For the General Public:
- What is TB?
- What are the symptoms of TB?
- How is TB spread?
- Is there a difference between TB Infection, and TB disease?
- What should I do if I have spent time with someone with TB infection?
- What should I do if I have been exposed to someone with TB disease?
- How do I get tested for TB?
- Who can administer a tuberculin skin test (TST)?
- How often can TSTs be repeated?
- Where can I get tested for TB?
- What does a positive TB test mean?
- Can I get vaccinated for TB?
- What if someone has received the BCG vaccine (which is given in many countries)?
- Why is TB infection treated?
- How is TB disease treated?
- How many people in Texas have TB?
For Health Care Professionals
- What are the recommendations for screening health care personnel (HCP) for tuberculosis upon hire?
- How often should HCP be screened for TB after hire? Is annual testing recommended?
- If annual testing with a TST or blood test is no longer routinely recommended, should HCP be checked for symptoms of TB periodically?
- How should I screen my employee for TB upon hire if they say they already have a positive TB skin or blood test?
- Can a new hire’s documented negative tuberculin skin test (TST) result be used in performing a baseline two-step TST?
- What do I need to know if my HCW has received a BCG vaccine?
- Are routine or annual CXRs still recommended?
- Can my employee with a positive TB skin or blood test return to work?
- What further actions do I need to take when HCP are diagnosed with TB infection or TB disease?
- Should HCP be treated for TB infection?
- Have the updated 2019 guidelines for screening HCP for TB changed the need for a facility risk assessment?
- Does DSHS have a sample form that health care facilities may use to document TB screening, testing, and education?
- Are there TB screening forms for health care professionals?
- Where can I find more information regarding screening health care personnel for TB?
TB and COVID-19
- Do COVID-19 and TB share similar symptoms?
- Are there recommendations to delay TB screening in persons recently vaccinated against COVID-19?
General Reporting Requirements
- How do I report tuberculosis screening results?
Recommendations for TB Screening of Adults and Children in Various Settings
- Are there general recommendations about which adults should and should not be screened for TB in Texas, and how to screen them?
- Are there general recommendations about which children should and should not be screened for TB in Texas, and how to screen them?
- What are the screening requirements for TB testing in facilities that provide care to children?
- What are the screening requirements for TB testing in adult care centers such as assisted living facilities?
- Do all employees in Texas schools still need a tuberculin skin test?
- Do all new students in Texas schools still need a tuberculin skin test?
For Correctional Settings
- Are correctional facilities in Texas required to screen inmates and employees for TB?
- What are other recommended sites where I can find information about tuberculosis?
For the General Public
What is TB?
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.
What are the symptoms of TB?
The general symptoms of TB disease include:
- Feelings of sickness or weakness
- Weight loss
- Night sweats.
The symptoms of TB disease of the lungs also include:
- Chest pain
- Coughing up blood
Symptoms of TB disease in other parts of the body depend on the area affected.
How is TB spread?
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.
Is there a difference between TB Infection, and 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 body. 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.
What should I do if I have spent time with someone with TB infection?
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 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.
What should I do if I have been exposed to someone with TB disease?
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.
How do I get tested for TB?
There are two tests that 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 health care 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.
Who can administer a tuberculin skin test (TST)?
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 health care worker. DSHS recommends those that administer a TST meet knowledge and clinical skills requirements, have received training, and demonstrated competency before administering a TST.
The Texas DSHS TB Program recommends that anyone who administers a TST has reviewed, is familiar with, and able to 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.
How often can TSTs be repeated?
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.
Where can I get tested for TB?
In general, 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.
What does a positive TB test mean?
A person with a positive TST or blood test has the 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 a testing of sputum (phlegm), are needed to determine whether the person has TB infection or TB disease.
Can I get vaccinated for TB?
There is a vaccine for TB, but it is not generally recommended for use in the United States. Bacille Calmette-Guérin, or BCG, is a vaccine used in many countries 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 diseases, specifically miliary TB and TB meningitis.
What if someone has received the BCG vaccine (which is given in many countries)?
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 overtime 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.
Why is TB infection treated?
