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Tuberculosis Information for Physicians

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Page Summary

According to the Health Promotion and Protection Act (HPPA) (external link) active tuberculosis (TB) disease and latent TB infection (LTBI) are both reportable diseases in Ontario to the local medical officer of health. Patient consent is not required for reporting. Physicians, healthcare providers, hospital administrators and superintendents of institutions, school principals, pharmacists and operators of a laboratory are required to report all positive Tuberculin Skin Tests (TSTs) and/or Interferon Gamma Release Assays (IGRAs), suspect and active tuberculosis cases to Halton Region Public Health.

CME Public Health Updates for Halton Physicians: Screening and Treating Tuberculosis

Active Tuberculosis (TB) Disease – Diagnosis, Treatment and Reporting

To report a suspect or confirmed active TB case

  1. Call Halton Region Public Health at 905-825-6000 ext. 7341 (Monday to Friday 8:30 a.m. to 4:30 p.m.) or dial 311.
  2. Advise the patient to self-isolate if pulmonary or laryngeal TB is suspected or confirmed. Advise the patient that a mask should be worn if he/she needs to go to an appointment or lab.
  3. Complete Tuberculosis Health Care Provider Reporting Form (PDF file) and fax to Halton Region Public Health at 905-825-8797.

Complete a clinical evaluation for TB including the following:

  1. Complete medical history to evaluate for potential risk factors such as:
    • Born or lived in a TB endemic country (including visiting friends and family)
    • Contact with a person with active TB disease
    • Immunosuppressed medical conditions or who receive immune-suppressant therapy
    • Lived on a First Nations reserve or community
  2. A physical exam to evaluate the presence of TB symptoms such as:
    • New or worsening cough greater than 3 weeks
    • Coughing up blood
    • Fatigue
    • Fever
    • Loss of appetite
    • Shortness of breath
    • Sweating at night
    • Unexplained weight loss
    This can also include unresolved and/or repeated respiratory symptoms despite treatment with antibiotics. If TB disease is in other parts of the body (extra-pulmonary), the symptoms will depend on the area affected, (i.e. enlarged lymph nodes, abdominal pain, meningitis). Pulmonary TB can occur without a cough and in some cases may have no symptoms.
  3. Diagnostic testing for TB includes:
    1. Chest Radiograph
      • Both posterior-anterior (PA) and lateral views are recommended (include reason for testing on requisition).
      • A normal chest x-ray does not exclude TB.
    2. Sputum Specimens
      • 3 specimens collected at least one hour apart or over three consecutive days. Specimens collected should include one early-morning specimen (use orange top sterile container). Consider an induced sputum if the patient is unable to produce sputum.
      • Always use a Public Health Lab requisition (external link). Send specimens directly to the Public Health Lab. Include symptoms, date of onset, and request “AFB and TB culture” on lab requisition.

A negative AFB does not exclude active TB. If the suspicion of TB is high, consider a referral to a respirologist or infectious disease (ID) specialist for further follow up i.e. bronchoscopy or biopsy. A TB culture can take up to 7 weeks for final results.

Note: Medication prescribed for active TB disease or LTBI is publicly funded through Halton Region Public Health regardless of OHIP status. If you have any questions regarding medication, call 905-825-6000 ext. 7341 Monday to Friday 08:30am – 4:30pm to speak directly with a public health nurse. Persons with active TB disease are managed by an ID specialist and/or a respirologist.

Clinical Guidelines:

Latent Tuberculosis Infection (LTBI) – Diagnosis, Treatment and Reporting

A referral to an ID specialist and/or respirologist or pending results (i.e. sputum results) should not delay the reporting of a positive TST and/or IGRA to your local public health unit.

Reporting positive TST and IGRA

  1. Assess for signs and symptoms of TB.
  2. Send patient for chest x-ray. Both posterior-anterior (PA) and lateral views.
  3. Counsel about TB risk.
  4. Consider LTBI treatment and/or referral to specialist. See clinical guidelines below
  5. Download, complete and fax the TB Health Care Provider Reporting Form (PDF file)

Clinical Guidelines:

Note: Medication prescribed for active TB disease or LTBI is publicly funded through Halton Region Public Health regardless of OHIP status.

