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TB Notes 1, 2004


Missed Diagnosis Leads to the Death of a 15-Year-Old in Detroit

On Wednesday, March 19, 2003, the Detroit TB Prevention and Control Program was notified by the Wayne County Medical Examiner’s Office of the death of a U.S.-born 15-year-old female foster child. The child died on March 1, 2003, and tissue specimens (lung and spleen) collected during the autopsy on March 2 were reported as positive for acid-fast bacilli (AFB). The laboratory results were available on March 19 and at that time the deceased was diagnosed with pulmonary and miliary TB. 

On March 20, a meeting was held at the request of the Medical Examiner’s Office with representatives from the Detroit TB Program, the Family Independence Agency (FIA), the Detroit Public Schools, and a foster child placement agency. During this meeting, the TB Control Program was informed by FIA that the child had been placed in foster care by the child placement agency in January 2002. This was her only placement; during most of 2001 she lived with an older sister. She had attended a middle school in suburban Detroit from September through November 2002 and later transferred to a school in the City of Detroit in January 2003, which she attended until her death. According to school records, her last day of attendance was February 21, 2003. During the meeting it was noted that the child had been under the care of a Detroit private physician and had been regularly examined during 2002. Medical record review revealed that signs and symptoms consistent with TB, including cough, weight loss, fever, fatigue, and possibly night sweats, had been exhibited by the child throughout 2002. However, neither a tuberculin skin test nor a chest x-ray had been ordered. Information shared in the meeting indicated that at various times the private physician had prescribed treatment for other respiratory illnesses. The last known visit to the private physician had been in early February 2003.

An official autopsy report was obtained by the Detroit TB Program, according to protocol, in order to initiate mandated follow-up, which included reporting the case to the Michigan Department of Community Health and to CDC and implementing the case investigation. The autopsy report indicated extensive damage to most major organs, in particular the lungs. According to the medical examiner who performed the autopsy, the lungs of the deceased were completely replaced by infection and were adhered to the chest lining and diaphragm. The lung damage could possibly have been evident on a chest x-ray at least 6 months prior to death. In addition, extensive cavities were indicated and were filled with necrotic granulomas. The Public Health Director of the Detroit Health Department submitted a written request to the Physician Licensing Board within the Michigan Department of Consumer and Industry Services to initiate an investigation of the private physician, in accordance with the Michigan Compiled Laws, to determine whether the life of this child could have been spared with the proper medical intervention. The deceased was neither a current nor a past patient of the Detroit TB Program.

After further examination and closer review of the autopsy findings, the Medical Examiner’s Office ruled the cause of death as homicide, based on the malnourished condition of the body. An investigation of the foster family as well as of the private physician is currently underway.

Contact Investigation/School Screening

The contact investigation conducted by the Detroit TB Program identified 26 contacts: 24 household and neighborhood contacts and 2 casual contacts. The close contacts consisted of the foster mother, foster siblings, case workers, and neighbors. The casual contacts consisted of neighbors who had limited contact with the patient. The biological parents of the deceased were notified for testing but did not respond; they had not had contact with their child in nearly 2 years. Three of the close contacts and two casual contacts were not tested. Sixteen (61.5%) of the 26 were tuberculin skin tested by the Detroit TB Program; 12 were negative, 3 were positive, and 1 had a normal chest x-ray (this individual was a known reactor). Five of the 26 were tested by their private medical provider; 4 tested negative and 1 had a normal chest x-ray (this individual was also a known reactor). The three with positive reactions were further evaluated by the medical staff at the Detroit TB Program; all three had normal chest x-rays and two of them were placed on treatment for latent TB infection.

The initial school screening was conducted by the Detroit TB Program staff at the most recent school that the deceased attended. Eighty-two students were identified; 74 as close contacts and 8 as casual contacts. Seventy (85.3%)  were screened and evaluated for M. tuberculosis infection. Sixty-seven (95.7%) tested negative and two (2.9%) tested positive. One student did not return for the skin test reading. Six students were tested by their private medical provider and all received negative readings. Six students were not tested. Eleven (11) faculty members were identified as close contacts to the deceased; all were tested by the Detroit TB Program and were negative.

The second school screening was conducted by the Oakland County TB Program staff,  a suburban county of the City of Detroit. The deceased attended this school for approximately 3 months before moving to Detroit. A total of 178 contacts were identified; 152 were students and 26 were members of the staff. Forty-two (23.6%) were tested for M. tuberculosis infection; one reactor (5 mm) was further evaluated and found to have a negative chest x-ray via private provider follow-up.

