Delayed Tuberculosis Diagnoses During the Coronavirus Disease 2019 (COVID-19) Pandemic in 2020—King County, Washington

Abstract

In 2020, a total of 92 tuberculosis (TB) cases were reported in Seattle and King County, Washington, 5% fewer than the median of 97 (range = 94 –132) reported during the same period 2015–2019 and 30% fewer than 132 cases reported in 2019. Interviews and chart reviews were completed as part of a public health investigation. This activity was reviewed by Centers for Disease Control and Prevention (CDC) and was conducted consistent with applicable federal law and CDC policy. Results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests performed prior to TB diagnosis were available to TB public health officials for 40 (43%) patients with TB: 3 had a positive result; 37 had negative results, with 12 having been tested twice or more. We were not able to verify SARS-CoV-2 testing status or results prior to TB diagnosis for 52 TB cases. We attempted to reach out to all pulmonary TB cases diagnosed in March 2020 or later and were able to interview 29 patients by telephone or in person about how pandemic coronavirus disease 2019 (COVID-19) affected their medical care. Four of them stated that their TB diagnosis had been delayed because of pandemic-related problems. Of these, 3 waited to seek care because of fear of contracting COVID-19, and one, patient 1, was told that she probably had COVID-19 by at least 2 healthcare providers. The stories of the following 3 patients who had prolonged respiratory illnesses with fever illustrate the delays in TB diagnosis during the COVID-19 pandemic. A woman in her late teens, originally from an African country with a World Health Organization (WHO)–estimated TB incidence of > 80 cases/100 000 persons* [1], sought medical care 5 times starting in May 2020 because of cough, night sweats, and weight loss beginning in March 2020. She was tested for SARS-CoV-2 4 times with negative results. Chest radiography was not performed until June, when pulmonary TB was diagnosed with findings of bilateral extensive pulmonary opacities and cavities and numerous acid-fast bacilli (AFB) on sputum-smear microscopy. A woman in her 80s, originally from a Southeast Asian country with a WHO-estimated TB incidence of > 500 cases/100 000 persons* [1], was admitted to different hospitals 4 times beginning in May 2020 with multiple problems, including staphylococcal bacteremia, cognitive impairment, and lack of appetite. Bilateral diffuse opacities were reported on chest radiography in July, with aspiration pneumonia diagnosed. She was tested 13 times for SARS-CoV-2 with negative results, including 3 times ≤ 2 months before her TB diagnosis. In September, chest computerized tomography revealed diffuse bilateral interstitial reticular nodular infiltrates, characteristic of miliary TB, and she died 6 days after TB was confirmed by polymerase chain reaction for Mycobacterium tuberculosis in bronchoalveolar lavage fluid. A woman in her 50s, originally from a Pacific Island nation with WHO-estimated TB incidence of > 400 cases/100 000 persons* [1], sought medical care twice in July 2020 for cough, weight loss, fever, night sweats, and dyspnea that began in June 2020. The result of a SARS-CoV-2 test at each visit was negative. A chest radiograph at the second visit revealed right-upper-lobe opacities without cavities, but TB was not considered. She had been treated for TB disease in King County 7 years before, and she had poorly controlled diabetes, which predisposes patients to TB progression. Pulmonary TB was diagnosed in August, with worsening opacities and new cavities in the right-upper-lobe on chest radiography and numerous AFB on sputum-smear microscopy. Globally, COVID-19, with > 108 million cases and > 2.3 million deaths as of 15 February 2021 [2], has eclipsed TB, with its estimated 10 million cases and > 1.4 million deaths in 2019 [1]. Clinicians can miss TB in patients who have respiratory illness while the focus is on COVID-19, as shown by the examples in this report. Patients sometimes are delayed in seeking care either because they fear COVID-19 exposure or because access to healthcare is reduced. The response to the COVID-19 pandemic has diverted public health staff from TB control [3]. The decrease of TB reports in King County supports concern for more instances of late TB case detection; diagnostic delays worsen TB morbidity and mortality and increase M. tuberculosis transmission potential [4], especially because TB persists as a chronic contagious infection when the diagnosis is missed, in contrast to COVID-19, which self-resolves in the majority of cases. The 3 patients described here came from countries with high incidence of TB. In King County, 117 (87%) of the 134 patients with TB in 2019 were born outside the United States, and the incidence among non–US-born persons was 24.0 cases/100 000 persons, compared with 1.0 case/100 000 for US-born persons [5]. The onset of active TB disease can be insidious, compared with the acute onset of COVID-19, but the possible symptoms of cough, fever, and fatigue are similar between the 2 diseases. Although typical radiographic findings of COVID-19 pneumonia include multifocal peripheral consolidation, or ground glass or nodular opacites [6], classic manifestations of TB include fibronodular opacities in upper lobes often with cavitation. However, as the patient may present with atypical radiographic findings, clinicians should consider further medical evaluation (eg, sputum collection) when anyone with an epidemiologic risk factor for TB has radiographic abnormalities. Clinicians should also consider the possibility of simultaneous infection with SARS-CoV-2 and M. tuberculosis. For a patient who has cough for > 2 weeks with fever and weight loss and an epidemiologic risk factor (eg, origin in a country with high TB incidence), if the chest radiograph findings are suggestive of TB, a sputum bacteriology for M. tuberculosis, should be undertaken at the time of SARS-CoV-2 testing [7]. Comparison of Clinical Characteristics Between Symptomatic COVID-19 and Pulmonary Tuberculosis (TB) Note: A patient can have TB disease at the same time as COVID-19 or have one after another. Clinicians should undertake medical evaluation for both conditions when appropriate. HIV, human immunodeficiency virus; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. ahttps://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html. bhttps://www.cdc.gov/tb/publications/guidelines/testing.htm. chttps://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. dRadiographic findings of pulmonary TB are highly variable and might overlap with those often present in COVID-19. ehttps://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html. fhttps://www.cdc.gov/tb/publications/guidelines/testing.htm. *The US TB incidence was 2.7 cases/100 000 persons in 2019. CDC Disclaimer. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention. Supplement sponsorship. This supplement is supported by the Infectious Diseases Society of America through Cooperative Agreement NU50CK000574 with the U.S. Centers for Disease Control and Prevention. Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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