TB disease and TB infection are both reportable diseases in Ontario. Patient consent is not required for reporting this information according to the Health Protection and Promotion Act, (HPPA).Please note that “Active TB disease” and “Latent TB infection (LTBI)” are referred to as TB disease and TB infection respectively, and LTBI treatment is referred to as “Tuberculosis Preventive Treatment (TPT)” to reflect updated terminology in the Canadian Tuberculosis Standards, 8th ed., 2022.
New first-line recommendations for TB Preventive Treatment have been updated.
New TB screening recommendations for health care and non-health care settings are currently being updated.
For a TB consultation, email targettb@toronto.ca.
TB Screening Recommendations
TB screening recommendations for newcomers
Individuals who have completed an immigration medical exam (IME) within the last year and are asymptomatic do not need a repeat routine workup for TB disease. Instead, the screening focus should be on TB infection and prevention:
TB screening recommendations for health care settings
All workers in healthcare settings should have a documented baseline TB skin test. IGRA testing may be an acceptable alternative, but is not currently covered by OHIP. The workplace/school program will advise staff/volunteers/students of their TB screening policy requirements.
TB screening recommendations in long-term care settings
The Long-Term Care Act, 2021 and Retirement Homes Act, 2010 require that all residents admitted to a long-term care or retirement home be screened for tuberculosis. For more information contact targettb@toronto.ca.
TB screening recommendations in childcare centres
With rare exceptions, employees working in non-health care settings, do not require routine screening for TB. However, in Toronto, baseline TB screening is recommended for employees of child care centres, shelters and correction facilities. For more information contact targettb@toronto.ca.
TB Disease – Guidelines, Ordering Free Medication and Reporting
Every year about 300 people are diagnosed with TB disease in Toronto. The major risk factor for all age groups is having lived in a TB endemic country (TB incidence >50/100,000) . This includes most countries outside of North America, Western Europe, Middle East, Australia, and New Zealand.
To report individuals with suspected or confirmed TB disease
- Call Toronto Public Health at 416-392-7457 (8:30 a.m. – 4:30 p.m.) with patient name, date of birth, address and phone number.
- If lab- or clinically-confirmed TB disease, download, complete and fax Notification of TB Disease reporting form to TPH at 416-338-8149.
- Consider infection control aspects. Educate patients with potential pulmonary TB to self-isolate at least until initial smear results are available.
Diagnostic workup for TB includes:
- Collect three sputum specimens at least one hour apart and send to the Ontario Public Health Lab. (Use orange top sterile container and write: “For TB AFB Smear and Culture” on requisition Drug sensitivity testing will be done automatically on all +ve specimens)
- chest x-ray – anterior/posterior and lateral
- potential extra-pulmonary TB – Imaging & biopsy (TB culture, pathology)
Signs/symptoms assessment
- new or worsening cough (greater than three weeks)
- fever, chills
- night sweats
- anorexia
- fatigue
- unexplained weight loss
- hemoptysis
- site-specific symptoms for extra-pulmonary TB (e.g. enlarged lymph nodes, abdominal pain, meningitis, joint swelling/pain)
Risk factors
VERY HIGH RISK
- HIV
- Child/adolescent (<18y) contact of person with TB disease
- Adult (>18y) contact of person with TB disease
- Silicosis
HIGH RISK
- Chronic kidney disease (stage 4 or 5) with or without dialysis
- Transplant recipients (organ or hematopoietic)
- Fibronodular disease
- Receiving immunosuppressing drugs (e.g., tumor necrosis factor α inhibitors or steroids)
- Cancer (lung, sarcoma, leukemia, lymphoma or gastrointestinal)
MODERATE RISK
- Granuloma on chest x-ray
- Diabetes
- Heavy alcohol use (three drinks/day)
- Heavy tobacco cigarette smoker (at least one pack per day)
LOW RISK
- General (adult) population with no known risk factor
- Person with a positive 2-step TST booster and no known risk factor
Detailed Clinical Guidelines
Note
All persons with TB disease should be managed by a specialist with TB experience. If your patient is less than five years old or human immunodeficiency virus (HIV) positive, refer to a TB clinic / HIV clinic for treatment. Patients with multi-drug resistant (MDR) TB should be referred to the TB Service at West Park Healthcare Centre, or to SickKids TB Clinic if <18 years old.
For assistance with referrals, call TPH at 416-392-7457. TPH provides free supportive community nursing care for all Toronto residents diagnosed with TB disease, regardless of OHIP/insurance, or immigration status.
All TB medication is free through Toronto Public Health (TPH) regardless of insurance/immigration status.
