Tuberculosis (TB) is a contagious disease caused by bacteria. TB usually affects the lungs but can affect any part of the body. TB spreads through the air when a person with TB disease coughs, sneezes, talks or sings. TB is preventable and curable.

TB disease

TB disease is not easy to catch. Close, regular or prolonged contact with someone with TB disease in the lungs or airway is needed to spread the disease. It is spread through the air when someone with TB disease coughs, sneezes, sings or talks. Symptoms of TB disease can include: a cough that lasts more than 2 weeks, coughing up blood, night sweats, unexplained weight loss, fever and fatigue. TB is not spread by sharing utensils, cups, clothing, bed linen, furniture, toilets, shaking hands or by touching surfaces that someone with TB disease has touched.

People who have TB in another part of the body (e.g. lymph nodes, spine, brain, etc.) cannot spread TB germs to others. See “TB Outside the Body” below.

TB infection

TB infection is when someone has breathed in TB germs, but their immune system has trapped the germs; they are not contagious. This is often the case when someone with a healthy immune system is exposed to someone with TB disease. The TB bacteria live in the body, but they are in a dormant “sleeping” state. People with TB infection do not have any symptoms. Individuals with TB infection usually have a positive reaction to a TB skin test. About 5-10% of people with TB infection will develop TB disease at some point in their life.

TB Outside of the Lungs

TB usually affects the lungs, but it can affect the entire body. Some areas of the body that can be affected include bones, lymph nodes, kidneys, stomach, spine and brain. When this happens, it is called extrapulmonary tuberculosis (TB outside of the lungs). People with extrapulmonary tuberculosis cannot give TB to others.

All medications used to treat TB disease and TB infection are FREE. You do not need to have OHIP to access these medications through the health unit. You do need a prescription from a healthcare provider.

Testing for tuberculosis is not routinely done in Canada.  There are several reasons why someone may need testing for tuberculosis, including screening for work, school, or volunteering, if you have certain medical conditions and/or if you have been in contact with someone with TB disease. Testing for tuberculosis does not tell you if you have TB disease or a TB infection.  Testing can tell if you have been exposed to the tuberculosis bacteria. You can speak with a healthcare provider about testing if you need it.  There are two options for testing: a Tuberculin Skin Test or an IGRA test. You and your healthcare provider can decide what is best for you.

A tuberculin skin test is a test that will tell you if you have been exposed to the tuberculosis bacteria at some point in your life. It does not tell you when the exposure might have occurred. It also cannot differentiate between TB disease and TB infection.

TB testing is not routinely required for many workplace settings; however, most healthcare settings require tuberculosis screening as part of their onboarding process.

As per the Canadian TB Standards 8th edition, TB screening is recommended in workplaces/settings where there may be a higher risk of tuberculosis exposure and/or transmission to vulnerable persons. TB screening is recommended for healthcare workers.

Please see TB Screening Tool for Long-Term Care and Retirement Homes for Grey Bruce Public Health’s TB screening recommendations. LTCHs and RHs in Grey Bruce may choose to use the screening tool; however, this is not mandatory.

In Ontario, health care providers are obligated to report both suspect and confirmed TB disease and TB infection to their local public health office.  Please note: Active TB is referred to as TB disease, and Latent TB Infection is referred to as TB infection. This is the updated terminology in the Canadian Tuberculosis Standards, 8th ed, 2022 (Canadian Journal of Respiratory, Critical Care, and Sleep Medicine: Vol 6, No sup1)

Call Grey Bruce Public Health 519-376-9420 ext. 6 (8:30 a.m. to 4:30 p.m.) with the patient’s name, date of birth and phone number.  Those diagnosed with TB disease should be reported as soon as possible; please contact our after-hours number if needed. Positive TST and IGRA Report Form

Please complete and fax the reporting form to 519-376-4152. TB Infection Report Form

A TB skin test (Mantoux tuberculin test) is not used to diagnose TB disease; it is a tool used to identify individuals with TB infection (latent), and those at risk of developing TB disease. These individuals may benefit from treatment to prevent TB Disease.

If the patient has been previously infected with TB, they will develop an induration within 48-72 hours after testing.

A TST is commonly recommended for:

• Contacts of a person diagnosed with pulmonary TB
• Individuals born in TB endemic countries or travellers to areas with a high incidence of TB
• Underhoused individuals
• People who inject drugs
• Individuals with health conditions that would increase the risk of developing TB
• Health care workers
• Indigenous people from areas with a high incidence of TB
• People < 65 years of age and living in congregate settings, i.e. correctional settings, long-term care and retirement homes
• Screening may be recommended for some students and volunteers

It is strongly recommended against testing for TB infection for anyone who:

• Had a previous positive TST result
• Had a severe hypersensitivity or anaphylactic reaction to previous TST testing
• Has been diagnosed with or treated for TB in the past
• Has received a live virus immunization in the past 4 weeks
• Has a current major viral infection
• Is > than 65 years old and is a resident of a long-term care home
• When a person has a low risk of infection and a low risk of progressing to TB disease if infected
• Currently has an active TB infection

One TST is often sufficient for people required to obtain a TB skin test for school admission or before starting immunotherapy.

Two TSTs are usually performed within 1 to 4 weeks of each other.  A 2-step TST is usually only indicated as an initial assessment for someone who will be having repeat TSTs (i.e. health care workers) or if someone is a contact who has active TB.

Some redness at the site is expected. The injection site may be itchy, but it is important not to scratch it, as this may cause redness or swelling, potentially making the test result inaccurate. Do not cover the site with a bandage. Applying a cold, wet cloth to the site is ok and may help with itchiness.

