#243 TB on the Rise: Infection Control Strategies for Dental Practices

 Tuberculosis (TB) may feel like a disease of the past—but it is making a concerning comeback, even in the United States. In this episode, we break down what the resurgence of TB means for today’s dental teams and why awareness is critical in the clinical setting. 

Resources:

• CDC Tuberculosis page - https://www.cdc.gov/tb/index.html
• CDC Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel (2019)  https://bit.ly/4t5ygeP

                                                 https://www.thecompliancedivas.com

Transcript

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SPEAKER_00 0:00

Welcome to the Compliance Divas Podcast. I'm Mary Gavoni and I'll moderate this episode along with our diva, Leslie Canum. Since 2025, there have been more than 10,000 cases of tuberculosis reported in the United States, according to the CDC. Not only are there an increasing number of cases of TB, the CDC estimates that up to 13 million people living in the U.S. have latent TB infections, which we'll explain a little bit later, which are inactive but not contagious. The CDC also estimates that up to 13 million people in the US live with latent TB infections, which are inactive and not contagious, but they can develop into active TB disease. In this episode, we're going to delve into recent outbreaks in the U.S., where the outbreaks were concentrated, and what dental practices need to know about respiratory protection and screening protocols for employees and patients. Leslie, first off, can you share with us the information about the most recent outbreaks in the U.S.?

SPEAKER_01 1:16

Well, Mary, it's startling that we're starting to see TB cases again, where we had only had around maybe 10,000 cases in a year that we were noting. And now we're seeing so many more with six states reporting outbreaks. Those states include Alaska, Arkansas, California, Indiana, Kansas, and Washington state. And the interesting thing about outbreaks and these six large outbreaks is that they involved a total of 129 cases. Nearly 53% of these cases, of these outbreaks, occurred in citizens born in the U.S. Children under 15 years old accounted for 36% of the cases in these large outbreaks. Percentages of these cases attributed to recent transmissions varied from 0 to 63% across the 52 areas. All but five areas had at least one case attributed to a recent transmission. So a point of reference for us in the number of cases that we've seen. In the United States, we had 14,648 cases, like 3,200 were in California, 956 were in Florida, 1,177 were reported in New York City. And in Texas, there was 1,777 cases. Washington state had 335 cases. Now, the total number of TB outbreaks eligible to be evaluated for recent transmission is actually a case that's attributed to a recent transmission, meaning if a plausible source case can be identified in a person who had M tuberculosis isolate or had an infectious form of TB, or was 10 years of age or older, or resided within 100 miles of the case, and was diagnosed within two years before the case. So, Mary, we're seeing these cases on the rise again.

SPEAKER_00 3:23

Yes, we are, Leslie. And the scary part about this is that healthcare officials will say that tuberculosis used to be one of the most infectious and deadliest diseases, not only in the United States but globally. And you mentioned the correlation between how do we see where these cases result from in terms of an outbreak. But it's also important to understand, as I mentioned earlier, what it means to have a latent TB infection. So people with latent TB are infected with bacteria. So they were exposed somewhere in the environment to a person or through aerosols or whatever, but they do not have TB disease. They don't have an active infection. But if these bacteria become active and multiply, that latent TB infection can develop into TB disease. So what you may see are patients in your practice that say, yeah, I tested positive for TB, but they didn't do anything to treat it, they will most likely always test positive for TB, and they have about a 10% chance, according to the CDC, in their lifetime of developing a TB infection. It is important that people understand that to treat people with a latent TB infection does substantially reduce the risk that it will progress to TB disease. So that's where tracking and tracing of cases comes into play. So again, a small number of TB bacteria within their body means that a person has TB that is inactive. It can't spread to others, they're not infectious, they typically don't feel sick, and they will have a positive TB blood test or a positive TB skin test. Typically, if people get a positive TB skin test, we don't do another skin test. They progress then to a blood test or possibly a chest x-ray to further diagnose them. And they may actually have a normal chest x-ray. So it is up to the healthcare provider and the patient, if they know they were exposed, they test positive but don't have symptoms, whether or not they should be treated with the appropriate antibiotics to prevent that latent infection from becoming active. But these people don't require any kind of isolation. It's okay to treat them in the dental practice, but it also is very important to get a medical opinion about this person. If they say they've tested positive for TB, you need to know what that means. Because if they actually had an active TB infection previously, they will always test positive for TB. So, Leslie, let's talk about screening procedures for anyone that has been exposed to tuberculosis.

SPEAKER_01 6:27

Hey, Mary, there's been some changes in the CDC recommendations for screening healthcare providers. The original recommendations were back in 2005. And in 2019, CDC updated those recommendations. So we will provide that information in our show notes, but there's some baseline screening steps that should be considered for dental workers. And what we should know is that all U.S. healthcare personnel should be screened for TB upon hire. And this process includes a risk assessment, symptoms evaluation, and either a TB blood test or a TB skin test. The TB skin test we know as the MENTU skin test. And it's one method of determining whether a person is infected with TB bacteria. So the TB screening process for healthcare personnel includes this baseline individual TB test, an individual TB risk assessment, a TB symptom evaluation, and additional evaluation for TB disease as needed. And then there's also the emphasis that CDC recommendations are recommendations, but states have regulations. So one should check with their own state TB regulations to determine what they should be doing. Because CDC recommendations do not override or replace state regulations. And state and local regulations may differ to meet the local needs. So it's important that our listeners contact their state or local TB control program for testing regulations in their state. I know you're going to touch a little bit more about those who work in hospital settings. Many of our dental clinics are in hospital settings and they have a little bit different type of requirement. It's important also to recognize that there's testing that is recommended whenever there's an exposure to TB. So if a dental team member has been exposed either to a family member or through a known exposure source, they should also take steps to not only notify their employer, but to go through the proper steps to see a risk assessment to see if they might have been infected and could possibly be infectious to others.

