TB Testing for Caregivers: Baseline, Annual and What CDC Stopped Recommending in 2019

Every October someone in the office pulls the list of caregivers whose TB test is "due," and dozens of people take time off to get a skin test and come back two days later to have it read. Many agencies have done this for years. For TB testing for caregivers, CDC stopped recommending routine annual testing in 2019 for health care personnel without latent TB infection, absent a known exposure or ongoing transmission.

That does not mean annual testing is wrong for your agency. It means the reason for it should be a rule you can name: a state requirement, a payer contract, a facility client's demand or a documented risk assessment. This guide covers what CDC recommends, how to choose a test, what your state may require, and a policy and tracking template.

What CDC Changed in 2019

On May 17, 2019, CDC and the National Tuberculosis Controllers Association published updated recommendations in MMWR: Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel. They update the 2005 CDC guidelines. The key changes:

• No routine serial testing. In the absence of known exposure or evidence of ongoing TB transmission, U.S. health care personnel without latent TB infection should not undergo routine serial TB screening or testing at any interval after baseline.
• Some settings may still choose serial testing for certain groups at higher occupational risk, decided case by case.
• Annual TB education for all health care personnel.
• Treatment encouraged for all health care personnel with untreated latent TB infection unless medically contraindicated. Those who decline treatment should have an annual symptom evaluation.

Baseline TB Testing for Caregivers Has Three Parts

At hire or placement, the recommendations call for:

1. 1.An individual TB risk assessment, a new element in 2019.
2. 2.A symptom evaluation.
3. 3.A test, either an interferon-gamma release assay (IGRA, a blood test) or a tuberculin skin test (TST), for people without documented prior TB disease or latent infection.

If the test is positive, the person should have a symptom evaluation and a chest radiograph to assess for TB disease, with further workup as those findings indicate. The recommendations also say that a person who tests positive, has no symptoms, is unlikely to be infected and is at low risk of progression on the basis of the risk assessment should have a second test, either IGRA or TST. Clinical decisions about results belong to a clinician, not to the scheduler.

IGRA or TST: Choosing the Test

CDC's tuberculin skin test guidance sets the logistics that drive most agency decisions:

• A TST must be read between 48 and 72 hours after it is placed, by a health care worker trained to read it. Anyone who does not return within 72 hours needs a new test.
• Two-step testing is used for the baseline skin test of people who will be retested periodically, including health care personnel, to avoid mistaking a boosted reaction for a new infection. If the first test is negative, a second is given 1 to 3 weeks later.
• For people who have received the BCG vaccine, TB blood tests are the preferred test, because BCG does not cause a positive IGRA.

For an agency, the trade-off is usually cost against logistics. A two-step TST can mean four visits over several weeks for one new hire. An IGRA is one blood draw. When onboarding speed matters and a caregiver cannot start until clearance is complete, the blood test often costs less in lost shifts than it does at the lab.

After an Exposure

The 2019 recommendations keep post-exposure testing. After a known exposure, health care personnel without documented prior latent infection or TB disease should be tested, and if the initial result is negative, retested 8 to 10 weeks after the last exposure. Coordinate with your local health department, which leads contact investigations.

Your State Decides What You Must Do

CDC recommendations are guidance. State licensing rules, Medicaid program rules, payer contracts and facility clients can require more, or less, and they differ widely.

Texas is a useful worked example because the answer surprises people. The Texas Health and Human Services Commission's HCSSA FAQ, dated July 2026, says there is no regulatory requirement for a home and community support services agency to conduct employee TB screenings. Under 26 TAC 558.285, the agency must adopt and enforce written infection control policies, including preventing the spread of communicable disease. TB is a notifiable condition that must be reported to the local health entity. HHSC encourages following CDC recommended guidelines and points to its provider letter PL 2020-25.

So in Texas the obligation is your own written policy, and surveyors will hold you to it. If the policy says annual TB tests and you stopped doing them, the finding is against the policy. Other states may require annual testing by rule. Check each state you operate in.

Build a requirement matrix:

• State licensing rule for each care line you operate.
• Medicaid program or MCO contract requirements.
• Facility clients such as assisted living communities, which may require annual results from anyone who enters.
• Your written policy, which must meet the strictest applicable requirement for each role.

Moving Off Habitual Annual Testing

If your agency has tested every caregiver every year and nothing requires it, changing course needs a short, deliberate process rather than a quiet stop:

1. 1.Confirm no requirement applies. Check the requirement matrix for every state, payer and facility client.
2. 2.Have the policy changed and approved by whoever signs clinical policy, usually the director of nursing or administrator, with a reference to the CDC recommendations.
3. 3.Replace the test with education. Annual TB education for every covered worker, with a completion record, takes the place of the annual test date.
4. 4.Tell staff why. Caregivers who have been tested every year may assume something has been missed.
5. 5.Update the tracking system, so the old annual test date stops generating "overdue" alerts that someone will act on.

Annual education does not need to be long. The 2019 recommendations describe it as covering TB risk factors and the signs and symptoms of TB disease, and it should cover your agency's own procedure: who to tell if a client or coworker has a TB diagnosis, and what happens next. Fold it into the annual in-service calendar you already run.

A TB Policy Template

1. 1.Scope: which roles are covered, including office staff with client contact.
2. 2.Baseline: risk assessment, symptom evaluation and IGRA or TST before the first client contact, with the acceptable window for prior results.
3. 3.Positive results: referral for clinical evaluation and chest radiograph, and work clearance criteria set by a clinician.
4. 4.Serial testing: none routinely, unless a state rule, contract or risk assessment requires it, and say which.
5. 5.Annual education for all covered staff, with a completion record.
6. 6.Annual symptom evaluation for staff with untreated latent infection.
7. 7.Exposure response: notification, testing and the 8 to 10 week retest.
8. 8.Reporting: how suspected or confirmed TB is reported to the local health authority.
9. 9.Recordkeeping and confidentiality: where health records live and who can see them.

Tracking Without Chasing Paper

For each caregiver, the record should show: baseline date, test type, result (and millimeters of induration for a TST), who read it, chest radiograph date if any, risk assessment date, annual education completion, any exposure event and follow-up, and the next date anything is due. If none is due because your policy follows CDC's baseline-only approach, the record should say that, so nobody "fixes" it by sending the caregiver for another test.

Health screening sits beside exclusion screening in the same employee file; the monthly OIG exclusion check covers the other half of that file. Nuraflow is being designed so that credentials and scheduling gates track TB and health documents against role and state requirement sets, and onboarding, orientation and training records annual education completion.

This article is general information, not medical advice. Review your TB policy with your director of nursing or infection preventionist, your state licensing agency and your local health department.