A strong reaction may cause mild pain or redness that can last for several weeks. If you develop fever, swelling in your arm or swollen lymph nodes in your armpit, talk to your healthcare provider.

IGRA testing is preferred over TST in the following situations:

• When children over 2 years of age and less than 10 years of age previously received a BCG vaccine
• When a person at least 10 years of age received a BCG vaccine after they turned 1 year of age, received a BCG vaccine more than once and/or are uncertain about when they received a BCG
• When a person is unable/unlikely to return to have their TST read
• When tuberculin skin testing is contraindicated

IGRA testing is not currently covered by OHIP.

TST is the preferred test when repeat testing is related to contact investigations, or for health care workers or other populations (persons who are incarcerated) with potential for ongoing exposure.

Both tuberculosis infection diagnostic tests may be used sequentially in the following situations:

• If either the tuberculin skin test or interferon-gamma release assay is negative, the other test may be used to increase sensitivity if the risk for infection is high, the risk for progression to tuberculosis disease is elevated, the risk for a poor outcome from tuberculosis disease is high and/or a person has conditions or habits that may reduce the sensitivity of the test.
• If the initial tuberculin skin test is positive, but the likelihood of tuberculosis infection is low, or the risk of a false positive result due to BCG is high. Then an interferon-gamma release assay may be used to increase specificity.

You may wish to consider using the Online TST/IGRA Interpreter.

BCG is a live, attenuated vaccine for tuberculosis.  It has not been given in Canada as a routine vaccine since the early 1970s. The protective effects of the vaccine decrease with time, and it does not offer lifelong protection against TB.  The BCG vaccine is given to children in many European countries, as well as developing countries.

Yes.

If a person has a reaction to a TST, it is likely because they have been infected with TB at some point in their lifetime.  Adults with a positive TST who were vaccinated as children should be considered to have a TB infection.

Complete medical history to evaluate for potential risk factors such as:

• Contact with a person with active TB disease
• Immunosuppressed medical conditions or those who receive immune-suppressant therapy
• Lived in an Indigenous community

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 some patients may have no or mild symptoms.

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.

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 induced sputum if the patient is unable to produce sputum.
• Always use a Public Health Lab requisition. Send specimens directly to the Public Health Lab. Include symptoms, date of onset, and request “AFB and TB culture” on lab requisition.

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 results.

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 TB preventative treatment and/or referral to a specialist. See clinical guidelines below

Clinical Guidelines:

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

If TB disease has been ruled out for your patient and you are treating your patient for a TB infection, TB treatment can be accessed through Grey Bruce Public Health. TB Preventative Treatment is free. You can fax the prescription to Grey Bruce Public Health.  A Public Health Nurse will check in with your patient regularly to offer support throughout treatment. Please ensure you order any necessary bloodwork for your patient before and throughout treatment.

TB immigration medical surveillance is a medical check-up you complete once you are in Canada, required by Immigration, Refugee and Citizenship Canada (IRCC).

When someone applies to come to Canada for six or more months and completes their immigration medical exam (IME), the panel physician may find some health conditions that require TB medical surveillance. These health conditions may include a previous history of TB, previously treated TB, latent TB (non-infectious) and/or an abnormal chest x-ray that suggests latent TB.

These health conditions can put someone at greater risk for developing active TB (infectious), and therefore another medical check-up is required. This check-up is to ensure you are and continue to be well and can access any TB care you may need.

Once TB medical surveillance is completed, the condition of landing on your immigration file is removed. If you do not complete TB medical surveillance, this may impact future immigration applications.

Please know that if you develop TB disease (active TB), this does not impact your immigration status.

To complete TB immigration medical surveillance, please get in touch with the health unit where you currently live. If you live in Grey Bruce, contact Grey Bruce Public Health and speak with a nurse in the Infectious Diseases Program. The nurse will ask you questions about your medical history, confirm that you are required to complete TB immigration medical surveillance, and may request your immigration medical exam from IRCC.

The medical check-up must be completed by a health care provider (e.g. your healthcare provider, walk-in clinic). This medical check-up often includes a review of your medical history, assessment, and chest x-ray. Please let your nurse know who your healthcare provider is. Your nurse will request the results of your TB medical check-up. 

If you do not have a healthcare provider, your nurse can support you in accessing care and review options with you.

If you have Ontario Health Insurance Plan (OHIP), there is no cost for TB medical surveillance. If you have private insurance, please confirm with your provider that the cost of the TB medical check-up is covered. In many cases, you can wait until you obtain OHIP before completing TB medical surveillance. Please discuss your personal circumstances with your nurse. If you develop signs and symptoms of TB disease (active TB), please let your nurse know immediately, and they will support you with next steps.

If you do not have health insurance, you must pay for the cost of TB medical surveillance.

Apply for OHIP and get a health card | ontario.ca

Wait times and accessing care can vary. This process can take several months.

Please contact the nurse at the health unit. In many situations, it will be better to complete TB medical surveillance where you will be living. If you are moving, please let your nurse know. If you move out of province and/or country before completing TB medical surveillance, this may impact future immigration plans.

The health unit offers translation services. Please let the nurse know your preferred language to speak in.

A nurse with the health unit will support you through this process. The nurse will work closely with you and your physician. The cost of TB medication is free in Ontario, even if you do not have health insurance. A diagnosis of active TB does not affect your immigration status.

Your healthcare provider may recommend treatment for TB infection; this is optional and does not impact your immigration status. This treatment is called TB preventative treatment. The goal is to reduce your risk of developing TB disease.  A nurse with the health unit will work closely with you and your physician. The cost of TB medication is free in Ontario, even if you do not have health insurance.

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