Tuberculosis and Long-Term Care Facilities

Last Updated June 2024

TB remains a problem in older individuals who may have been infected many years ago and did not develop active disease at the time. Also, there have been outbreaks of TB occurring in nursing home residents when a patient with active TB disease infects a population of older people who are newly exposed to that case.

TB prevention and control in nursing homes and long-term care facilities must begin with a careful assessment of TB status upon admission, including a diagnostic test for LTBI (TST or IGRA). For those with a positive diagnostic test for LTBI, an assessment and chest x-ray should be performed as described above to exclude active TB disease.

Since people over 50 years old may have diminished skin test reactivity, the two-step technique (see Two-Step Testing) of tuberculin skin testing is recommended upon admission to the nursing home if the TST is the diagnostic test being performed to screen for LTBI. A “booster effect” with the TST has been noted in elderly persons in whom the delayed type hypersensitivity (DTH) reaction to tuberculin may have waned over the years.

In these situations, an initial tuberculin skin test may demonstrate a negative reaction, but it boosts the immune system so that subsequent tuberculin skin tests may be increased in size and may be interpreted as positive. This “boosted” response is considered as the valid baseline for the individual and thought to represent latent TB infection (after active disease is excluded).

Residents of nursing homes or long-term care facilities whose baseline two-step skin tests are negative (or whose baseline IGRA is negative if the IGRA is being used to screen for LTBI) on admission should have repeat testing performed when an exposure to a case of potentially infectious TB has occurred.⌃

Any person who converts a TST or IGRA from negative to positive should be considered for treatment of LTBI after active TB is ruled out (by chest x-ray at a minimum and sputum specimen if indicated).
Any resident with symptoms of TB regardless of LTBI diagnostic test result (TST or IGRA) should have a chest x-ray performed to evaluate for active TB disease.
Treatment of active TB disease (Class III) is the same as that used for younger adults.

Employees of nursing homes or long-term care facilities should have two-step tuberculin testing when they start to work in the nursing home if the TST is used for testing of health care workers (if they have not had a TST in the year prior to initiating employment). The frequency of subsequent testing of healthcare workers is described on page 102.

Employees who have a positive LTBI diagnostic test at baseline should be evaluated for treatment of LTBI (see pages 25—27). In addition, those with a recent LTBI diagnostic test conversion should be encouraged to take treatment for LTBI after active TB disease is excluded. Routine annual symptom screening for health care workers with a previously positive diagnostic test for LTBI (TST or IGRA) is recommended instead of an annual CXR.