Tuberculosis Information for Physicians

For health care workers/volunteers/students/staff

All healthcare workers should have a documented baseline 2 step TB skin test (TST).

Staff/volunteers/students will be advised by their workplace/school program when they are required to complete TB screening.

Newcomers

TB screening is recommended for all persons from TB endemic countries. Refugees/claimants and newcomers within two years of arrival are at higher risk of TB.

For further information see the Immigration Medical Surveillance section below.

Long-term care setting

All residents admitted to a long-term care or retirement home must be screened for tuberculosis as per the Long-Term Care Homes Act, 2007 (external link) and Retirement Homes Act, 2010 (external link). For more information contact Halton Region Public Health by dialing 311.

• Canadian Tuberculosis Standards (8th Edition, March 2022) (external link)
• TB Public Health Ontario (external link)

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 Physician 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:

• Canadian Tuberculosis Standards (8th Edition, March 2022) (external link)

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 physician reporting form (PDF file)

Clinical Guidelines:

• Canadian Tuberculosis Standards (8th Edition, March 2022) (external link)
• Assessment and Treatment of Latent Tuberculosis Infection (external PDF)

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

Resources:

• BCG Atlas (external link)
• Online TST/IGRA interpreter (external link)

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.

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.

• A-Z index
• Disease of Public Health Significance (DOPHS)
• Communicable Disease Information for Physicians
• Tuberculosis (TB)
• Tuberculosis physician reporting form (PDF file)
• BCG Atlas (external link)
• Online TST/IGRA interpreter
• Assessment and Treatment of Latent Tuberculosis Infection (external PDF)
• Canadian Tuberculosis Standards (8th Edition, March 2022) (external link)