Resources:

Tuberculosis Diagnostic and treatment Services for Uninsured Person (TB-UP)

TB-UP is a Ministry of Health program that covers the cost of Ontario Hospital Insurance Plan (OHIP)-billable care related to TB screening, diagnostic tests and physician care (outpatient services) for uninsured persons.

TB-UP eligibility

  • patients who do not have other medical insurance/coverage for TB services
  • and who are
    • patients with suspected or confirmed active TB; even if the final diagnosis is not TB, the work-up is still covered; or
    • patients who are a contact of a person with active TB; or
    • patients at high risk of developing active TB as determined by the board of health

TB-UP registration

Contact Halton Region Public Health at 905-825-6000 ext. 7341 prior to providing service, and ask to speak with a public health nurse to register your patient.

The Ministry of Health will not issue retroactive payments for persons who receive TB diagnostic and/or treatment services prior to registration on TB-UP.

Immigration Medical Surveillance (IMS)

Individuals who have applied to enter, extend their stay or become a permanent resident in Canada, are required to undergo an immigration medical exam (IME) by panel physicians as designated by the Immigration Refugees and Citizenship Canada (IRCC). Through their IME with an IRCC authorized panel physician, they may have had an abnormal chest x-ray, a positive tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA), previous history of tuberculosis (TB) or been in close contact with an active TB case. As such, this patient may be at high risk for developing active TB and a medical assessment is required as part of this process.

If you see an individual who requires TB medical surveillance, please follow these steps:

  1. Conduct a physical exam and assess for symptoms of pulmonary and extra-pulmonary (e.g., lymph node) TB.
  2. Send the patient for a chest x-ray – anterior/posterior and lateral views.
  3. Collect three spontaneous sputum specimens (at least one hour apart), for TB testing if symptomatic and/or if they have an abnormal chest x-ray.
  4. If active TB disease is suspected, call Halton Region Public Health immediately at 905-825-6000 ext. 7341 and instruct client to isolate at home and refer to an ID specialist and/or respirologist.
  5. Consider doing a TST or an IGRA if active TB is ruled out, and discuss treatment for latent tuberculosis infection (LTBI) as appropriate.
    Note: LTBI management is not an IRCC requirement for TB medical surveillance.
  6. Complete the medical assessment form that the patient will provide and return it to Halton Region Public Health by fax to 905-825-8797. A referral to an ID specialist and/or respirologist or pending lab results (sputum results) should not delay the return of the completed form(s).
  7. Halton Region Public Health will advise IRCC that the medical surveillance requirement has been met.

Recommendations for Tuberculosis (TB) Screening in Long-Term Care and Retirement Homes

Recommendations for Residents Prior to or on Admission, including Residents admitted to Short-term Care of less than 3 months

The Fixing Long-Term Care Act (2021) and the Retirement Home Act (2010) requires that all new residents must be screened for active tuberculosis (TB) by a health care provider within 90 days prior to admission or within 14 days after admission.

The Canadian Tuberculosis Standards (8th Edition) were released in March 2022, and provide updated screening recommendations for LTC home residents. These recommendations should also be applied for RH residents as per the Ministry of Health, Tuberculosis Program Guideline, 2023.

Halton Region has updated our TB Screening Recommendations based on these updates and recommends that this screening include:
  • History and physical exam
  • A respiratory tuberculosis (TB) symptom review- completed prior to and on admission
If signs and symptoms suggest possible active respiratory TB disease, the resident should not be admitted and/or be isolated and should complete:

Management of Residents with Suspected Active Pulmonary TB Disease

If at any time, active pulmonary TB disease is suspected in a resident, the individual should be isolated and Public Health should be notified immediately. This involves:

  • Calling 311 or 905-825-6000 to report any suspect cases.
  • Placing the resident in a single room.
  • Keeping the door closed.
  • Limiting interactions with staff and visitors.
  • Ensuring appropriate personal respiratory protection (i.e., have resident wear a medical mask, if tolerated, while others are in the room; fit-tested N95 masks are recommended for staff).
  • Immediate steps should be taken to ensure appropriate medical care, investigation, and follow-up, according to facility policies and procedures.

