Transcript No Slide Title - AIDS Education and Training Centers

Module 10
Tuberculosis:
Guidelines for Oral Health
Professionals
Tuberculosis:
Guidelines for Oral Health
Professionals
Louis G. DePaola, DDS, MS
Professor
Department of Diagnostic Sciences
and Pathology
Dental School
University of Maryland Baltimore
Director, Dental Training
Pennsylvania Mid-Atlantic AIDS ETC
Mycobacterium tuberculosis
Transmission and Pathogenesis
Tuberculosis Transmission
 Caused by Mycobacterium tuberculosis
 Spread by:
Airborne route
Droplet nuclei
 Affected by:
Infectiousness of patient
Environmental conditions
Duration of exposure
 Most persons exposed do not become
infected
Transmission of M. tuberculosis
 Spread by droplet nuclei
 Expelled when person with infectious
TB:
 Coughs, sneezes, speaks, or sings
 Close contacts at highest
risk of becoming infected
 Transmission occurs from person with
infectious TB disease
 Latent TB infection not infectious
Pathogenesis
Latent M.tuberculosis Infection
 Inhaled droplet nuclei with M.
tuberculosis :
Reach alveoli
Are taken up by alveolar macrophages
Reach regional lymph nodes
Enter bloodstream and disseminate
 Chest radiograph may have transient
abnormalities
 Specific cell-mediated immune
response controls further spread
1. Tubercle bacilli enter
alveoli and multiply;
2. Organisms disseminated
systemically;
3. Trigger immune reaction
4. Special immune
cells form a hard
shell
(Latent TB
infection)
5. Hard shell breaks
down and tubercle
escape and
multiply causing
active TB infection
Pathogenesis
Active M. tuberculosis Infection
• Active disease state
• Symptoms present:
– Cough
– Fever
– Chills
– Night sweats
• May be infectious
• Disease both treatable & preventable
Pathogenesis
Active M.tuberculosis Infection
• Latent M. tuberculosis progresses to active
disease in:
– A very small number of persons soon after infection
(Primary progression)
– About 5% of infected persons within first 2 years of
infection
– About 5% of infected persons at sometime in later life
• Risk of progression greatest in first 2 years
• Risk greater if cell-mediated immunity
impaired
Symptoms
Suggestive of TB





Chronic cough,
Coughing blood,
Night sweats, and
Unexplained weight loss.
Positive TB skin test without
symptoms does not indicate
active infection in most cases.
Tuberculosis
 Infects an estimated one-third of
the world population
 Globally causes one death every
10 seconds
 50 million people worldwide
infected with drug-resistant strains
 One of leading causes of
death in HIV/AIDS patients
CDC HIV/STD/TB Prevention News Update 3/23/99
Tuberculosis (TB)
The number one single infectious disease killer
• TB is not on the decline.
• One third of the world's population is
infected with TB
 In 1999 TB caused 8,000 deaths/day
The most deaths from TB in history




7- 8 million people become infected with TB/year
5-10 % of these people will develop active TB
Between 1993 and 1996, TB increased 13 %
TB accounts for more than 1/4 of all preventable
adult deaths the developing world.
nfid.org/factsheets
Tuberculosis (TB)
The number one single infectious disease killer
• Someone is newly infected
with TB every second !
 TB is the leading killer of women
 TB outranks all causes of maternal
mortality
 TB creates more orphans than
any other infectious disease
 TB is the leading cause of death
among HIV-positive individuals
nfid.org/factsheets
Tuberculosis Incidence
 USA:18,371 total cases in 1998;
- 7.5% decline compared to 1997;
- Decline expected in 1999
 RUSSIA: < 100,000 cases in 1998,
- Significant increase expected in 1999
 LONDON,UK: 50 new cases/week.
 THE AMERICAS (PAHO):
- 1997 > 250,000 cases reported;
- Estimate as many as 400,000 cases;
- Cause of 50,000 deaths/yr.
