Tuberculosis (TB) is a disease caused by germs that spread from person to person through the air. TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine. A person with TB can die if they do not get treatment.

The general symptoms of TB disease include:

• Feelings of sickness or weakness
• Weight loss
• Fever
• Night sweats.

The symptoms of TB disease of the lungs also include:

• Coughing
• Chest pain
• Coughing up blood

Symptoms of TB disease in other parts of the body depend on the area affected.

TB germs go into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. These germs can stay in the air for several hours, depending on the environment.  People who breathe in air containing these TB germs can become infected.  This is called TB infection or latent TB infection (LTBI). If untreated, TB infection can become TB disease. 

People with TB infection have TB germs in their bodies, but they are not sick because the germs are not active. These people do not have symptoms of TB disease and they cannot spread the germs to others. However, they may develop TB disease in the future. They are often prescribed treatment to prevent them from developing TB disease.

People with TB disease are sick from TB germs that are active, meaning that they are multiplying and destroying tissue in their bodies.  They usually have symptoms of TB disease.  People with TB disease of the lungs or throat are capable of spreading germs to others. They are prescribed drugs that can treat TB disease.

A person with TB infection cannot spread germs to other people. You do not need to be tested if you have spent time with someone with a TB infection. However, if you have spent time with someone with TB disease or someone with symptoms of TB, you should contact your doctor or local or regional health department for TB screening recommendations.

Not everyone who is exposed to TB becomes infected with the TB germs. If you believe you have been exposed to TB, you should contact your doctor or the local health department for more information about screening and testing.

Two tests can be used to help detect TB infection: a skin test or a TB blood test.

The Mantoux tuberculin skin test (TST) is performed by injecting a small amount of fluid (called tuberculin) into the skin in the lower part of the arm. A person given the TST must return within 48 to 72 hours to have a trained healthcare worker look for a reaction on the arm; this must be done in person.

The TB blood test, known as the Interferon Gamma Release Assay (IGRA), measures how the patient’s immune system reacts to the germs that cause TB when present. There are currently two Federal Drug Administration (FDA) approved blood tests on the market: the QuantiFERON®–TB Gold In-Tube test (QFT-GIT) and the T-SPOT®.TB test (T-Spot).

Although the tuberculin skin test has been the most common screening method in Texas, many health departments now use the IGRA test as the standard tool. When choosing a skin test or blood test, consideration can be made based on age, health status (see policy TB 1004), BCG status, and other factors of the person needing the test.

A positive TST or IGRA only tells you if you have TB germs in your body. Other tests may be needed to tell if you have TB disease, such as a chest x-ray (CXR) and other laboratory testing of sputum.

A tuberculin skin test (TST) is considered a medical act and should only be performed by an individual working under the order of a licensed physician. There is no requirement for the individual to be a licensed healthcare worker. DSHS recommends those who administer a TST meet knowledge and clinical skills requirements, have received training, and demonstrate competency before administering a TST.

The Texas DSHS TB Program recommends that anyone who administers a TST has reviewed, is familiar with, and can readily access the recommendations within the following documents:

• CDC Fact Sheet “Tuberculin Skin Testing”
• CDC fact sheet “Targeted Tuberculin Testing and Interpreting Tuberculin skin Test Results”
• CDC Mantoux Tuberculin Skin Testing Facilitator Guide
• Tubersol package insert
• Aplisol package insert

In-person training on how to administer a TST is available through the Heartland National TB Center.  For a listing of TB training opportunities, visit the Heartland National TB Center website.

In general, there is no risk associated with repeated tuberculin skin test placements. If a person does not return within 48-72 hours for a tuberculin skin test reading, a second test can be placed as soon as possible. There is no contraindication to repeating the TST unless a previous TST was associated with a severe reaction.

In general, the Texas Department of State Health Services does not recommend that low-risk individuals be tested for tuberculosis. If a test is needed or recommended, the general public may ask their primary care provider, local clinics, or pharmacies, among other sites. You may also contact your local or regional health department for recommendations regarding individual testing needs.

