The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#195 Infection Control Alert - Tuberculosis Outbreak in Kansas
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In this episode, the Compliance Divas discuss the ongoing tuberculosis outbreak in Kansas City, KS and why dental professionals should evaluate their patient screening protocols to prevent potential exposures during dental treatment. Learn the difference between active tb disease and latent tb, risks of transmission for the public vs. dental health care workers, and identify resources for additional information regarding tuberculosis.
Resources:
- US News and World Report – Kansas: TB Outbreak is Largest in History. CDC: No It’s Not https://bit.ly/4hoGEQB
- Time Magazine - The Tuberculosis Outbreak in KS is Alarming. Here's What the CDC Has to Say https://bit.ly/3CERNxF
- CDC Tuberculosis - https://www.cdc.gov/tb/index.html
- CDC MMWR Outbreak of Multidrug-Resistant Tuberculosis 2021-2022 https://bit.ly/4aMUOZx
- CDC Signs and Symptoms of Tuberculosis https://bit.ly/4gqXwov
- City of Long Beach, CA Press Release May 2024 - Localized TB Outbreak https://bit.ly/3wF5Os1
- CDC Guidelines for Infection Control in Dental Healthcare Settings - 2003 https://www.cdc.gov/mmwr/pdf/rr/rr5217.pdf
Welcome! I'm Leslie Catham.
SPEAKER_02I'm Mary Gavoni. I'm Linda Harvey. I'm Olivia Juan. And together we are the Compliance Divas. Welcome to the Compliance Divas podcast. I'm Mary Gavoni and I will be the moderator for this episode. The Divas today are going to discuss an outbreak of tuberculosis in the state of Kansas that has had some sort of alarming headlines. We're going to have some clarification about that. And we're going to also touch on what kind of communication we can expect going forward from our favorite, most trusted source of infection prevention information, the Center for Disease Control and Prevention. The Compliance Divas bring clarity and simplicity to you by navigating the regulatory world to keep you on course. You can subscribe to the Compliance Divas podcast through your favorite podcast channel or on the Compliance Divas website, thecompliancedivas.com. The resources we mentioned during this episode can be found in the show notes on your podcast app. Please, when you're finished listening, scroll down to the end of the episode and leave us a review or some comments. And you can submit questions to us through our email support at the compliancedevas.com. So many of our listeners, as well as the Compliance Divas, have been watching the headlines about the largest outbreak in U.S. history of tuberculosis in Kansas, specifically in Kansas City, Kansas. But is it really the largest outbreak or not? And we're going to ask our diva Linda to start us off with that clarification and also to give us some really important information about the difference between active TB and latent TB.
SPEAKER_00Mary, I would love to qualify that fact that you just mentioned because there was some confusion. And it's actually these cases in Kansas City are actually the largest ongoing outbreak in the US over a one-year period, not in history in general. So it's over a one-year period. And that's still very concerning, Mary, because there's already been two deaths. And we think about that just since been, you know, since last year in January. But I'd like to break it down and share with our listeners the number of active cases that are active cases of TB and those that are latent infections, because there's a difference. And it's important that we understand that in working with patients day in and day out. So since 2024, there's been 64 cases, and it's broken down into two main categories, whether it's latent or active cases, Mary. The Wyandotte County has 60 cases of active TB cases, while Johnson County has seven. And those as we we talked about before the show, identifying for those of us that don't live in Kansas, those are the two counties associated with the downtown area. While those same two counties have or then the largest outbreak as well of associated latent infections since 2024. And that is 77 cases in Wyandotte County and two cases in Johnson County. So those numbers may not seem like a lot, Mary, but when you compare across the country and the fact that these are, this is a significant outbreak for just us to be aware of. So I'm so glad we're bringing this to our listeners' attention. Because we work very closely with patients in a dental setting, and oftentimes we can have the false sense of security that a level three mask is protecting us from every single virus, germ, bacteria that walks in the door, especially when we're working so closely in the patient's mouth for extended periods of time. So let's take a moment to distinguish between latent infection and active TB disease. So when you think about something being latent or latent TB infection, that can be confusing because, like, well, what does it mean? How is it different from active? Well, it's very different because in this case, Mary, individuals have inactive bacteria. It's alive, but it's not active in their body. So they are not actually sick. They don't have any symptoms like somebody with active TB. They're not contagious. And to be diagnosed, that's usually detected through a positive TB skin test or maybe even a blood test. So they're walking around with these T bacteria that's alive in their body, but it's inactive. That's what latent means. And there's a risk of progression as someone ages or they could possibly develop TB later in life, especially if their immune system weakens. And