CDC HIV/STD/TB Prevention News Update 3/23/99
Epidemiology
of TB
in the USA
Areas of Concern
 TB cases continue to be reported
in every state
 Drug-resistant cases reported
in almost every state
 Estimated 10-15 million persons in
U.S. infected with M. tuberculosis
 Without intervention, about 10% will
develop active TB disease at some
point in life
TB Morbidity Trends in the USA
 From 1953-1984, reported cases
decreased by an average of 5.6% a year
 From 1985 to 1992, reported TB cases
increased by 20%
 Since 1993, reported TB cases have
been declining again:
 18,361 cases reported in 1998
 Decreased to 17,531 cases in 1999
Tuberculosis
in the United States
 30% decline in cases 1992-1999
 Increase in foreign-born cases
41% of cases in persons born outside US
 Concentration in few states
 50% of cases in 4 states
California
New York
Texas
Florida
Reported TB Cases
United States, 1953 - 1998
Cases (Log Scale)
100,000
70,000
*
50,000
*
30,000
20,000
10,000
53
60
* Change in case definition
70
80
Year
90
98
Cases
Reported TB Cases
United States, 1980-2000
28000
26000
24000
22000
20000
18000
16000
80
82
84
86
88
Year
90
92
94
96
98
00
TB Morbidity
United States, 1996-2000
Year
1996
1997
1998
1999
2000
*Cases per 100,000
Cases
21,337
19,851
18,361
17,531
16,377
Rate*
8.0
7.4
6.8
6.4
5.8
Reported TB Cases by State
United States, 1997 and 1998
Change
%
in Cases Change
1997
New York 2,265
California 4,056
1,992
Texas
Illinois
974
Florida
1,400
All Others 9,164
1998
2,000
3,852
1,820
850
1,302
8,537
-265
-204
-172
-124
-98
-627
-11.7
-5.0
-8.6
-12.7
-7.0
-6.8
19,851
18,361
-1,490
-7.5
State
Total
TB Case Rates by State
United States, 1998
D.C.
P.R.
<3.5 (Year 2000 target)
3.6 - 6.8
>6.8 (National average)
TB Case Rates, 2000
D.C.
Rate: cases per 100,000
< 3.5 (year 2000 target)
3.6 - 5.8
> 5.8 (national average)
TB Case Rates
by Age Group and Sex, USA, 2000
20
15
10
5
0
<15 yrs
15-24 yrs
25-44 yrs
Male
45-64 yrs
Female
65+ yrs
Number of TB Cases in USA, 1992-2000
US-born vs. Foreign-born Persons
20000
15000
10000
5000
0
1992 1993 1994 1995 1996 1997 1998 1999 2000
US-born
Foreign-born
Percentage of TB Cases
Among Foreign-born Persons
1992
2000
>50%
25%-49%
<25%
Global Tuberculosis: 2000




7.8 million incident cases
1.8-2.4 million deaths
Co-epidemic with HIV in Africa, Asia
MDRTB in former USSR, South
America and other pockets
 Concentration of cases in few
countries
22 countries with 80% of cases
www.hopkins-tb.org
Trends in TB Cases in Foreign-born
Persons, United States*, 1986-1998
45
14,000
35
12,000
30
10,000
25
8,000
20
6,000
15
10
4,000
5
2,000
0
0
Number of Cases
Percentage of TB Cases
40
16,000
Percentage of Cases
Number of Cases
86 87 88 89 90 91 92 93 94 95 96 97 98
Year
* Comprises the 50 states, the District of Columbia, and New York City
Country of Origin of Foreign-born
Persons with TB, United States,1998
Other*
36%
Mexico
23%
South Korea
3%
Haiti
4%
Philippines
13%
*Includes 149 countries
Republic of China
5%
India
Vietnam 7%
10%
Drug Use and TB
 Persons who inject drugs are
at high risk for:
- HIV disease
- Developing active TB if infected
 Crack cocaine has been associated
with the transmission of HIV and TB
HIV
Related
Increase
Tuberculosis
 Multiple Drug Resistant TB
 Related to HIV AIDS and non-compliance
 Some strains resistant to up to 8 drugs
 Virulent TB (NEJM 1998;338:633-9)
 21 cases in non-TB endemic areas between 1994
and 1996
 Apparently spread by casual contact
 Growth characteristics exceeded other clinical
isolates
www.hopkins-tb.org
Drug-Resistant TB
 Drug-resistant TB transmitted same
way as drug-susceptible TB
 Drug resistance is divided into two types:
 Primary resistance develops in persons
initially infected with resistant organisms
 Secondary resistance (acquired
resistance) develops during TB therapy
www.hopkins-tb.org
Factors Contributing to the Increase
in TB Morbidity: 1985-1992
 Deterioration of the TB public health
infrastructure
 Decreased funding for surveillance and
treatment programs
 Poverty and crowding in urban centers
 HIV/AIDS epidemic
 Immigration from countries where TB is
common
 Transmission of TB in congregate settings
www.hopkins-tb.org
Factors Contributing to the Decrease
in TB Morbidity Since 1993
Increased efforts to strengthen TB control
programs that
•
Promptly identify persons with TB
•
Initiate appropriate treatment
•
Ensure completion of therapy
www.hopkins-tb.org
MDR TB Cases, 1993 - 1998
None
> 1 case
Diagnosis of TB
Diagnosis of Active TB
 History and epidemiologic clues





Think TB!!!