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 TB infection. This includes people with HIV infection, people who were recently exposed to someone with TB disease, and people with certain medical conditions.
How is TB disease treated?
TB disease can be treated by taking multiple drugs for several months, generally 6 to 12 months. It is very important that people who have TB disease 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.
How many people in Texas have TB?
Each year, DSHS provides information on numbers of TB cases per county. The most current information is found on the TB statistics page.
For Health Care Professionals
What are the recommendations for screening health care personnel (HCP) for tuberculosis upon hire?
The Department of State Health Services (DSHS) in partnership with the National Tuberculosis Controllers Association (NTCA) and Centers for Disease Control and Prevention (CDC), recommend that both paid and unpaid health care personnel (HCP) receive the following upon hire:
- A single blood test known as an interferon gamma release assay (IGRA) or a two-step tuberculin skin test (TST);
- An individual risk assessment to determine baseline risk for TB and interpret the IGRA or TST results; and
- A signs and symptoms screening assessment.
DSHS developed a sample Baseline Tuberculosis Assessment for Health Care Personnel form (PDF) that may be used by health care 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 health care facilities and other entities to guide the development of their internal TB screening policies. These recommendations should not be interpreted as DSHS policies.
After hire, how often should HCP be screened for TB? Is annual testing recommended?
Annual TB testing using an IGRA or TST is not routinely recommended. Health care 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 HCP with untreated TB infection. HCP should also be educated about TB treatment options for TB infection.
We developed a sample After Hire Tuberculosis Assessment for Health Care Personnel form that may be used for HCP with untreated TB infection or anytime a 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 risk, such as pulmonologists or respiratory therapists in high risk settings, or in settings where TB exposures have occurred in the past (i.e. emergency departments). This decision should be developed by the healthcare staff responsible for infection control and may be done in collaboration with your local health department.
If annual testing with a TST or blood test is no longer routinely recommended, should HCP be checked for symptoms of TB periodically?
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.
How should I screen my employee for TB upon hire if they say they already have a positive TB skin or blood test?
HCP 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:
- Complete a TB signs and symptoms assessment.
- 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.
Can a new hire’s documented negative tuberculin skin test (TST) result be used in performing a baseline two-step TST?
Yes, a new hire’s documentation of a negative TST result can be recorded as step one of the two-step TST when administered 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.
What do I need to know if my employee has received a BCG vaccine?
The IGRA and TST are not contraindicated for persons who have been vaccinated with Bacillus Calmette-Guérin (BCG). The effectiveness of BCG wanes overtime 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.
Are routine or annual CXRs still recommended?
No, chest x-rays should not be performed routinely or annually for persons with a positive IGRA or TST. Health care 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 are not needed unless signs or symptoms of TB develop, or a clinician recommends a repeat chest radiograph, or after a new exposure to TB.
Health care 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.
Can my employee with a positive TB skin or blood test return to work?
HCP 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 prior to returning to work. If a diagnosis of TB infection is made, 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.
HCP 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 (PDF).
HCP with TB infection should be offered treatment in accordance with 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 results of an individual risk assessment. Refer to the following for more details on diagnosing TB infection: academic.oup.com/cid/article/64/2/e1/2629583.
What further actions do I need to take when HCP are diagnosed with TB infection or TB disease?
TB infection, TB disease, and suspicion of TB disease are all reportable to your local health department. See How do I report TB? for reporting requirements.
Should HCP be treated for TB infection?
Treatment for TB infection should be considered in all persons to prevent the progression to TB disease. This decision should be made between the HCP and their health care provider.
When facilities screen for TB, DSHS recommends that an annual education component is included in the screening plan. Education can include information on signs and symptoms of TB, the difference between TB infection and disease, TB risk factors, and the risks for developing TB disease if not treated.
Have the updated 2019 guidelines for screening HCP for TB changed the need for a facility risk assessment?
No, facility risk assessments are still recommended. The results of the assessment are no longer used to determine 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.
Does DSHS have a sample form that health care facilities may use to document TB screening, testing, and education?
Yes. DSHS has developed the following forms that facilities may use or modify to fit their need.
- Baseline Tuberculosis Assessment for Health Care Personnel. It is intended for use in health care facilities when assessing employees for TB upon hire.