A person with a positive TST or blood test has a TB germ in their body. It does not tell whether or not the person has TB infection or TB disease. Other tests, such as a chest x-ray, symptom screening, and testing of sputum (phlegm), are needed to determine whether the person has TB infection or TB disease.

Bacille Calmette-Guérin (BCG) is a vaccine for TB. It is used in many countries outside the United States (U.S.) with high rates of TB. BCG vaccination does not completely prevent people from getting TB, but it is used to protect infants and young children from serious, life-threatening forms of TB.

The vaccine is not available for routine use in the U.S.

According to the CDC, the vaccine is not generally used in the U.S. because of:

• The low risk of infection with TB bacteria in the United States,
• The variable effectiveness of the vaccine against adult pulmonary TB, and
• The vaccine’s potential to cause a false-positive TB skin test reaction.

If traveling outside the U.S. and the vaccine is available in the country you will be visiting, consult with your physician to determine if the vaccine is recommended.

In many parts of the world where TB is common, Bacille Calmette-Guérin, (BCG) vaccine is used to protect infants and young children from serious, life-threatening diseases, specifically miliary TB and TB meningitis. However, it does not completely prevent people from getting TB.

The effect of the BCG vaccine wanes over time and may have little to no effect on positive TST results among adults who received the vaccine as a child.  

A person with a history of BCG vaccination can be tested and treated for TB infection if they react to the TST. TST reactions should be interpreted based on risk stratification regardless of BCG vaccination history. IGRAs use M. tuberculosis-specific antigens that do not cross-react with BCG, and therefore, do not cause false positive reactions in BCG recipients—this means a blood test, or IGRA, is preferred for BCG-vaccinated individuals.

If you have TB infection but not TB disease, your doctor may want you to take a drug to kill the TB germs and prevent you from developing TB disease. The decision about taking treatment for TB infection will be based on your chances of developing TB disease. Some people are more likely than others to develop TB disease once they have a TB infection. This includes people with HIV infection, people who were recently exposed to someone with TB disease, and people with certain medical conditions.

TB disease can be treated by taking multiple drugs for several months, generally 6 to 12 months. People who have TB disease must finish the medicine and take the drugs exactly as prescribed. If they stop taking the drugs too soon, they can become sick again; if they do not take the drugs correctly, the germs that are still alive may become resistant to those drugs. TB that is resistant to drugs is harder and more expensive to treat. In some situations, local health department staff meets regularly with patients who have TB to watch them take their medications. This is called directly observed therapy (DOT). DOT helps the patient complete treatment in the least amount of time.

DSHS provides TB medications to public health clinics across Texas. These clinics treat patients with TB disease. Also, people who are presumed to have TB may be given treatment while their clinicians perform further testing to confirm or rule out TB disease.

Each year, DSHS provides information on the number of TB cases per county. The most current information is found on the TB statistics page.

HCP are defined as paid and unpaid staff working in health care settings. HCP have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air.

HCP include, but are not limited to, emergency medical service staff, nurses, nursing assistants, home health staff, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and people not directly involved in patient care, but who could be exposed to infectious materials that can be transmitted in the health care setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer staff). See Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services (2019) (cdc.gov).

The Department of State Health Services (DSHS) in partnership with the National Tuberculosis Coalition of America (NTCA) and Centers for Disease Control and Prevention (CDC), recommends that both paid and unpaid healthcare personnel (HCP) receive the following upon hire:

1. A single blood test known as an interferon-gamma release assay (IGRA) or a two-step tuberculin skin test (TST);
2. An individual risk assessment to determine baseline risk for TB and interpret the IGRA or TST results; and
3. A TB signs and symptoms screening assessment.

DSHS developed a sample Baseline Tuberculosis Assessment for Health Care Personnel form that may be used by healthcare facilities. DSHS also recommends completing the Tuberculosis Screening Results and Work Clearance for Health Care Personnel after performing a baseline TB assessment.

These recommendations may be used by healthcare facilities and other entities to guide the development of their internal TB screening policies. These recommendations should not be interpreted as DSHS policies.

Annual TB testing using an IGRA or TST is not routinely recommended. Healthcare facilities should perform TB testing and complete a signs and symptoms assessment after known or ongoing exposure to TB or complete a signs and symptoms assessment annually for HCPs with untreated latent TB infection. HCPs should also be educated about treatment options for latent TB infection.