Reporting Requirement for Tuberculosis

Under the Health Promotion and Protection Act, R.S.O. 1990, c. H.7, diagnoses of TB infection and cases of suspect and/or confirmed active TB disease are reportable to Public Health. For information on how to report or to ask for advice related to TB infection or active TB disease, please contact your local Public Health Unit.

Employees and Volunteers

Recommendations for Employees and Volunteers (Volunteers include those who expect to work at least one-half day per week)

The following assessment must be initiated within 6 months before starting work or within 14 days of starting work:

  • An individual risk assessment to determine if individuals are at increased risk for TB, such as:
    • Temporary or permanent residence in a country with a high incidence of TB,
    • History of active TB disease or TB infection,
    • Current or expected disease or treatment that suppresses the immune system making them more susceptible to infection, and/or
    • Close contact with someone with TB who is infectious since the last TB skin test
  • A symptom evaluation
  • Tuberculin skin test (TST) for those without prior documented TB disease or TB infection (TBI)
Person with unknown TST:

2-step TST is required:

  • If both TSTs are negative, no further testing
  • If either TST is positive, Refer to *Person with a positive TST
Person with documented results of previous 2-step TST
  • If both TSTs were negative:
    • Done > 6 months ago (regardless of when it was conducted), 1 step TST is recommended, if result of this TST is positive, refer to Refer to *Person with a positive TST
    • Done < 6 months ago, no further testing
  • If any previous TST was positive, Refer to *Person with a positive TST
Person with a positive TST
  • Should be assessed for active pulmonary TB disease, including a chest x-ray and a medical evaluation, TB symptom review and medical evaluation to rule out active pulmonary TB disease.
    Note: The chest x-ray can be from within the last three months unless the person is symptomatic.
  • Consideration for treatment of TB infection in the absence of contraindications and education on the signs and symptoms of active pulmonary TB disease by their health care provider
  • Further skin testing is not recommended.
  • Report person with positive TST to local Public Health Unit.
If person has symptoms of TB or an abnormal chest x-ray
  • Collect 3 sputum samples at least 1 hour apart
  • Should not work until health care provider provides documentation that the person does not have infectious TB disease.
If person has no symptoms

Can continue to work while physician completes an assessment to rule out active pulmonary TB disease.

Recommendations for Contract Workers and Students

Supplying agencies or schools are responsible for pre-placement TB assessment and follow-up. This should be clarified with agencies or schools to confirm that individual contract workers and/or students have had their TB skin test and any additional assessment as above to rule out active TB disease prior to starting their placement.

Regular Screening Employees and Volunteers

The Canadian Tuberculosis Standards (8th edition) strongly recommends against routine or periodic TB testing of all health care workers with a negative baseline TB skin test. Health care organizations can consider whether periodic screening for selected health care workers is warranted based on their organizational risk assessment. If an employee or volunteer is exposed to someone with TB disease, consult with Halton Region Public Health by calling 311.

Frequently Asked Questions

Why are chest x-rays no longer recommended for all residents prior to admission?

The Canadian Tuberculosis (TB) Standards, 8th edition (CTS, 2022) advises that residents of Long-Term Care (LTC) undergo a symptom screen to rule out active pulmonary TB disease prior to and on admission to the home. If the resident has symptoms suggestive of active pulmonary TB disease (i.e., cough lasting longer than 2-3 weeks, unexplained weight loss, fever, chills, night sweats, fatigue), a medical assessment, a posterior-anterior and lateral chest x-ray and sputum collection should be done to rule out active pulmonary TB disease.

Why are TB skin tests (TSTs) no longer recommended for residents under 65 years of age prior to admission?

The CTS, 2022 advises that residents of LTC are considered to be at the same risk for having TB infection (TBI) as other populations in the community and have the same risk of developing active pulmonary TB disease as persons of the same age in the general population, except for those belonging to identified at-risk-groups. Therefore, routine TSTs are no longer recommended for residents upon or prior to admission. Rather, it is recommended that the resident be screened by a health care provider within 90 days prior to admission or within 14 days of admission. The screening should include the likelihood of respiratory TB such as history, a physical exam, and a respiratory TB symptom review prior to and on admission.

If a resident has had an exposure to active pulmonary TB disease, the need for testing will be individualized as part of contact tracing as directed by Public Health.

What if a resident has symptoms that could be due to active pulmonary TB?

