Missouri Recommendations for the Use of Tuberculin During the Nationwide Shortage

On June 6, 2019, the Missouri Department of Health and Senior Services (DHSS) distributed information from the Centers for Disease Control and Prevention (CDC) that provided patient care and public health recommendations in the context of the nationwide shortage of tuberculosis skin test (TST) antigens.

This information is available on the DHSS website, health.mo.gov/emergencies/ert/alertsadvisories/pdf/cdc-advisory6-6-19.pdf.

The following SLCR recommendations provide additional guidance for long-term care providers:
The Section for Long-Term Care Regulation (SLCR) recognizes that there may be some delay in obtaining the supplies needed to do the required TST testing and will allow the following:

  • Make every effort to obtain the TST testing supplies including checking with your local health department, all suppliers, etc. in a timely manner.
  • Document all attempts to obtain the TST testing supplies and estimated times of delivery.
  • Until you can obtain the necessary TST testing supplies:
    • Establish a written plan for the TST shortage for testing of potential new employees and new residents within the same timeframes as required for the TST testing.
    • The plan must, at a minimum, include assessing new employees for signs and symptoms of TB prior to allowing direct contact with residents.
    • The plan must include assessing any new resident upon admission for signs and symptoms of TB.
    • Upon admission of residents, complete an evaluation to rule out signs and symptoms of TB and postpone the TST until supplies are available.
    • Document this assessment.
  • During the shortage, if supplies are still available, new employees should be administered the one-step TST upon hire, and then defer the second step TST until the shortage resolves. If supplies are not available, conduct a symptom screen and document. Defer the two-step until the shortage resolves.
  • Defer the annual testing of current employees, but if the annual comes due during this time, assess the current employee for signs and symptoms.

If the assessment of any employee or resident results in signs and symptoms of possible TB, instruct them to see their physician or their local public health department.

Once the TST testing supplies become available all employees or residents who required testing and were not tested, must be tested. SLCR expects the testing to be completed within a reasonable time period, usually within 30 days of obtaining the supplies.

TST testing is not an annual requirement for residents. Some homes have elected to do the TST instead of an annual review of symptoms. The only requirement for residents after the admission two-step TST is an annual review of symptoms to assure no signs of TB.


You may follow the CDC guidance as noted below:
CDC recommends any of three general approaches for addressing the shortages of tuberculin skin test antigens:

  • Substitute IGRA blood tests for TSTs. The costs associated with using the blood tests can be greater than the cost of TSTs. The blood tests require phlebotomy, preparation of blood specimens, and specific laboratory services for analysis. Thus, these tests are not available in all practice settings. Clinicians who use the IGRA blood tests should be aware that the criteria for test interpretation are different than the criteria for interpreting TSTs.
  • Allocate TSTs to priority indications, such as TB contact investigations, as determined by public health authorities. This might require deferment of testing some persons. CDC does not recommend testing persons who are not at risk of TB.
  • Substitute TUBERSOL® for APLISOL® for skin testing. In cross-sectional studies, the two products give similar results for most patients.


If you have any questions, please contact the Missouri Department of Health and Senior Services (DHSS) Bureau of Communicable Disease Control and Prevention at 573-751-6113.