SPEAKER_00 8:49

Thank you so much for that information, Leslie. And what I do want to add in is that if any of our listeners come from a, say, an oral surgery practice or pediatric practice or other specialty where they actually do hospital cases, or if their clinic is based in a hospital, then they have to follow the hospital recommendations for TB testing, which is typically annual, and that's part of the joint commission requirements for hospital accreditation. So you have to follow those rules. But that does not apply to private practice. There's not a recommendation that we're aware of that requires annual TB testing. But again, check with your state because if you're a state that has a high number of cases, there may be something that is required in your state. The other thing that we talked about before is the CDC recommendation for TV screening pre-employment. So you have to be very careful about following labor laws and make sure that you're not violating any of those. So the best way to deal with this is to make an offer of conditional employment to a potential employee. And you can list in that offer of conditional employment the hours and all the details of the job. And then you say that it is predicated on being screened for tuberculosis. And if they are found to have active TB disease, then that conditional employment offer is null and void. That's a really critical thing because you cannot require somebody to pass, so to speak, a TB test in order to hire them. You make the offer of employment, then you screen them, and then you deal with it. The reason that it makes that offer of conditional employment null and void is because if they have active disease, they cannot work in a healthcare setting. So that's a really, really critical thing to note. As Leslie said, there are forms for doing pre-employment assessments and checking for symptoms and assessment of the team. Those can be utilized from the CDC. But again, once you've given that offer of conditional employment. And make sure that you have documentation of that in the employee file, their confidential medical history to prove that you did that screening. And it's not something, as Leslie said, it's not a rule because it's CDC, it's a guideline. But if your state dental board requires you to follow CDC guidelines, then you need to follow those particular guidelines. And if there, heaven forbid, would be an outbreak of tuberculosis that could be traced to your practice, boy, you'd be hard pressed to defend yourself if you hadn't been doing that pre-employment screening. So that's really, really important to note. And that is a change. So to sort of recap this episode, we've discussed outbreaks of tuberculosis across the U.S., recent outbreaks of tuberculosis, and the risks to dental professionals. What we didn't really talk about, but I will mention is that if you had to provide emergency treatment for a patient who has tuberculosis, who you know has active disease or you suspect may have active TB disease, then the only type of treatment should be emergency treatment. They don't come for their routine preventive care. We don't do crown preps, we only do palliative care, wearing N95 respirators and following what are called transmission-based guidelines, that the clothing that you wear, your lab coat that you wear for treating that patient, be taken off as soon as you're finished treating that patient. And making sure that you take appropriate precautions for that person if they have to be waiting in the reception area to be seen. If you know that they're a confirmed case, then you need to make sure that they are isolated from the rest of the staff and patients. Leslie.

SPEAKER_01 13:27

Also be aware that in California, with the aerosol transmissible disease standard, there are certain steps that must be taken when someone is confirmed with an aerosol transmissible disease. So employees cannot be exposed to that individual. Dentists have to take steps to make sure that they don't provide treatment to those individuals, except in a healthcare setting where they have the negatively pressured air exchange room, so that not only are the N95 respirators worn by the healthcare providers, but that individual is does not come in contact with anybody at all who they may spread their infection to. So in California, again, dentists may not treat those individuals in a dental setting when they have an active TB case, just like in any other active aerosol transmissible disease that's listed in the appendix A of the aerosol transmissible disease scanner.

SPEAKER_00 14:22

Thanks for sharing that, Leslie. And in the ideal world, this is much like it was during COVID that if you do have to do emergency treatment on this patient, the best case for it to be done or the best place for it to be done would be in a hospital isolation room because dental practices don't have that negative air pressure room in order to treat those patients. So if you're in doubt, you can always contact your local health department and they can walk you through what you need to do. But if you have a person in your office who indicates that they've had a cough for three or four weeks or longer, and that they may have coughed up some blood, they have a fever and night sweats, and they just generally don't feel good, the alarm bells ought to be going off for you that this is not a person who is healthy, and they should have a medical evaluation prior to doing anything on that patient and alert the team that they immediately need to get those N95 respirators out while they are having any kind of contact with that patient while they are in the practice. So hopefully, this is helpful information for everyone to remind us what we need to do or not do with the spread of tuberculosis and protecting ourselves and keeping us safe from disease transmissions. The compliance divas bring clarity and simplicity to compliance by navigating the regulatory world to keep you on course. You may submit questions by email to support at thecompliancedivas.com. Any of the resources we mentioned in this episode are listed in the show notes section of your podcast app. And we invite you to subscribe to the podcast at our website, thecompliancedeevas.com, or through your podcast app so that you never miss an episode. And please, on your podcast app, leave us some feedback and a review. Thanks for listening. We'll see you next time.