thinking about just the immune system in general, that does have a tendency to weaken as one gets older. And given the fact that any other active disease or medication someone can be taking could also weaken their immune system. Now, to compare latent with active TB, you do have symptoms when you have an active case of TB. And you are contagious. So when somebody walks in your practice and they're coughing everywhere, sneezing, and they can't seem to control it. And they may think they're just having a reaction or they may think it's allergies. We always try to have a socially polite response or excuse for sneezing and sniffing because we don't want someone to think we're sick, especially if you don't want to cancel that dental appointment. But there's active bacteria in this patient. They're actively multiplying, they're actively causing this disease. And Mary has to be diagnosed through the symptoms, like a positive TB skin test, a blood test, sputum samples, or even a chest x-ray. So it's very important that if you someone has a cough or we have a patient who's having what seems to be TB symptoms, and I think Leslie's going to talk to us about that in a few minutes, that we be very careful as healthcare professionals. Because years ago, Mary, when I was working in the medical arena with risk management, we had a few employees that were exposed to a pediatric patient who had an active case of TB. So we counted it as a workforce-cont case and sent them to get evaluated and follow that protocol, just like we do for a post-exposure protocol for a needle stick or poke or scrape. So a lot of things to think about with this. It's not just a brush it off, throw on a mask, and business as usual, Mary. So thanks for bringing this topic up today.
SPEAKER_02Thank you, Linda. And the other interesting thing to note about Kansas City is that this isn't the first outbreak in recent years. There was one in 2021 and one in 2017. So obviously there are some issues, and it could be related to, I think at least one of those was related to homeless shelters. It could be homeless population. We don't know for sure. And Kansas Health Department officials have not said what the source of this infection is at this point. They may still be evaluating and investigating. So it is important. And those of us that have been around in dentistry for a while, like the three of us or the four of us divas, know that in the 1990s and the 2000s, we had a resurgence of tuberculosis and we had multidrug-resistant tuberculosis, which then pushed the CDC to issue some directives to us about how we work with those patients. So our California diva Leslie is going to talk about an outbreak that happened also in 2024 in California. And then she will be filling in today for our diva Olivia, who is lecturing at the ADS boot camp, and talk about signs and symptoms of TB.
SPEAKER_01Mary, there was an outbreak in May of 2024. The local public health department declared an emergency to strengthen the city's preparedness to respond to this localized TB outbreak. And the outbreak was isolated to a district population. And the risk to the general public, of course, was low, but the population at risk in this outbreak had significant barriers to care, including homelessness, housing insecurity, mental illness, substance abuse, and serious medical comorbidities. And so about the outbreak, there were several individuals associated with what was a single room occupancy hotel in Long Beach. And there was someone that was identified that had TB disease. Back in April of 2024, there were 14 cases of TB disease associated with this particular outbreak. Nine of those cases, people were hospitalized at some point in their illness, and one person actually died. So again, to protect the privacy and follow HIPAA regulations, the public health department did not disclose the name of that hotel. But through the course of the investigation, the staff at the public health department identified that there were approximately 170 people who had likely been exposed to TB, and they were in the process of contacting them to get that blood test or skin test and chest x-ray. Those two were found to have active TB or latent TB infection, are going to be provided treatment. So it's interesting that this is something that has been on our radar recently. And just to kind of qualify a number of cases, in the United States, there isn't a large number of cases. If you could say that under 10,000 people, considering the population of the United States, is not really large. There was a low number of individuals, like so there was around 9,633 cases in 2023 or 2022 that we could document. But there was a lower number in in 2019 to 2020, where it fell by 19% to 7,170 cases. And you know, another thing I wanted to point out is regarding that case that was uh in Kansas, you mentioned, Mary, that there was an earlier outbreak, and that was in 2021, 2022. It was a multi-drug-resistant tuberculosis, which is uncommon and unusually occurs in the United States of U.S.-born citizens, and they're very much unlikely to get infection. But when other individuals come in from other countries, that's where they may be bringing this bacterium. So this multidrug resistant TB outbreak involved 13 people with active disease and nine with latent or inactive TB infections that were identified within four Kansas households in 2021, and included multiple US-born children who became infected in Kansas. One person in a neighboring state with an epidemiologic connection to the Kansas outbreak was also identified. Thank you, Leslie.
