key: cord-0814915-yzebo1sh
authors: Narita, Masahiro; Hatt, Grace; Toren, Katelynne Gardner; Vuong, Kim; Pecha, Monica; Jereb, John A; Goswami, Neela D
title: Delayed Tuberculosis Diagnoses During the COVID-19 Pandemic in 2020 — King County, Washington
date: 2021-05-06
journal: Clin Infect Dis
DOI: 10.1093/cid/ciab387
sha: a30bea944a929613e19f288cacb062a724eabd4c
doc_id: 814915
cord_uid: yzebo1sh

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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 CDC and was conducted consistent with applicable federal law and CDC policy. 1 § Results for SARS-CoV-2 tests performed prior to TB diagnosis were available to TB public health officials for 40 (43%) patients with TB: three 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 COVID-19 affected their medical care. Four of them stated that their TB diagnosis had been delayed because of pandemic-related problems. Of these, three 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 two health-care providers. The stories of the following three patients who had prolonged respiratory illnesses with fever illustrate delays in TB diagnosis during the COVID-19 pandemic.

Patient 1. 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* Patient 2. A woman in her eighties, originally from a Southeast Asian country with a WHO-estimated TB incidence of >500 cases/100,000 persons* [1], was admitted to different hospitals four 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 three 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.

Patient 3. A woman in her fifties, originally from a Pacific Island nation with WHOestimated 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 February 15, 2021 [2] , has eclipsed TB, with its estimated 10 million cases and >1. 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 three patients described here came from countries with high incidence of TB. In None of the authors has any potential conflicts of interest to disclose. Note: A patient can have TB disease at the same time as COVID-19, or have one after another. Radiographic findings of pulmonary TB are also highly variable, and certain findings overlap with those often present in COVID-19. Clinicians should undertake medical evaluation for both conditions when appropriate.

WHO. Coronavirus Disease (COVID-19) Dashboard. Available at

Notes from the Field: Effects of the COVID-19 Response on Tuberculosis Prevention and Control Efforts -United States

Tuberculosis Outbreaks in the United States

The role of chest radiography in confirming covid-19 pneumonia

Developing health policies in patients presenting with SARS-CoV-2: consider tuberculosis