We developed a sample After Hire Tuberculosis Assessment for Health Care Personnel form that may be used for HCPs with untreated TB infection or anytime an HCP is tested for TB after hire.

Annual TB testing using an IGRA or TST and symptom screening may be considered for HCP with significant occupational risks, such as pulmonologists or respiratory therapists in high-risk settings, or in settings where TB exposures have occurred in the past (e.g. emergency departments). This decision should be developed by the healthcare staff responsible for infection control and may be made in collaboration with your local health department.

We recommend that facilities consider the local epidemiology of TB in their county, including risk factors for TB in their staff, and any past TB exposures in the facility when deciding to implement periodic TB screening after baseline testing. The purpose of screening for TB using a signs and symptoms assessment questionnaire is to ensure active TB is identified early. Anyone with symptoms of TB should be referred for medical evaluation. 

HCPs with documentation of a previous positive TST or IGRA result, or documentation confirming completion of treatment for TB infection or disease, should be screened for TB in the following way:

1. Complete a TB signs and symptoms assessment.
2. Have a baseline chest x-ray (CXR) performed (unless a recent copy is available).

HCP with documentation of a previous positive TST or IGRA result should not be re-tested with a TST or IGRA.

After the baseline screening, serial or routine CXRs are not recommended; however, persons exhibiting symptoms of TB disease require a CXR regardless of history.

HCP without documentation of the previous test result should undergo baseline screening with a two-step TST or an IGRA. An individual risk assessment and signs and symptoms screening assessment should also be completed (refer to Baseline Tuberculosis Assessment for Health Care Personnel). Copies of the TB screening results and responses to the symptom screen and individual risk assessment should be kept by the employee as documentation in case of future screenings.

For new hires with documentation of a previous positive TST or IGRA, their baseline TB screening includes a CXR or a recent copy of a CXR. It is up to each facility to determine the timeframe for accepting a recent CXR. Considerations may be made about the HCP’s individual risk factors and if the CXR result was normal or abnormal.

A new hire with documented prior positive TST or IGRA and documented treatment for LTBI or TB would not need a CXR. They would need a symptom screen only.

For more information, refer to Tuberculosis Screening, Testing, and Treatment of US Health Care Personnel.

Yes, a new hire’s documentation of a negative TST result can be recorded as step one of the two-step TST when administered at any time during the previous 12 months, if the result was documented in millimeters (mm). The TST administered at hire will be recorded as step two of the two-step TST.

For more details, refer to the Guidelines for Preventing the Transmission of M. TB in Health-Care Setting, 2005 TB Infection-Control Surveillance.

The IGRA and TST are not contraindicated for persons who have been vaccinated with Bacillus Calmette–Guérin (BCG). The effectiveness of BCG wanes over time but it may cause a false-positive reaction to the TST, which may complicate decisions about diagnosing TB infection and prescribing treatment. IGRAs use M. tuberculosis-specific antigens that do not cross-react with BCG, and therefore, do not cause false positive reactions in BCG recipients. This means an IGRA test is preferred for BCG-vaccinated individuals. More information can be found on the CDC website.

No, chest X-rays should not be performed routinely or annually for persons with a previous positive IGRA or TST. Healthcare personnel, patients, or institutional residents with a baseline positive or newly positive IGRA or TST result who are likely to be infected with TB should receive one chest radiograph to exclude a diagnosis of TB disease.

Repeat chest x-rays after baseline are not required unless signs or symptoms of TB develop, or after a new TB exposure, or unless a clinician recommends a repeat chest radiograph.

Healthcare personnel who have a previously positive IGRA or TST result and who change jobs should carry documentation of the results of their IGRA or TST, chest radiograph, and documentation of treatment history for TB infection, if applicable, to their new employer.

HCPs who are likely * infected with TB based on a positive TST or IGRA result and individual risk should be referred for a CXR and medical evaluation to rule out active TB before returning to work. If a diagnosis of TB infection is made, the HCP may return to work, as TB infection is not contagious. They should be educated on treatment options for TB infection to reduce their chance of developing TB disease.