SPEAKER_02And we'll have you continue in Olivia's place. As I said earlier, she is lecturing and representing the compliance divas at the ADS boot camp this week. So can you explain for us what are signs and symptoms of TB? What is the risk to the public versus the risk to dental health care professionals?
SPEAKER_01Oh, absolutely, Mary, and I'll shout this out for Olivia today. The signs and symptoms of TB. So symptoms of active TB depend on where the TB germs are growing in the body. So common symptoms of active TB include cough, pain in the chest, and coughing up blood or sputum. People with inactive TB, also called latent infection, do not have any symptoms of TB disease and cannot spread the TB bacterium to others. So let's take a look at the signs and symptoms of what we could see if there was an active TB case. And I just want to remind everyone in California our OSHA requirement for OSHA compliance is there's an aerosol transmissible disease standard. And dental practices can be exempt from this standard, unlike bloodborne pathogen standard or hazard communication standard. The ATD standard says if you screen patients for aerosol transmissible diseases, then you can be exempt from this standard. But you have to screen, you have to have written plans in your injury and illness prevention program, and you have to train your team on how to screen for aerosol transmissible diseases. And what's an interesting point, Mary, is that they use the 2003 CDC guidelines for dental health care settings with the recommendations on how to screen for TV, as how they recommend that we screen our patients in California to be exempt from the standard. So, what would be the signs that we'd be screening from? Well, it could be an active TB disease that's in the lungs may cause these symptoms, such as a bad cough that lasts three weeks or longer, pain in the chest, toughing up blood or sputum, as I mentioned earlier. But other symptoms of active TB could be weakness or fatigue, weight loss, no appetite, chills, fever, and sweating at night. And symptoms that may be indicative of active TB in other parts of the body, again, depend on where that and the body is affected. So TB disease of lymph nodes may cause red or purple swelling under the skin. TB disease of kidney may cause blood and urine. TB meningitis, that's TB disease of the brain, may cause headache or confusion. TB disease of the spine may cause back pain. And TB disease of the larynx may cause hoarseness. Now, when people in dentistry, our screening patients, of course, recognize that if you've been exposed to someone who does test positive for TB, then you need to take precautions yourself. And the CDC guidelines recommend that we take precautions in advance by if we are in a community where there's a high risk of TB infection, higher than other parts of the country, and you can check with your public health department to find out if your community is among those, then you should actually have a tuberculin skin test to do a baseline to determine whether you have ever been exposed to TB and maybe you have latent TB, but it's also in use if you've been exposed to determine if the disease has progressed. So the CDC guidelines from 2003 are a very good document to have in your practice to include in your injury and illness prevention plan with your written plans on TB and also how to screen for aerosol transmissible diseases.