Chest X-ray
Tuberculin skin test
AFB smear
AFB culture
Nucleic acid amplification
Fast but sensitivity poor in smear neg.
 Empiric treatment trial
AFB Smear
AFB (shown in red) are tubercle bacilli
Cultures
 Use to confirm
diagnosis of TB
 Culture all specimens,
even if smear negative
 Results in 4 to 14 days
when liquid medium
systems used
Colonies of M. tuberculosis
growing on media
Testing for
TB Disease and Infection
All Testing Activities Should Be Accompanied
By a Plan for Follow-up Care.
Administering the Tuberculin Skin Test
 Inject intra-dermally:
 0.1 ml of 5 TU PPD tuberculin
 Produce wheal:
 6 mm to 10 mm in diameter
 Do not recap, bend,
or break needles,
or remove needles
from syringes
 Follow universal
precautions for
infection control
Reading the Tuberculin Skin Test
 Read reaction:
 48-72 hours
after injection
 Measure only
induration!
 Record reaction
in millimeters
Factors that May Affect the
Skin Test Reaction
Type of Reaction
False-positive
False-negative
Possible Cause
Non-tuberculous mycobacteria
BCG vaccination
Anergy
Recent TB infection
Very young age (< 6 months old)
Live-virus vaccination
Overwhelming TB disease
Anergy
• Do not rule out diagnosis based on negative
skin test result
• Consider anergy in persons with no reaction if
- HIV infected
-
Overwhelming TB disease
Severe or febrile illness
Viral infections
Live-virus vaccinations
- Immunosuppressive therapy.
• Anergy skin testing no longer routinely
recommended
Drugs for Tuberculosis
 First line drugs (active against wild type)
Isoniazid (INH or I)
Rifampin (RIF or R)
Pyrazinamide (PZA or Z)
Ethambutol (EMB or E)
Streptomycin (Strept or S)
 Second line drugs (for drug resistant strains)
- PAS - Capreomycin - Kanamycin
- Ethionamide - Quinolones
www.hopkins-tb.org
Second Line Drugs
for Tuberculosis
PAS
Cycloserine
Ethionamide
Injectables
Capreomycin
Kanamycin
Amikacin
Quinolones
GI toxicity
CNS toxicity
GI toxicity
Vestibular, renal toxicity
Vestibular, renal toxicity
Auditory, renal toxicity
GI, CNS and skin toxicity
www.hopkins-tb.org
Latent Tuberculosis
• Infection with M. tuberculosis
organisms that have been adequately
contained by host defenses
• But that retain the
capacity to replicate
and cause disease
at a future date.
Importance of
Latent Tuberculosis
• Infection with TB is a 2-step process
• Active disease is invariably preceded by
latent infection
• About 70% of TB arises from remote
infection
• Latent infection can be treated with
antibiotics which reduce the risk of future
reactivation
• TB control and elimination strategies
depend on treatment of latent tuberculosis
www.hopkins-tb.org
Targeted Tuberculin Testing and
Treatment of Latent TB
• Tuberculin testing should only be
performed on people at high risk of
disease, who would be treated
should they test positive
• Patients at high risk with a positive
tuberculin test should be treated for
latent tuberculosis regardless of age
www.hopkins-tb.org
Who Should be Screened for Latent TB?