HCPs who are asymptomatic, unlikely* to be infected with TB, and who are at low risk for progression to TB disease based on individual risk, should have a second test (either an IGRA or a TST) if their first test is positive. Only when the second test is positive in low-risk individuals is TB infection considered an accurate diagnosis.

HCPs with TB infection should be offered treatment by CDC guidelines, after discussion with a licensed healthcare provider. 

*Determining if an individual is likely or unlikely to be infected with TB is based on the results of an individual risk assessment. Refer to the following for more details on diagnosing TB infection: Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children | Clinical Infectious Diseases | Oxford Academic.

TB infection, TB disease, and suspicion of TB disease are all reportable to your local or regional health department. See How do I report TB? for reporting requirements.

Treatment for TB infection should be considered in all persons, including HCP, to prevent the progression of TB disease. This decision should be made between the HCP and their healthcare provider. Visit the CDC's Treatment for Latent Tuberculosis Infection webpage for more information.

When facilities screen staff for TB, DSHS recommends that an annual education component be included in the screening plan. Education can include information on the signs and symptoms of TB, the difference between TB infection and disease, TB risk factors, and the risks of developing TB disease if not treated.

No, facility risk assessments are still recommended. The results of the assessment are no longer used to determine the frequency of TB screening but are useful in documenting infection control in facilities. Refer to the CDC website for more details on the use of the risk assessment and updates to the 2019 guidelines.

Yes. DSHS has developed the following forms that facilities may use or modify to fit their need.

1. Baseline Tuberculosis Assessment for Health Care Personnel. It is intended for use in healthcare facilities when assessing employees for TB upon hire.
2. After Hire Tuberculosis Assessment for Health Care Personnel. It is intended for use in healthcare facilities when assessing employees for TB any time after baseline screening.
3. Tuberculosis Screening Results and Work Clearance for Health Care Personnel. It allows facilities to document the results of baseline and after-hire screening including the recommended annual education.

These forms are not required by DSHS but may be used to guide and document facility screening practices, as they align with DSHS and CDC recommendations.

Yes. You can find a list of forms on the TB Forms and Resources page.

Refer to the Centers for Disease Control and Prevention (CDC) website for more information.
 

Yes, TB and COVID-19 have some similar symptoms such as a cough or a fever. Only a licensed healthcare provider can determine the cause of symptoms and further testing may be needed. For healthcare providers, it is important to “Think TB” when symptoms and risk factors for TB are present. See Tuberculosis and COVID-19 Know the Difference for details.

No, TB screening should not be delayed for people with risk factors for TB who have been vaccinated against COVID-19.

It is recommended that those in charge of TB screening visit the CDC website periodically for any updates regarding TB screening practices.  When considering the impact of TB in your area, please consult with your regional or local health department (R/LHD). Report suspected and confirmed TB infections to your R/LHD.

Both TB infection and TB disease are Notifiable Conditions reportable to the local or regional health department TB Programs. Reporting details can be found on the DSHS website, which includes reporting forms.

Tuberculosis Infection- Reportable within one (1) week to the local or regional health department.  A diagnosis of a latent TB infection is NOT complete until the following criteria have been met:

1. Positive skin test with results written in millimeters and date read, or positive IGRA blood test results; and
2. Documentation that the patient has no current signs or symptoms of active tuberculosis disease; and
3. CXR results that are read as normal, or not consistent with TB; and
4. There is no suspicion of Active TB disease

TB Disease or Suspicion of TB Disease- Reportable within one (1) working day.

Yes, the DSHS TB Unit has recommendations for TB screening of adults in Texas, depending on identified TB risk factors. Please refer to the information in Tuberculosis Screening Recommendations for Adults in Various Settings (TB-1002).

Yes, the DSHS TB Unit has recommendations for TB screening of children in Texas, depending on identified TB risk factors. Please refer to the information in Tuberculosis Screening Recommendations for Children in Various Settings (TB-1003).

Facilities with a permit or license from Texas Health and Human Services (HHS) to provide care to children will abide by the chapters that apply to each type of facility in the Texas Administrative Code (TAC) Title 26, Part 1.