SPEAKER_02Excellent job, Leslie, explaining that. And we tend to think of tuberculosis infections primarily in the lungs, and that poses the greatest risk to us in dentistry, but there are other forms of tuberculosis. The bottom line is that every dental practice, because of our exposure to aerosols and aerosol transmissible diseases, should have a TB screening protocol. It should be part of the questions that are asked on the health history. And if someone says they've had TB in the past, we might want to have a medical consult and get a little bit more information. As Linda said, that even if you have latent disease, it can recur. And so we just need to be cautious and make sure that we are following appropriate treatment protocols. If you have a patient that you suspect has tuberculosis based on symptoms, the prolonged cough, and if they tell you they've coughed up blood, hopefully the alarm bells are going off. And you know that you shouldn't do any treatment on that patient until they have been evaluated by someone at your local health department or a primary care physician, had a medical evaluation. And the only type of treatment that you might provide to somebody in that case would be emergency palliative treatment. If you are going to do that, it may be easier to have that patient treated in the hospital just like we saw during COVID in a TB isolation room. But if it was very short duration, maybe you were going to reseat a crown that came unseated, wearing an N95 mask and only wearing an N95 mask, no level three masks, N95 masks. And the other issue is that the CDC in around 2017 updated some of their tuberculosis screening guidelines. And that includes a screening TB test, as Leslie said, a baseline upon hire, but before actually working in a practice. And many practices don't make that part of their onboarding protocol that you should have TB skin test. And if that person tests positive for active disease, they cannot work in a healthcare setting. Linda, you had something you wanted to add.
SPEAKER_00Mary, you raised the point about the medical history. And so that brings back to me, you know, from the risk management perspective, is we have to be asking the questions. Just because the patient was either presented with a paper copy to look at or complete or to review, or whether it's on a tablet, many times over, we're asking the patient leading questions. Are you still taking X medication? Are you still taking this? Is your is your health history still negative? Those are leading questions where we're not giving them a chance to say anything else else or being questioned in a way that, and I don't mean questioned in a negative way, of course, Mary, but it's questions or asked asking the patient, you know, what else has been going on in their life. And so I think it takes only just a few more seconds while you're placing the bib, doing your hand hygiene, so greeting the patient to ask those extra questions about coughing and symptoms. And as Rosalie mentioned, the respiratory screening that has to take place in California should be taking place all over the country.
SPEAKER_02Absolutely. Whether you have an outbreak like they do in Kansas City, or whether you're anywhere else in the country, you should be screening your patients. And we've sort of been preaching that all along for the last couple of years because we still have COVID and we still have RSV and we have other respiratory viruses. We just need to be screening our patients. Leslie, you wanted to share something.
SPEAKER_01Yes, I did. I wanted to also point out that it could be not the individual healthcare worker who might have been exposed that we need to be concerned with, sometimes a family member that has been diagnosed. And so if someone comes to work and says, oh, gee, I you know, I have a terrible news, one of my family members has TV and I was just at their house, then they should be considered one of the ones that are on work restriction until they get tested and cleared.
SPEAKER_02Oh, great point. And so many folks just don't understand that it is not appropriate, according to public health rules, for anyone with active TB disease to be working in a healthcare setting. And that doesn't mean just the clinical team, it means the business team as well, anywhere in a healthcare setting because of close proximity. So thank you all for joining us for this episode. We hope that this gives some clarity to the headlines that we're hearing. There is, in spite of what we've been hearing on the news about information not being available on the CDC website, it is true that the CDC is not publishing their weekly newsletter, the Morbidity Mortality Weekly Report, the MMWR. And currently the Health Alert Network, which we've talked about numerous times on this podcast, is not being utilized. But there is information about tuberculosis, there is information about other respiratory infections. So go to the CDC website, go to the Association for Dental Safety and go to your local and state health departments. That's one of your best resources to know what's going on in your community. So make sure that you contact those resources. All is not lost for now with information, but we may have to work a little harder to get it. So the compliance divas bring clarity and simplicity to you by navigating the regulatory world to keep you on course. If you have questions from this or any episode, please submit them by email to support at thecompliancedivas.com. The resources that we've mentioned today will be available in the show notes on your podcast app. And again, when you finish listening to the episode, scroll down to the end of the episode on your podcast app and leave us a review or give us a like or give us some comments. We'd appreciate your feedback. We'll see you next time.