1. Persons whose tuberculin skin test (TST) status is unknown must have a 2-step TST, regardless of prior BCG vaccination:
   • If the TST is negative – no further testing is needed at this time. (Persons with medical conditions that severely weaken the immune system, such as dialysis, HIV or cancer, may have a negative TST even though they are infected with TB. Further assessment by a physician is recommended).
   • If the TST is positive – a physical examination and chest x-ray are required. Sputum should be collected if the person is symptomatic or has an abnormal chest x-ray. TST positive persons who are symptomatic should not work until a physician provides documentation that they are free of TB disease. TST positive persons who are asymptomatic may continue to work while waiting for a physician to rule out TB disease. So long as the person is asymptomatic, a chest x-ray done within the last 3 months is acceptable; if the person is symptomatic a current chest x-ray is required.
     
     
2. For persons with documented results of a previous 2-step TST done within the last 6 months, accept this as their baseline test result:
   • If the TST is negative – no further testing is needed at this time.
   • Persons with a previous positive TST should be evaluated via chest x-ray and physical examination if this was not done previously; no further skin testing is recommended.
     
   • Persons with history of a documented severe positive reaction after TST, such as blistering, should be considered positive reactors, and evaluated for TB (chest x-ray, physical examination) if not done previously (within the last 6 months); no further skin testing is recommended.
     
     
3. Persons who have a positive TST should be informed of the signs and symptoms of TB disease and be instructed to promptly report signs or symptoms of TB disease to their physician. If they are diagnosed with TB, they must inform the infection control staff at the facility as soon as possible. Early diagnosis and treatment of TB disease is critical for the ill person as well as those around them at home and work.
   
   • Testing should be done for volunteers who:
     Expect to work 150 or more hours during the next year (approximately a half day per week).

Note: Regardless of number of hours worked, volunteers who may have risk factors for TB infection or disease (e.g. medical conditions that severely weaken the immune system) should be considered for TB testing.

Requirements for Contract Workers and Students

Supplying agencies/schools are responsible for pre-placement TST and follow-up. The facility should clarify this with the agencies they work with, and confirm with the supplying agency/school that individual contract workers/students have had their TST prior to starting the placement.

Requirements for Residents Upon Admission to the Facility

All residents must undergo baseline posterior-anterior and lateral chest x-rays upon admission. Residents must also have a 2-step TST within 14 days of admission, regardless of prior BCG vaccination, unless documented results of a previous 2-step TST done within the last 6 months are available.

• If the TST (current or previous) is negative – no further TB testing is needed once the baseline posterior –anterior and lateral chest x-rays are completed. (Similar to employees/volunteers, residents with medical conditions that severely weaken the immune system may have a negative TST even though they are infected with TB, and so require further assessment by a physician).
• If the current TST is positive – a physical examination and chest x-ray are required. Sputum should also be collected if the person is symptomatic or has an abnormal chest x-ray.
• Residents with a previous positive TST should be evaluated for TB by chest x-ray and physical examination if this was not done previously.
• Residents with history of a documented severe positive reaction after TST should be considered positive reactors, and evaluated for TB by chest x-ray and physical examination if this was not done previously (within the last 6 months); no further skin testing is recommended.

Continuing Surveillance for Workers and Residents

Routine repeat skin testing is not recommended. Repeat chest x-rays are not recommended in the assessment of positive reactors. Repeat testing is required only if there is an infectious case of TB disease in the facility. Should this occur, contact follow-up will be coordinated by Toronto Public Health. Skin testing is free for persons identified as a contact of a case of TB disease. Medication for prophylaxis of TB (treatment of latent TB infection) as well as treatment of active TB disease is free through Toronto Public Health.

TB infection and TB disease are reportable to Toronto Public Health

References

• Public Health Agency of Canada and Canadian Lung Association/Canadian Thoracic Society. (2007).
  Canadian Tuberculosis Standards. (6th ed.). Ottawa: Public Health Agency of Canada and
  Canadian Lung Association/Canadian Thoracic Society.
• Ontario Ministry of Health and Long-Term Care. Tuberculosis Protocol, 2006.
• Health Canada. Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and Other Institutional Settings, 1996. Canada Communicable Disease Report 1996; 22S1.
• Residential Services Branch, Ontario Ministry of Health. Guidelines for the Detection and Management of Tuberculosis in Residents of Long-Term Care Facilities (amended), 1994.
• Residential Services Branch, Ontario Ministry of Health. Communicable Disease Surveillance Protocols for Workers in Ontario Long-Term Care Facilities, 1994.