Lessons Learned

Family Independence Agency: The rules and regulations regarding routine TB screening and testing of foster care placements — the foster family as well as the child being placed — should be reinstituted. This would consist of tuberculin skin testing, with chest x-rays and full evaluations for persons with positive reactions. The state of Michigan currently has rules regarding testing of the foster parents but none requiring TSTs for the children being placed; thus, some of the children have been from home to home and frequently exposed without detection.

Private Provider: Even though the private health care provider had an opportunity every month for at least 6 months to evaluate the child, a skin test or chest x-ray or referral to another physician was never done.

Education and Awareness: Despite the clarity of symptoms presented by the child, no one made the association with TB; instead, numerous unlikely speculations were explored. The “Think TB” message should be circulated and communicated by the health department to private physician offices, and it should be the focus of CME topics. Teachers should also be educated about TB to ensure that they have the ability to identify TB symptoms presented by their students.

—Submitted by Kathy Harris, PhD
Detroit TB Control and Prevention Program Manager
Linda Dix, Detroit TB Control and Prevention Program Administrative Assistant and
Dee Simmons Smith, Public Health Advisor


Seminar Series – Collaboration Between the New York State Department of Health Bureau of Tuberculosis Control and the Medical Society of the State of New York

As the science around diagnosis and treatment of TB evolves, and as new guidelines for management of infection and disease are issued, it is critical to ensure new information is disseminated to those actively engaged in managing patients. One of the challenges faced by TB control programs is developing strategies or forums for providing new and updated information. Physicians, as a group, are sometimes difficult to access for continuing education. Recognizing the challenges associated with reaching the practicing physician, the New York State Department of Health, Bureau of Tuberculosis Control (BTBC), contracted with the Medical Society of the State of New York’s (MSSNY) educational subsidiary, the Medical, Educational and Scientific Foundation, Inc. (MESF), to collaborate on a series of TB educational programs. 

The MSSNY contacted local medical societies to establish date, time, location, registration information, and a contact person, and subsequently promoted the educational initiative to its 27,000 members. The BTBC also identified local physician experts to present the programs and customize the presentation to highlight local data. The program was presented as a 2-hour dinner-lecture, which included a 45-minute presentation with an additional 15-minute question-and-answer period. Handouts included a copy of the PowerPoint presentation, the CDC Core Curriculum, national guidelines and recommendations, case report forms, local data, and resources for additional TB information at the local and state level.

The contract with the MSSNY operated in two successive years. The first year’s program, “TB: The Continuing Challenge,” was held in 10 sites over a 3-month period and reached over 300 physicians. The core elements of the program included epidemiology and current TB trends in New York State, targeted testing and treatment of latent TB infection, an update on new treatment recommendations and guidelines, and state and local reporting requirements. Since over 60 percent of reported TB cases in New York State are among foreign-born populations, the second program series focused on “TB and Other Health Issues in Refugee and Immigrant Populations.”  The topics addressed in this program were related to newly arrived immigrants and refugees who have a high risk for communicable diseases. The program outlined the geographic areas of origin of immigrants and refugees, described recommendations for medical examinations, and gave the mandatory reporting procedures. In a 3-month period, 392 physicians attended one of the 14 sponsored seminars throughout the State.

Results from the 287 evaluations submitted in the second year showed more than 80 percent of the attendees felt the information they received would positively influence their practices.  Over three-quarters of those surveyed felt the information provided was new and helpful in raising awareness and insight into the medical and social problems of newly arrived immigrants and refugees. Most attendees felt the information provided an enhanced understanding of TB and other diseases, and having the opportunity to network and discuss these types of patients with colleagues, as well as confer with the local leading expert in the field, proved to be a valuable experience.

    —Submitted by Judi A. Bulmer and
John C. Grabau, PhD, MPH
Bureau of Tuberculosis Control
New York State Department of Health


A Statewide Targeted Tuberculin Testing Program In Tennessee

Dr. Connie Haley, TB Controller for Tennessee, came to CDC in 2002 and gave a presentation to DTBE staff about Tennessee’s targeted tuberculin testing program among foreign-born persons. In the following article, she provides an update on the program.

While the tuberculosis (TB) case rates in Tennessee have steadily decreased over the last decade, there continues to be a significant disparity in the rate of TB in foreign-born (FB) residents compared to U.S.-born residents (31.4 per 100,000 and 4.7 per 100,000, respectively, in 2002). Since 1996, the proportion of TB cases in Tennessee occurring among foreign-born residents has increased from 7 percent to 18 percent.  During the same time period there has been a 42 percent annual increase in Hispanic persons receiving services at Tennessee’s local health departments. According to the 2000 Census, approximately 160,000 Tennessee residents were born outside of the United States, the majority in TB-endemic countries. In consideration of the growing foreign-born population residing in Tennessee, a statewide Targeted Tuberculin Testing and Treatment Initiative (TTI) was implemented to address the potential of TB transmission within this and other high-risk groups, whose health directly affects that of the entire population.