Prior to admission to the facility, if the resident has symptoms suggestive of active pulmonary TB disease (i.e., cough lasting longer than three weeks, unexplained weight loss, fever, chills, night sweats, fatigue), a medical assessment, a posterior-anterior and lateral chest x-ray should be done to rule out active pulmonary TB disease. In addition, 3 sputum samples should be collected, each at least one hour apart and submitted to the Public Health Laboratory for testing (Acid Fast Bacilli and TB Culture). Sputum results should be negative and active pulmonary TB disease ruled out before admitting the resident to the facility. If the resident has already been admitted to the facility, the resident should be referred for a medical assessment. Refer to the Recommendations for TB Screening in Long-Term Care and Retirement Homes, specifically the section regarding "Management of Residents with Suspected Active Pulmonary TB Disease”. Suspect cases of active TB disease are to be reported to Halton Region Public Health by calling 311.

What is recommended for residents being transferred to another facility?

Prior to transfer, the resident should be assessed using the Active Pulmonary Disease TB Screening Checklist for Health Care Providers for signs and symptoms of active pulmonary TB disease, including unexplained weight loss. If there are any indications of possible active TB pulmonary disease, a medical assessment, an anterior-posterior and lateral chest x-ray and sputum testing should be done to rule out active pulmonary TB disease before the resident is transferred.

What is a 2-step Tuberculin skin test (TST) for TB?

This consists of 2 TSTs usually performed within 1 to 4 weeks apart of each other. A baseline 2-step TST, rather than a single TST, is generally only indicated at the initial assessment of someone who will be having repeat TSTs at regular intervals or if public health requires a 2-step TST for a TB contact investigation.

Can Interferon Gamma Release Assays (IGRAs) be used for healthcare workers prior to employment?

IGRAs are blood tests used to detect TB bacteria. The IGRA test cannot tell if an individual has active TB disease or TB infection and measures the individual’s immune response to the TB bacteria. The use of IGRA for serial (repeated) testing of health care workers is not recommended because serial testing studies have shown high rate of conversions and reversions, unrelated to TB exposure or treatment. This is to reduce the chance of a false positive TST conversion when the TST is repeated (CTS, 2022). Therefore, the TST is the preferred diagnostic test for pre-employment for TB infection among health care workers.

What if a new employee/volunteer had a 2-step TST done, but the 1st and 2nd steps were done more than 4 weeks apart?

According to the CTS, 2022, the 1st and 2nd step of a 2-step TST should be done 1-4 weeks apart. Less than 1 week does not allow enough time to elicit the booster phenomenon, while more than 4 weeks allows the possibility of a true TST conversion. The 2nd test can be accepted up to 1 year later if no exposure to active pulmonary TB disease occurred within the time in between. If an employee has a documented negative 2 step TST (regardless of when the 2 step TST was completed), only a 1 step TST is recommended.

What if an employee/volunteer has never had a 2-step TST done, but had a 1-step TST done within this past year?

If the previous TST result was positive (≥ 10 mm) and documented, no further skin testing should be done. The person should proceed with a physical exam and a chest x-ray to rule out active pulmonary TB disease.

If the previous TST was negative and documented, another 1-step can now be done and accepted as the 2nd step of a 2-step TST as long as it is within a 1-year period from the time of the 1st step. It is important to assess the likelihood that the employee was exposed to active pulmonary TB disease since the last TST. If an exposure is suspected, the 2nd TST should be done at least 8 weeks after the TB exposure to provide a reliable baseline for future assessments.

If an employee has received the BCG vaccine in the past does he/she still need a TST?

Yes. TB skin testing is required for staff who have received BCG vaccines in the past. People vaccinated with BCG may have a positive TB skin test if the BCG was given after infancy. However, it is also possible for this positive TST to have been caused by TB infection, especially if the person was born in or travelled to a country with high rates of TB. It is worth remembering that countries with much higher rates of TB than Canada also use BCG routinely. Thus, adults with a positive skin test who had a BCG vaccination should still be carefully evaluated for possible TB infection (TBI) and be offered treatment for TBI if appropriate.

The following resources may be helpful in interpreting a positive TST:

For more information, please call Halton Region Public Health at 905-825-6000 or 311.

Resources

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