BCG vaccine
against TB (which is not administered in the U.S.). The World Health Organization estimates
that 2 billion people worldwide have latent TB, while around 3 million people worldwide die of
TB each year.

DEFINITION:

The tuberculosis skin test is also known as the tuberculin test or PPD (purified protein
derivative) test.The tuberculin skin test is based on the fact that infection with M.
tuberculosis bacterium produces a delayed-type hypersensitivity skin reaction to certain
components of the bacterium. The components of the organism are extracted from TB cultures
and are the core elements of the classic tuberculin PPD (also known as purified protein
derivative).

This PPD material is used for skin testing for tuberculosis. Reaction in the skin to
tuberculin PPD begins when specialized immune cells, called T cells, which have been sensitized
by prior infection, are attracted by the immune system to the skin site where they release
chemical messengers called lymphokines. These lymphokines induce induration (a hard, raised
area with clearly defined margins at and around the injection site) through local vasodilation
(expansion

ADMINISTRATION OF TUBERCULIN TEST:

The standard recommended tuberculin test, known as the Mantoux test, is administered by
injecting a 0.1 mL of a liquid containing 5 TU (tuberculin units) of PPD into the top layers of
skin (intradermally, immediately under the surface of the skin) of the forearm. The use of a skin
area that is free of abnormalities and away from veins is recommended. The injection is typically
made using a 27-gauge needle, and a tuberculin syringe. The tuberculin PPD is injected just
beneath the surface of the skin. A discrete, pale elevation of the skin (a wheal) 6 mm-10 mm in
diameter should be produced when the injection is done correctly. This wheal or "bleb" is
generally quickly absorbed. If it is recognized that the first test was improperly administered,
another test can be given at once, selecting a site several centimeters away from the original
injection.

PROCEDURE

Supplies

 Alcohol Swabs

 Tuberculin syringe with attached safety needle

 Vial of Tuberculin Purified Protein Derivative (PPD) solution

STEPS-

1. Administration of Monteux Test

2. Check the label of the PPD vial for proper strength, expiry date and the date vial was

Opened (if applicable)

3. Clean top of vial with an alcohol swab and let dry. Draw 0.1 ml (5 tuberculin units) into

Tuberculin syringe.

4. Place the patient’s forearm palm side up on a firm, well-lit surface and select an area of
healthy skin approximately 3 finger widths below the ante-cubital space. This area should be free
of muscle margins, heavy hair, vein, sores or scars. Clean site with alcohol

5. Keeping the skin taut, hold the syringe almost parallel to the skin (at approximately 15
degrees) and insert needle with the bevel up into the superficial layer of skin until the
bevel is fully inserted and the tip is visible under the skin. Relax the skin and inject the

6. Do not press the site after injection to prevent displacement of the solution.

7. Inform the patient that mild itching, swelling, or irritation may occur and these are normal
reactions that do not require any treatment. Inform the patient to avoid scratching the site, keep
the site clean and avoid putting creams, lotions, or adhesive dressings on the site.

Reading the Results of the Mantoux Test

The standard reading time of the test is 48-72 hours. However, induration of 10 mm or greater
can be read at 6-24 hours and at 72-96 hours. Record in the same way.

 Palpate and measure the transverse diameter of the induration by placing a pen mark on
each side of the induration and measuring in mm the distance between using a flexible
ruler. (The ruler will be supplied by pharmacy with the PPD)

There are four important steps to properly measure the induration.

 Inspect: Visually inspect the site on a firm, well-lit area.

 Palpate: Induration is not always visible or present and can only be determined by
palpation with the fingertips. Using a light, gentle motion, sweep the fingertips over the
surface of the forearm in all four directions to locate the margins or edges of induration.

 Mark: The induration must be marked with a pen at the widest edges of the raised area.

 Measure: Using a plastic flexible ruler, place the zero ruler line inside the left dot edge
and read the ruler line inside the right dot edge.

Documentation and Reporting

 Record date and time to measure induration on Nursing Care Plan.

  Record any adverse effects and patient response on progress notes/flow sheet and report
to pharmacy.

 When induration is measured, record date and result of test on the Tuberculin Skin Test
Report. Record the results in millimeters. If there is no induration, record as 0 mm.

 Report result and any adverse effects to physician.

 Send or fax copy of the Tuberculin Skin Test Report to Tuberculosis Control
Saskatchewan. Contact information is indicated on the form

METHOD OF READING THE TUBERCULOSIS SKIN TEST

"Reading" the skin test means detecting a raised, thickened local area of skin reaction, referred to
as induration. Induration is the key item to detect, not redness or bruising. Skin tests should be
read 48-72 hours after the injection when the size of the induration is maximal. Tests read after
72 hours tend to underestimate the size of the induration and are not accurate.

Results interpretation:

The basis of the reading of the skin test is the presence or absence and the amount of induration
(localized swelling). The diameter of the induration should be measured transversely (for
example, perpendicular) to the long axis of the forearm and recorded in millimeters. The area of
induration (palpable, raised, hardened area) around the site of injection is the reaction to
tuberculin. It is important to note that redness is not measured.

A tuberculin reaction is classified as positive based on the diameter of the induration in

conjunction with certain patient-specific risk factors. In a healthy person whose immune system
is normal, induration greater than or equal to 15 mm is considered a positive skin test.
If blisters are present (vesiculation), the test is also considered positive.

In some groups of people, the test is considered positive if induration less than 15 mm is present.
For example, an area of induration of 10 mm is considered positive in the following groups:

 Recent immigrants from high-prevalence areas

 Residents and employees of high-risk areas
  IV drug abusers
 Children under 4 years old
 Pediatric patients exposed to high-risk adults
 People who work with mycobacteria in laboratories

An induration of 5 mm is considered positive for the following groups:

 People whose immune system is suppressed

 HIV-infected people
 People with changes seen on chest X-ray that are consistent with previous TB
 Recent contacts of people with TB
 People who have received organ transplants

Risks from having the PPD skin test

The test typically does not produce side effects. There is a very slight risk of having a severe
reaction to the test, including-

 Swelling and redness of the arm, particularly in people who have had tuberculosis or
been infected previously and in those who have previously had the BCG vaccine.
 Allergic reactions are also rare complications.