• People likely to have recently been
infected
– Contacts of infectious cases, health care
workers, prisoners
• People from high prevalence areas
– Immigrants from endemic areas (<5 years)
– Residents of inner cities or other high-risk
areas
• People with medical conditions conferring
increased risk of reactivation of latent TB
– HIV infection or other immunosuppression
– Renal failure, diabetes or silicosis
– Injection drug use
www.hopkins-tb.org
Who Should Not be Screened
for Latent TB?
• People with no risk factors
for TB:
–
–
–
–
Food industry workers
Public employees
Schoolchildren
Healthy adults
www.hopkins-tb.org
Problems in Diagnosing
Latent Tuberculosis
• Lack of a gold standard in humans
• Distinguishing infection with TB from
NTM and BCG
• Distinguishing latent infection from active
disease
• Sensitivity, specificity and predictive value
of tests
• Identification of infected individuals likely
to develop active disease
www.hopkins-tb.org
Tuberculin PPD for
Diagnosis of Latent TB
•
•
•
•
•
Strengths
Standardized
Extensively
validated
Safe
Relatively cheap
It’s the best we’ve
got
•
•
•
•
•
•
Weaknesses
Specificity
Anergy
Application errors
Reading errors/bias
Requires
needles/syringes
Old and crude
www.hopkins-tb.org
Appropriate Use of the
Tuberculin PPD Test
•
•
•
•
Apply 5 TU (0.1 ml) by Mantoux method
Self-reading no better than coin toss
Measure induration at 2-3 days
Positive tests remain positive for up to
7-10 days
• Two-step test only recommended if
repeated exams anticipated (e.g.,
HCWs)
www.hopkins-tb.org
Interpretation of PPD
Skin Test Results
• Positive-predictive value of PPD skin
test is dependent on the prevalence of
TB infection in the population tested
• Different cut points are used depending
on the risk of TB infection in the
population being tested:
 > 5 mm for highest risk groups
 > 10 mm for persons with other risk factors
 > 15 mm for persons with no known risk factors
Treatment of Latent TB Infection (LTBI)
Treatment of TB Disease
Directly Observed Therapy (DOT)
• Health care worker watches patient
swallow each dose of medication
 Consider DOT for all patients
 DOT should be used with all
intermittent regimens
• DOT can lead to reductions in relapse
and acquired drug resistance
• Use DOT with other measures to
promote adherence
www.hopkins-tb.org
Drugs for Treating
Latent Tuberculosis
 Isoniazid
 Rifampin
 Isoniazid and rifampin
 Rifampin and pyrazinamide
 Rifabutin (+ isoniazid or
pyrazinamide)
 Rifapentine and isoniazid
www.hopkins-tb.org
Problems with Isoniazid Therapy
for Latent TB
• Adherence with long
duration of therapy
• Toxicity
• Isoniazid-resistant
infection
www.hopkins-tb.org
Fundamentals of
TB Infection Control
• Assign responsibility
• Conduct a risk assessment
• Develop, implement and enforce TB
policies for:
- Early identification of TB
- Evaluation and diagnosis
- Timely referral for anti-TB treatment
• Initiate and maintain TB isolation for
patients who may be infectious for TB
Cough Producing and
Aerosol-Generating Procedures
• Do not perform these procedures on patients who
may be infectious for TB unless absolutely
necessary
• Perform these procedures in a room that meets
ventilation requirements for TB isolation
• Wear respiratory protection when performing
these procedures
• Isolate patient after procedure until no longer
coughing
• No evidence of TB transmission via aerosol
generated from dental handpiece
Identifying Patients Who
May have Active TB
• Develop, implement and enforce protocols
for early TB detection
• Base protocols on the characteristics and
number of patients seen in the facility
• Consider the diagnosis of TB in patients
with signs and symptoms
• Suspect TB more readily in at risk
populations
• Evaluate TB protocols periodically
TB
Isolation Room
• Designed to prevent the escape
of droplet nuclei from the room
Single patient room
Negative pressure (monitored
daily)
Closed door
Negative Pressure Room
With In-Room HEPA Filtration
TB
Isolation Room
Reduce the concentration of droplet nuclei
> 6 air changes/hour for existing rooms
> 12 air changes/hour for new
construction
Exhaust air directly to outside or through
HEPA filter if recirculation unavoidable
Consider supplemental UV germicidal
irradiation (UVGI) or air recycled through
HEPA filtration
Tuberculosis
Infection Control Hierarchy
Administrative
Controls
• Assess TB risk and develop appropriate
written protocols based on the risk
assessment
• Implement and enforce effective work
practices
• Educate, train and counsel HCWs about
TB
• Screen HCWs for TB infection and disease
when indicated
Engineering Controls
High Efficiency Particulate Air (HEPA) Filtration
• To reduce or eliminate infectious droplet
nuclei, HEPA filters may be used in:
- Exhaust ducts from booths or enclosures
