Delayed TB Diagnosis Thomas R. Navin MD Chief, Surveillance, Epidemiology, and Outbreak Investigations Branch Division of Tuberculosis Elimination CDC

Test of Baseline Knowledge How many patients are evaluated for TB each year in the United States? Are the number of persons evaluated going down or staying stable? Are delays in TB diagnosis getting worse? Are delays worse for racial/ethnic minorities?

Patients Evaluated for TB at CDC-funded Public Health Laboratories, 2008-2009 % change Patients evaluated for TB 103,708 97,568 -5.9% Patients with cultures positive for M. tuberculosis 4,972 4,217 -15.2% Ratio of patients evaluated to patients diagnosed with TB 21 : 1 23 : 1

Measuring TB Diagnostic Delay Preliminary Results from TBESC Task Order 23: National Study of Early Diagnosis of TB in the African-American Community Co-Principal Investigators: Dolly Katz, Ph.D., CDC Rachel Royce, Ph.D., M.P.H., RTI International Charles Wallace, Ph.D., Texas Department of Health

Months from Symptom Onset to Diagnosis (N=346)  Race Mean (SD) Median African-American 4.4 (6.1) 2 White 19.7 (48.4) 4 p=0.04  

Months from Symptom Onset to First Medical Care: Patient Delay (N=346)  Race Mean (SD) Median African-American 2.4 (5.2) 1 White 9.2 (29.5) p=0.8  

Months from First Medical Care to Diagnosis: Provider Delay (N=346)  Race Mean (SD) Median African-American 2.2 (3.5) 1 White 4.5 (4.5) p=0.4  

Summary of Findings from Task Order 23: Study of Patient and Provider Delay Snap shot in time (rather than trend over time) Both patient and provider delay observed Delay not worse for African Americans compared with whites

Number of Outbreaks where item was considered a contributing factor Contribution of Provider Diagnostic Delay to 27 TB Outbreaks Investigated by CDC* Contributing factors Number of Outbreaks where item was considered a contributing factor Prolonged infectious period 24 Provider-related diagnostic delay 12 Patient-related delay in access to care 6 * From: Mitruka et al., EID 2011;17(3):425

National TB Surveillance System: Trends in culture-positive, smear-negative pulmonary TB

Data from Recent TB Outbreak Cases by sputum smear status TB Cases Treatment Start Date

Culture-confirmed Pulmonary TB by Sputum Smear Status, United States 2000-2009 Smear negative TB Cases Smear status unknown/not done

Proportion of Pulmonary TB Cases Proportion of Pulmonary TB Cases* That Are Sputum Smear-Negative, United States, 2000-2009 Culture-positive TB cases

Proportion of Pulmonary TB Cases Proportion of Pulmonary TB Cases* That Are Sputum Smear-Negative, by Race/Ethnicity United States, 2000-2009 TB Case Count Date * Culture-positive TB cases

Test of What You Have Learned How many patients are evaluated for TB each year in the United States? Are the number of persons evaluated going down or staying stable? Are delays in TB diagnosis getting worse? Are delays worse for racial/ethnic minorities?

Test of What You Have Learned How many patients are evaluated for TB each year in the United States? 100,000 persons evaluated each year at public health labs alone Ratio of evaluated-to-diagnosed: 20+ Are the number of persons evaluated going down or staying stable? Number is going down, but ratio of evaluated-to-diagnosed may be going up

Test of What You Have Learned Are delays in TB diagnosis getting worse? Data are not good, but no evidence of worsening Are delays worse for racial/ethnic minorities? Data are not good, but no evidence of a difference

Getting Physicians to “Think TB” is asking them to look for a needle in a haystack

Can Physicians be Educated to “Think TB”? As TB rates decline, general medical expertise and education targeted at TB will decline Untargeted campaigns may not be successful “Think TB” campaigns may have impact in targeted situations: In high-risk communities During outbreaks

Can Physicians be Educated to “Think TB” Can Physicians be Educated to “Think TB”? Challenges During TB Outbreaks Most media stories about TB “outbreaks” describe contact investigations at schools Most contact investigations at schools do not detect additional TB cases Health Departments often work hard to keep information on large TB outbreaks out of media

Outbreak-associated TB cases can make up a significant portion of TB cases in a community and can continue for years

Outbreak Associated TB Cases, 2002-2010 (N=109) No. of cases a As of August 2010