Tuberculosis Screening: Long-Term Care and Retirement Homes

Long-term care homes and retirement homes are legislated under the Long-Term Care Homes Act, 2007 and Retirement Homes Act, 2010 respectively, to ensure that staff and residents are screened for tuberculosis upon admission or employment at the facility.

The legislation reads as follows:

“The licensee shall ensure that each resident is screened for tuberculosis within 14 days of commencing residency in the home, unless the resident has been screened not more than 90 days before commencing residency and the documented results of the screening are available to the licensee”.

“The licensee shall ensure that each member of the staff has been screened for tuberculosis and all other infectious diseases that are appropriate in accordance with evidence-based practices or, if there are no such practices, in accordance with prevailing practices”.

Tuberculosis skin tests are no longer required under the Long-Term Care Homes or Retirement Homes Acts. Because of the possibility of false negative TB skin tests in the elderly and treatment for latent TB is generally not considered in people 65 years of age and older, TB skin testing is now only recommended for new residents less than 65 years of age, staff and volunteers. As well, a chest X-ray is recommended for TB screening for all new residents, and also for new staff and new volunteers who are 65 years of age and over.

TB Screening recommendations are summarized as follows:

Residents

All residents must have the following on admission to a long-term care facility or retirement home:

• A routine admission symptom review and assessment.
• Baseline posterior-anterior and lateral chest X-ray. Portable chest X-rays are not recommended as they do not provide a posterior-anterior view and may not be of optimal quality. A portable chest X-ray may only be used under exceptional circumstances and the radiologist should indicate that the image is of acceptable quality to rule-out active tuberculosis. The chest X-ray must be done either within the 90 day period before admission or the 14 day period after admission.

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Residents less than 65 years of age

In addition to the chest X-ray, all residents who are less than 65 years of age must have
a two-step TB skin test (regardless of prior BCG vaccination). The first step should be done within 14 days after admission.

If the resident has:

• A previously documented positive TB skin test or history of active TB disease, then only the chest X-ray is required.
• A negative TB skin test that was done in the last 12 months, then only a single skin test and the chest X-ray are required.
• A previously documented negative two-step TB skin test with the last step more than 6 months ago, then only a single TB skin test and the chest X-ray are required.
• A previously documented negative two-step TB skin test with the last step within the past 6 months, then no further TB skin testing is needed and only the chest X-ray is required.

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Staff and volunteers

All staff, regular volunteers, and certain other volunteers (see below) must have the following:

• A two-step TB skin test, ideally before starting to work or volunteer, or within 14 days of beginning work (regardless of prior BCG vaccination).

If the staff member or volunteer has:

• A previously documented positive TB skin test or history of active TB disease, then a chest X-ray is required.
• A negative TB skin test that was done in the last 12 months, then only a single skin test is required.
• A previously documented negative two-step TB skin test with the last step more than 6 months ago, then only a single TB skin test is required.
• A previously documented negative two-step TB skin test with the last step within the past 6 months, then no further TB skin testing is needed.

New volunteers and new staff who are 65 years of age and over should also have a chest X-ray.

Note: A regular volunteer may be defined as one who expects to work 150 or more hours during the coming year, meaning approximately a half day per week. Volunteers expecting to work less than 150 hours during the coming year should be tested if they are known to belong to an at-risk population group:

• History of active TB (screen using a chest X-ray only)
• Staff and residents of homeless shelters
• Staff and inmates of correctional facilities and previously incarcerated people
• People who use injection drugs
• People infected with HIV
• Aboriginal Canadians residing in communities with high rates of TB
• Elderly Canadian-born people (born before 1955)
• People born or previously residing in countries with a high Incidence of TB such as Asia, Eastern Europe, Africa and Latin America

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Follow-up for positive TB skin tests for staff and volunteers, and residents less than 65 years of age

A positive TB skin test (on either the first or second step) requires a medical evaluation including, but not limited to a chest X-ray, and if symptomatic, sputum testing, to rule out active TB. All positive TB skin tests, including details of the follow-up, must be reported to the Middlesex-London Health Unit (see below for reporting requirements).

Symptoms of active TB may include:

• Cough lasting more than 2-3 weeks
• Fever
• Chest pain
• Fatigue
• Coughing up blood
• Night sweats/chills
• Weight loss
• Loss of appetite

Note: If active TB is suspected, place the patient in a private room, close the door, limit entry into the room, ensure staff wear a fit-tested N95 mask and if tolerated, have the resident where a surgical mask when others are in the room. Contact the Health Unit immediately.

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Reporting requirements

Tuberculosis is a reportable disease under the Health Protection and Promotion Act - R.S.O. 1990, Chapter H.7. Therefore, long-term care homes must report all residents and staff with any of the following to Public Health:

• Positive TB skin test (indicates latent TB)
• Suspect or confirmed active TB – Contact the Health Unit immediately

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How to report

• Call the Communicable Disease Intake Line at: 519-663-5317 ext. 2330 press “4”; after hours 519-663-5317 (option 2); or
• Download a Positive TB Skin Test and TB Medication Order Form (PDF 40KB) from and fax the completed form to 519-663-8241.

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