- Units to recirculate air within a room
- Portable cleaners
- Exhaust ducts discharging air to the outside
- Ducts discharging air from TB isolation room
• Filters should be installed carefully and
meticulously maintained
Engineering Controls
Ultraviolet Germicidal Irradiation (UVG)
• May be used as an adjunct to ventilation in
general use areas to reduce the
concentration of infectious droplet nuclei
• May be installed in upper portion of room
or corridor or in ducts
• Should be installed properly and
maintained adequately to reduce hazards
to HCWs and ensure proper function
Personal Respiratory Protection
• Use in settings where exposure to
M. tuberculosis may still occur:
TB isolation rooms
Rooms in which aerosol-generating
or cough-inducing procedures are
performed
Other selected settings identified by
the risk assessment
Respiratory Protection
• Personal respiratory protection
should be used by persons:
Entering rooms which contain patients
with suspected or confirmed infectious TB
When performing aerosol-generation or
cough inducing procedures on patients
with suspected or confirmed infectious TB
When engineering or administrative
controls are not likely to protect from
inhaling droplet nuclei
Respiratory Protection
Standard Performance Criteria
• The ability to filter 1um particles with a filter
efficiency of > 95% in an unloaded state with
flow rates of up to 50 L/min
• The ability to be fit tested in a reliable way to
obtain a face-seal leakage of < 10%
• Be available in different sizes to fit all HCWs
• The ability to be checked for facepiece fit in
accordance with OSHA standards by HCWs
before each use
Screening HCWs for
Latent TB Infection
• Use risk assessment to identify
HCWs who have the potential for
exposure to M. Tuberculosis
• Consider including other HCWs
who are from high risk groups
• Perform baseline testing upon
employment
Screening HCWs for
Latent TB Infection
• Exempt HCWs who have a previous positive
PPD test
• Exempt HCWs with TB infection or disease
who have been adequately treated and are
assymptomatic
• Repeat PPD testing at regular intervals as
determined by risk assessment
• Administer, read and interpret PPD results
according to current guidelines
• Record results in employee record
• Maintain confidentially
Interpretation of PPD
Skin Test Results
• Positive-predictive value of PPD skin
test is dependent on the prevalence of
TB infection in the population tested
• Different cut points are used depending
on the risk of TB infection in the
population being tested:
 > 5 mm for highest risk groups
 > 10 mm for persons with other risk factors
 > 15 mm for persons with no known risk factors
OSAH TB Inspection
Scheduling and Scope
• CDC has identified the following
workplaces as having high incidences of
TB:
–
–
–
–
–
Healthcare Facilities
Correctional Institutions
Homeless Shelters
Long-term Care Facilities for the Elderly
Drug Treatment Centers
Inspection Scheduling
and Scope
• Health care facilities include hospitals where
patients with confirmed or suspect TB are
treated or to which they are transported
• Coverage of non-health care setting includes
only personnel present during performance
of high hazard procedures on suspect or
active TB patients
• Dental health care personnel are covered
only if they treat suspect or active patients in
a hospital, correctional facility, or as part of
their practice.
General Duty Clause
Section 5 (a)(1) of the OSH Act states:
“Each employer shall furnish to each of
his employees employment and a place
of employment which are free from
recognized hazards that are causing or
are likely to cause death or serious
physical harm to his employees”
General Duty Clause (Continued)
 Four required elements necessary for
issuing general duty clause violations
include:
– The employer failed to keep the workplace
free of a hazard to which employees of that
employer were exposed
– The hazard was recognized
– The hazard was causing or was likely to
cause death or serious physical harm
– There was a feasible and useful method to
correct the hazard
Respiratory Protection
• Respirators shall be provided by the
employer when such:
– equipment is necessary to protect the
health of the employee
– equipment is applicable and suitable for
the purpose intended
The establishment and maintenance of the
respiratory protective program shall be
the responsibility of the employer
Respiratory Protection
• The 1994 CDC Guidelines specify the
following criteria for respirators for exposure
to TB:
– Ability to filter 1 micron in size in the
unloaded state with a filter efficiency greater
than 95%;
– ability to be qualitatively or quantitatively fir
tested in a reliable way to obtain face-seal
leakage of less than 10%
Dental Offices
“….No specific dental procedure
has been classified as cough
inducing!
