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

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Presentation on theme: "Delayed TB Diagnosis Thomas R. Navin MD Chief, Surveillance, Epidemiology, and Outbreak Investigations Branch Division of Tuberculosis Elimination CDC."— Presentation transcript:

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

2 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?

3 Patients Evaluated for TB at CDC-funded Public Health Laboratories, 2008-2009 20082009% change Patients evaluated for TB 103,70897,568-5.9% Patients with cultures positive for M. tuberculosis 4,9724,217-15.2% Ratio of patients evaluated to patients diagnosed with TB 21 : 123 : 1

4 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 4 Measuring TB Diagnostic Delay

5 Months from Symptom Onset to Diagnosis (N=346) 5 RaceMean(SD)Median African-American4.4(6.1)2 White19.7(48.4)4 p=0.04

6 Months from Symptom Onset to First Medical Care: Patient Delay (N=346) 6 RaceMean(SD)Median African-American2.4(5.2)1 White9.2(29.5)1 p=0.8

7 Months from First Medical Care to Diagnosis: Provider Delay (N=346) 7 RaceMean(SD)Median African-American 2.2(3.5)1 White 4.5(4.5)1 p=0.4

8 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

9 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

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

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

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

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

14 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

15 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?

16 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

17 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

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

19 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

20 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

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

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


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