TB Infection – Guidelines, Ordering Free Medication and Reporting
It is estimated that one in four persons worldwide has TB infection. The major risk factor in Toronto for all age groups is having lived/born in a TB endemic country (TB incidence >50/100,000). This includes most countries outside of North America, Western Europe, Middle East, Australia, and New Zealand.
Report a positive TB skin test/IGRA and order free medication
Complete all four steps for patients with newly positive TST/IGRA, whether you are ordering TB preventive medication or not:
- Assess for signs and symptoms of TB disease (pulmonary and extra-pulmonary).
- Send patient for a chest x-ray anterior/posterior and lateral.
- If asymptomatic, a chest x-ray done within the last 6 months is acceptable (within last 3 months for patients with TB exposure in the last 2 years)
- a) If chest x-ray is normal and patient is asymptomatic, counsel about TB reactivation risk and recommend TB Preventive Treatment (TPT).
- b) If chest x-ray is abnormal see Interpretation of Chest x-ray
*Regardless of CXR results, if client has symptoms suggestive of TB, order sputum TB testing and refer client to a TB clinic or specialist
- Download, complete & fax the Notification of TB Infection and TB Preventive Treatment Order Form. All TB medication is free through Toronto Public Health regardless of insurance/immigration status.
Detailed clinical guidelines
Note on medication logistics
- You will receive notification from TPH that your order was processed. The notification includes a patient identification (ID) number: please place this in your patient’s record. This number will identify to which patient the medication belongs when it is delivered to your office.
- Allow two weeks for the medication to arrive at your office. To ensure confidentiality, the medication will be labelled with the patient ID number previously provided to you by TPH.
- It is your responsibility to dispense the TB medication to the patient for whom it has been ordered and to safely dispose of any expired medication.
Resources
Treatment Services for Uninsured Person Program (TB-UP)
TB-UP is a Ministry of Health program that covers the cost of Ontario Hospital Insurance Plan (OHIP)-billable TB care, such as diagnostic tests (chest x-rays, sputum, other lab tests, TB skin tests, etc.) and physician care (outpatient and inpatient) for uninsured persons.
TB-UP will not cover non-OHIP-billable costs of inpatient TB care. TB-UP eligibility
- patients who do not have other medical insurance/coverage for TB services such as:
- homeless/underhoused individuals who do not have OHIP, Interim Federal Health (IFH) or other health insurance coverage
- international students without OHIP, IFH or private health insurance coverage
- visitors without health insurance coverage
- persons who do not have legitimate immigration status
- persons who have been discharged from prison who are not currently eligible for OHIP
- and who are
- patients with suspected or confirmed TB disease; even if the final diagnosis is not TB disease, the work-up is still covered; or
- patients who are a recent contact of a person with TB disease; or
- patients at high risk of developing TB disease as determined by the board of health
TB-UP registration
Contact Toronto Public Health at 416-392-7457 prior to providing service and ask to speak with a TB nurse to register your patient, or email targettb@toronto.ca.
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.
TB Medical Surveillance (MS)
Individuals who apply to live, work or visit Canada for six months or more, are required to undergo an immigration medical exam (IME) by panel physicians designated by Immigration, Refugees and Citizenship Canada (IRCC). If the IME finds no TB disease but the individual is at higher risk for future TB disease, they are required to complete a second TB assessment on arrival in Canada as a formal part of their immigration process. This is IRCC’s Post-landing TB Medical Surveillance program.
If you see a Toronto resident who requires TB immigration medical surveillance, please ensure they have the Toronto Public Health – TB Medical Surveillance Assessment Form before proceeding. If they do not have this form please direct them to TB Immigration Medical Surveillance to self report to TPH and TPH will send them their form.
Once they have the TPH form follow the steps below:
- Conduct a physical and symptom assessment for pulmonary and extra-pulmonary (e.g., lymph node) TB.
- Send the individual for a chest x-ray – anterior/posterior and lateral.
- If symptomatic and/or have an abnormal chest x-ray, collect three spontaneous sputum samples (at least one hour apart) for TB testing.
- If TB disease is ruled out, consider doing a tuberculin skin test (TST)/Interferon Gamma Release Assay (IGRA) and discuss TB Preventive Treatment, Quick Reference. TPT management is not an IRCC requirement for TB medical surveillance but is good clinical care. TB medication is free through TPH regardless of immigration/insurance status.
- Complete the TPH TB Medical Surveillance Assessment Form provided and return it to Toronto Public Health by fax (416-338-8149).
- Toronto Public Health will confirm to IRCC that the medical surveillance requirement was met. Your patient will receive a confirmation from TPH at the email or address they provided at self report.
More information on TB-IMS
TB Best Practice and Guidelines
TB best practices and guidelines
TB epidemiology and elimination strategy
TB resources
Associations
Government organizations