- After Hire Tuberculosis Assessment for Health Care Personnel. It is intended for use in health care facilities when assessing employees for TB any time after baseline screening.
- Tuberculosis Screening Results and Work Clearance for Health Care Personnel. It allows facilities to document 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.
Are there TB screening forms for health care professionals?
Yes. You can find a list of forms on the TB Forms and Resources page.
Where can I find more information regarding screening health care personnel for TB?
Refer to the Centers for Disease Control and Prevention (CDC) website for more information.
TB and COVID-19
Do COVID-19 and TB share similar symptoms?
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.
Are there recommendations to delay TB screening in persons recently vaccinated against COVID-19?
No, TB screening should not be delayed for people with risk factors for TB who have been vaccinated against COVID-19. The Centers for Disease Control and Prevention (CDC) has information about TB screening practices and the COVID-19 vaccine.
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.
General Reporting Requirements
How do I report tuberculosis screening results?
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 include 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:
- Positive skin test with results written in millimeters and date read, or positive IGRA blood test results; and
- Documentation that patient has no current signs or symptoms of active tuberculosis disease; and
- CXR results that are read as normal, or not consistent with TB; and
- There is no suspicion of Active TB disease
TB Disease or Suspicion of TB Disease- Reportable within one (1) working day.
Recommendations for TB Screening of Adults and Children in Various Settings
Are there general recommendations about which adults should and should not be screened for TB in Texas, and how to screen them?
Yes, the DSHS TB Unit has recommendations for TB screening of adults in Texas, depending on identified TB risk factors. Please refer to information in Tuberculosis Screening Recommendations for Adults in Various Settings (TB-1002).
Are there general recommendations about which children should and should not be screened for TB in Texas, and how to screen them?
Yes, the DSHS TB Unit has recommendations for TB screening of children in Texas, depending on identified TB risk factors. Please refer to information in Tuberculosis Screening Recommendations for Children in Various Settings (TB-1003).
What are the screening requirements for TB testing in facilities that provide care to children?
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.
What are the screening requirements for TB testing in adult care centers such as assisted living facilities?
Screening requirements for adults working in these facilities are outlined in the Long-Term Care Regulatory Provider Letter:
- Assisted Living Facility
- Day Activity and Health Services Facility
- Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions
- Home and Community Support Services Agency
- Nursing Facility, and
- Prescribed Pediatric Extended Care Center
Facilities licensed by HHS for adult care in Type A and Type B Assisted Living Facilities will abide by Texas Administrative Code (TAC) Title 26 Part 1 Chapter 553 Subchapter E Rule §553.261B. TB requirements are summarized below; however, each facility should review the TAC for specific details:
- Facilities must develop written policies for the control of communicable diseases in employees and clients, including TB screening and the provision of a safe and sanitary environment for clients and their families.
- Screen employees for TB within two weeks of employment.
- After hire, facilities must follow CDC guidance in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. See FAQs for Health Care Professionals.
- Facilities must screen residents for TB upon admission and after exposure to TB. Any facilities that provide care to adults and are not listed above 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.
Do all employees in Texas schools still need a tuberculin skin test?
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 the tuberculin skin testing or IGRA blood test 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 their own policy.
Do all new students in Texas schools still need a tuberculin skin test?
No. A tuberculosis questionnaire has been developed by Texas Department of State Health Services to identify children at high risk for TB infection. Refer to the list of counties with a high incidence of TB where use of the questionnaire is recommended prior to 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 prior to school entry.
Children who have a positive reaction to the TB skin test but 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, day care 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 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 (en Español)
For Correctional Settings
Are correctional facilities in Texas required to screen inmates and employees for TB?
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:
- a capacity of 100 or more beds,
- housing inmates transferred from a county that has a jail with a capacity of 100 or more beds, or
- 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.
What are other recommended sites where I can find information about tuberculosis?
Centers for Disease Control and Prevention:
- Basic TB Facts
- Tuberculosis Fact Sheet
- Tuberculosis Fact Sheet Courtesy of CDC
- Frequently asked questions about HIPAA Privacy Rule
- TB Medical Consultation Process