TB screening requirements for healthcare workers: Federal baseline and state rules

"What are the TB screening requirements for healthcare workers?" has no single answer, and the reason is structural: at least three different bodies of rule can apply to the same nurse.

The short answer

CDC recommendations set the clinical baseline. On top of that sit state health codes, facility licensing conditions, and in California a specific OSHA standard. You have to satisfy the strictest of them, and that is rarely the federal one.

The four layers

1. CDC recommendations

The 2019 CDC guidance changed practice materially and a surprising number of programs still run the old one. The headline changes: baseline screening on hire for everyone, and no routine annual testing for healthcare personnel without known exposure, replaced by annual education and testing after exposure or if there is ongoing transmission risk.

If your program still does universal annual TSTs on everyone, the first question is not "what does my state require" but "why are we doing this at all," and the answer is often that nobody revisited it after 2019.

2. State health codes

Many states impose their own requirements on healthcare facilities, and some of them do still require annual testing regardless of CDC's position. Where a state requires more, the state wins.

3. Facility licensing and accreditation

Licensing conditions for hospitals, skilled nursing and home health frequently carry their own screening requirements, and long-term care is usually stricter than acute care. Accreditation bodies add their own expectations at survey.

4. Cal/OSHA §5199, for California

California's aerosol transmissible diseases standard requires an annual TB assessment for covered employees, which means California employers land on annual regardless of the CDC position. This is a regulation with citations attached, not a recommendation.

How to work out what you actually owe

1. Start from the current CDC guidance as the clinical floor.
2. Check your state health department's requirements for your facility type. Not "healthcare" generally, your type.
3. Check your licensing conditions, which are often stricter than the health code and are checked at survey.
4. If you are in California, apply §5199 and stop looking for a lighter answer.
5. Write down which rule drives each element of your program. When somebody asks in two years why you test annually, you want the citation rather than a memory.

What to record, whatever your rule

The requirement varies; the record does not vary much. Capture:

• Baseline: the test type, date, result, and for two-step TSTs both steps.
• Whether the individual has a documented history of positive results, which changes what happens next permanently.
• The annual symptom assessment where one is required, as a dated record rather than a check mark.
• Post-exposure testing against the exposure that triggered it, not floating free.
• For positives: evaluation, chest imaging, and treatment status.

TST versus IGRA

Both are acceptable. IGRA (QuantiFERON, T-SPOT) avoids the two-visit problem and is not confounded by prior BCG vaccination, which matters in a workforce with internationally trained staff. TST is cheaper per test and needs a return visit that a meaningful number of people never make.

The operational point is that a program running both needs to record which was used, because the follow-up logic differs and a result without its test type is hard to act on later.

The retention question

TB screening records are employee medical records. Under 29 CFR 1910.1020 that is duration of employment plus thirty years. This is far longer than most people assume and far longer than the five-year OSHA log retention that sits next to it.

Verify for your own state

State requirements change and vary by facility type, so confirm against your state health department and your licensing conditions rather than relying on any summary, including this one. Related: our guide to baseline and annual TB testing.