[Table of Contents]

Volume: 22S1 • April 1996

Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and Other Institutional Settings

V. TB CONTROL IN RESIDENTIAL SETTINGS

This section discusses the management of TB in specific residential settings. Facilities, such as correctional facilities, hostels, hospices and long-term care facilities, are unique in that they are residential.

A person who resides or works in a correctional facility, a shelter for the homeless, a hospice or long-term care facility may be more likely than other Canadians to be in contact with individuals who belong to risk groups for TB. Delays in making a diagnosis of TB and overcrowded living conditions may result in increased rates of transmission, if someone with active TB is present in these facilities. Transmission may occur to other residents, as well as to staff and volunteers.

Correctional Facilities

The presence of individuals at high risk of either being infected with M. tuberculosis or having active TB (e.g., Aboriginal Canadians, foreign-born individuals, and injection drug users) in Canadian correctional facilities raises questions about the risk of transmission of TB in these facilities. In 1994, five new cases of active TB were identified among 21,936 individuals residing in 61 Canadian federal correctional facilities (Dr. J. Roy, Correctional Services Canada: personal communication, 1995). Although the number of cases is small, the rate of TB is 26.9 per 100,000 population compared with the Canadian rate of 6.9 per 100,000 population.

The federal correctional system has had a long-standing policy of performing a one-step TST on newly admitted inmates. In December 1992, the policy was expanded so that all inmates who tested negative on admission would receive an annual one-step TST. In April 1994, the one-step TST on admission was replaced with a two-step TST. Any individual with a positive TST is referred for additional medical evaluation. All staff working in federal correctional facilities will have their TB infection status determined and be re-tested annually if the staff member is TST negative. The TST result should be recorded in millimeters on the individual's health record and interpreted to be either a negative or positive result (see Appendix B).

In addition to the previously recommended TB management program (see Section IV.D), TB management in correctional facilities should also include the elements listed below.

• The Canadian Tuberculosis Standards recommend pre-employment screening, routine ongoing screening and post-exposure screening.
• An inmate who is suspected of having active TB (cough, fever, weight loss) should undergo immediate medical assessment. This individual should be placed in appropriate isolation either at the correctional facility or at a local medical facility (see Section IV.D.2).
• If an inmate is transferred to another correctional facility or to a medical facility for evaluation of suspected TB, he or she should wear a surgical mask during transfer. Individuals involved in the transfer of the inmate should be informed of the potential need to wear personal respiratory protection.
• Inmates who are diagnosed as having active TB may be returned to the cell block after they have begun appropriate treatment and are no longer considered to be infectious. Arrangements must be made to ensure the completion of appropriate therapy at the correctional facility.
• If an inmate has not completed therapy at the time of discharge, arrangements must be made to notify the appropriate public health authorities to ensure that therapy is completed after discharge.
• If an inmate is diagnosed with active TB, contact follow-up among other inmates, staff and visitors must be initiated (see Section IV.D.7).
• Local public health authorities should be notified of all individuals in the correctional facility with active TB.

Hostels and Hospices

In addition to the previously recommended TB management of individuals with TB (see Section IV.D), TB management in hostels and hospices should also include the elements listed below.

• Hostel and hospice staff and volunteers should be made aware of the symptoms of TB through educational programs. Clients who have these symptoms should be referred for appropriate medical evaluation.

• Pre-placement and post-exposure TST screening is recommended for staff and volunteers unless the individual has had a documented positive TST on previous testing, has been previously treated for active TB, or has received preventive treatment for TB. The TST result should be recorded in millimeters on the individual's health record and interpreted as being either a negative or positive test (see Section IV.C and Appendix B). The rates of TB occurring in individual agencies should be used to determine how frequently ongoing regular screening should be performed.

• A program should be established for counselling employees and volunteers about TST conversions (see Section IV.G).

• Clients with active pulmonary TB must receive appropriate medical therapy because they can transmit TB to other clients, staff and volunteers.

• Until clients with active TB are non-infectious, they should be cared for in facilities where the likelihood of transmission is reduced.

• After a person with active TB is identified, contact follow-up among other clients, staff, volunteers and family should be initiated (see section IV.D.7).

• Local public health authorities should be notified of all individuals with active TB residing in the hostel or hospice.

• Clients who are diagnosed as having active TB may return to the hostel or hospice after they have begun appropriate treatment and are no longer infectious.

• Arrangements must be made to ensure the completion of appropriate therapy after discharge from the medical facility.

Long-term Care Facilities

• A resident should receive a two-step TST on admission unless the individual has had a documented positive TST, has been previously treated for active TB, or has received preventive treatment for TB. The TST result should be recorded in millimeters on the resident's health record and interpreted to be either a negative or positive result (see Appendix B).
• TB should be considered in the differential diagnosis of residents in long-term care facilities who are demonstrating signs and symptoms of clinical deterioration, such as dyspnea, weight loss and fever.

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