In light of these observations
the following additional
considerations appear
prudent in dental settings:
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
Risk of Occupational
TB Transmission
Private Dental Offices
• Considered minimal
• Follow CDC/ADA
guidelines
• No OSHA regulations
(to date)
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
TB
Guidelines
• During initial medical history and
periodic updates DHCW should:
 Routinely ask all patients
about a history of TB;
 And signs and
symptoms
suggestive of TB
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
TB
Guidelines
• All elective dental care should
be deferred until a physician
determines:


That the patient doesn’t have TB ;
or
Anti-TB therapy has
been rendered and the
patient is no longer
infectious!
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
TB
Guidelines
 If urgent care must be provided for
a patient with active TB or signs &
symptoms suggestive of TB,
 TB isolation practices
should be implemented
 DHCW should use appropriate respiratory
protection while performing procedures on
these patients
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
Emergency Dental Treatment
for TB Patients
 Perform treatment in facilities with TB isolation
capability
 Use recommended respiratory protection
 Fit tested HEPA filter mask
 Select least invasive treatment options
 Accomplish definitive care after patient isno
longer infectious
 Sputum Negative for Acid Fast Bacillus (AFB)
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
Tuberculosis
 Dental-care in “high risk” facilities
 Use engineering controls similar to those in
general use areas of medical facilities with
similar risk profile.
 Evaluation of Dental HCW TB symptoms
 Evaluate promptly
 Do not return to clinic until:
 TB Diagnosis is ruled out or;
 DHCW is on therapy and non-infectious
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
CDC/ADA Dental Office
TB Recommendations
• Perform initial and periodic health
assessment
• Initial and periodic questions
about TB, S & S of TB, and/or
exposure to TB in health history
• Postpone elective dental treatment!
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
CDC/ADA Dental Office
TB Recommendations
• Perform urgent dental care in facilities
with isolation rooms
• Utilize indicated engineering,
administrative and infection control
practices
• DHCW with persistent cough should be
evaluated for TB
• Infection control program to include
written TB plan
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
CDC/ADA Dental Office
TB Recommendations
Written Plan Should Include:
 Protocol for referring TB patients
to dental isolation facility
 Protocol for identifying and referring
patients for medical evaluation for TB
 DHCW education, training, counseling
and screening
 Periodic risk assessment and updates
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
TB
Guidelines
• DHCW who are employed in a
facility where there is a likelihood
of exposure to active TB should
be included in an employer
sponsored PPD
testing program
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
CDC/ADA Dental Office
TB Recommendations
• Perform initial and periodic
assessment
• Initial and periodic questions
about TB in health history
• Postpone elective dental
treatment
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Facilities, MMWR; October 28, 1994 / 43(RR13);1-132
Questions
and
Answers
Louis G. DePaola, DDS, MS
410-706-7628
[email protected]
Selected Biobiography
1.
2.
3.
4.
5.
Guidelines for Preventing the Transmission of Mycobacterium
tuberculosis in Health-Care Facilities, MMWR; October 28,
1994 / 43(RR13);1-132
www.hopkins-tb.org
Bartlett J and Gallant J. Medical Management of HIV Infection,
2001-2002 Edition, Publisher: Johns Hopkins University School
of Medicine, Department of Infectious Diseases, Baltimore, MD.
Department of Health and Human Services (DHHS).
USPHS/IDSA Guidelines for the Prevention of Opportunistic
Infections in Persons Infected with Human Immunodeficiency
Virus. July 2001. Available for download at:
http://www.hivatis.org.
Infection Control Guidelines: September,1997; Organization for Safety &
Asepsis Procedures (OSAP); available for download at
http://www.osap.org/resources/IC/icguide97.htm.