The Minimum Standards page on the HHS website contains links to the standards related to daycare facilities, 24-hour residential care, and child-placing agencies. These links are located at the bottom of the page.

Any facilities that provide care to children and are not listed above should first review the Texas Administrative Code for any statutory requirements or check with their licensing or credentialing agency. Collaboration with a local or regional TB program may assist in developing screening, testing, and treatment plans.

Screening requirements for adults working in  long-term care facilities who are regulated by the Health and Human Services Commission (HHSC) should follow the TB screening recommendations outlined above in the Health Care Personnel (HCP) section. HCP include both direct and non-direct patient care staff as defined in the DSHS TB Screening for Adults in Various Settings guidance document.

In general, staff who work in any health care setting that provides care for adults should follow the TB screening recommendations outlined above in the Health Care Personnel (HCP) section. HCP include both direct and non-direct patient care staff as defined in the DSHS TB Screening for Adults in Various Settings guidance document.

Staff in facilities regulated by HHSC should also review the Texas Administrative Code Title 26, Part 1 for any statutory requirements and check with their licensing or credentialing agency.

There is no statewide requirement for teachers or other school employees to have a tuberculin skin test or TB blood test. The Centers for Disease Control and Prevention (CDC) and DSHS discourage the use of tuberculin skin testing or IGRA blood tests for persons who have no risk factors for TB exposure.

However, anyone with signs or symptoms of TB should be considered for medical evaluation.

Specifications for employee or volunteer TB screening may be required by a licensing, credentialing, or insurance policy, or by the school district’s regulations and requirements. Each school should defer to its policy.

No. A tuberculosis questionnaire has been developed by the Texas Department of State Health Services to identify children at high risk for TB infection. Refer to the counties with a high incidence of TB (A–B | C | D–F | G–H | I–L | M–P | R–S | T–Z | TDCJ | Texas) where the use of the questionnaire is recommended before entering school. As resources allow, school districts in other counties may use the TB questionnaire to identify children who should receive a TB skin test before school entry.

Children who have a positive reaction to the TB skin test but have no symptoms of TB disease should NOT be kept out of school while they are being evaluated for treatment of TB infection.

The American Academy of Pediatrics (AAP) recommends that physicians routinely assess a child's risk of TB exposure with a questionnaire and offer tuberculin skin testing only to at-risk children. The AAP does not recommend routine tuberculin skin testing of children with no TB risk factors for school entry, daycare attendance, WIC eligibility, or camp attendance.

A tuberculin skin test may be applied on the same day as routine immunizations. The skin test will need to be read 48-72 hours later. If a skin test is not placed on or before the day of a live virus immunization such as measles-mumps-rubella (MMR), then the skin test should be postponed for at least six weeks.

For more information about TB screening for children in school settings visit the following links:

• Recommendations for TB Screening of School Aged Children
• Tuberculosis Questionnaire in English
• Tuberculosis Questionnaire in Spanish

The law (Chapter 89 of the Texas Health & Safety Code) in Texas requires county correctional facilities that meet any one of three criteria to screen all inmates for TB by the seventh day of incarceration and annually thereafter, and to screen all employees and volunteers both pre-employment and annually thereafter.

The three criteria are as follows:

1. A capacity of 100 or more beds,
2. Housing inmates transferred from a county that has a jail with a capacity of 100 or more beds, or
3. Housing inmates from another state.

The law also requires all correctional facilities in the state, including youth detention facilities, regardless of whether they meet the criteria stated above, to report to the Texas Department of State Health Services, Infectious Disease Intervention and Control Branch, the release of inmates being treated for TB so that the Department can arrange for continuity of care.

Centers for Disease Control and Prevention:

• Tuberculosis Overview
• Talking with Your Health Care Provider about Tuberculosis
• Clinical Overview of Tuberculosis
• What You Need to Know About Tuberculosis Fact Sheet
• Tuberculosis Centers of Excellence for Training, Education, and Medical Consultation

HIPAA:

• Frequently asked questions about HIPAA Privacy Rule

Medical Consultation:

• TB Medical Consultation Process