In 2001, the Tennessee State Legislature increased the TB Elimination Program budget by $5 million annually to provide foreign-born persons with tuberculin testing, clinical evaluation, and treatment for TB or latent TB infection (LTBI), and new public health staff were hired to provide these services. The funds also enabled clinic renovations, the purchase of new clinic and laboratory equipment, transportation of patients to clinics, translation and interpretation services, and expanded physician services.  Outreach was implemented in local communities to identify and establish a relationship with foreign-born populations that would benefit from TB services.  Two concurrent arms of the TTI were developed. The first arm involves ensuring that TB services are provided to foreign-born persons already coming to the local health departments for other services such as immunizations, prenatal care, STD/HIV treatment or primary care visits.  The second arm involves the provision of TB services at community sites where foreign-born persons can be accessed. Specific community sites where TTI services can be delivered include churches or other religious gatherings, factories, grocery stores, restaurants, community centers, and residential sites such as apartment complexes.  

A statewide needs assessment indicated that to effectively implement planned TTI services, the following barriers must be addressed: cultural and linguistic diversity, Title VI requirements,1 lack of education among foreign-born clients, fear of the government and the health department, misconceptions and stigma surrounding TB and LTBI, and competing priorities of work schedules or family care. In reviewing these issues, the TB Elimination Program recognized that a successful initiative must strive to improve the quality of services provided to the foreign-born in addition to increasing the number of individuals tested and treated for LTBI. All health department TB staff received extensive cultural and linguistic competency training, and trained interpreters and telephone interpretation services were hired to facilitate communication. Standardized procedures for performing tuberculin skin testing, evaluation, treatment and follow-up were developed. In addition, written guidelines have been developed and in-person training was provided to TB control staff statewide. To enhance access to TTI services, public health staff provide tuberculin testing, dispensation of TB or LTBI medications, and routine clinical and laboratory monitoring during treatment at local community sites as well as at local health departments. 

In order to overcome patient fear and misconception about both the health department and about TB, avoid the appearance of discrimination by "targeting" a specific population, and increase acceptance of TTI services, a new policy of performing individualized TB risk assessment and counseling prior to tuberculin testing was established. A Risk Assessment Tool (RAT) was developed to serve as a flow chart for assessing an individual’s risk for TB or LBTI and to determine the need for tuberculin testing. The tool also serves as a data collection instrument and as documentation of services provided. Specific information obtained using the tool includes demographic information and patient identifiers, risk factors for TB infection, medical conditions associated with progression to active TB once infected, HIV risk factors, TB symptoms, and history of previous tuberculin testing or LTBI treatment. To ensure effective and accurate education of all patients, as well as encourage disclosure of personal information, a standardized script has been developed for use with the tool. This script outlines specific teaching points regarding TB and LTBI diagnosis, evaluation, treatment, follow-up, and clinical outcomes. 

Persons whose individualized risk assessment detects evidence of active TB are referred immediately to a physician. Persons who are identified as high risk for TB or LTBI or who have a history suggestive of untreated LTBI are provided tuberculin skin testing. Persons with a positive tuberculin skin test (TST) are then referred to regional heath department TB clinics for evaluation by experienced TB providers and are placed on appropriate therapy as indicated. Persons with no risk factors, medical conditions, TB symptoms or history suggestive of TB or LTBI are counseled that they are low-risk for developing active TB disease. Tuberculin testing is strongly discouraged for all low-risk persons, and these persons are dismissed with a health department card stating that they have been evaluated and found to be free of infectious TB. The card also contains written instructions to return if their risk of TB or LTBI changes or if they develop symptoms of TB disease. 

During the first year of the initiative (March 2002 to February 2003), over 40,000 persons received education and individualized risk assessment for TB and LTBI.   Almost 23,000 of the individuals screened and educated were identified as having increased risk for TB infection and subsequently received tuberculin skin testing.  Of note, five cases of active TB disease were detected as a direct result of targeted testing activities. LTBI was diagnosed in 15 percent of all high-risk persons tested, and in 36 percent of foreign-born persons tested. In contrast, only 1 percent of low-risk individuals were found to have a positive TST, and many of these could represent false-positive results due to environmental mycobacteria. These data indicate that tuberculin testing programs targeting high-risk populations enable early detection of active TB cases and identification of persons with LTBI who would benefit from treatment. Persons born in TB-endemic areas appear to have the highest rate of TB infection and are thus an appropriate priority group for tuberculin testing and treatment of LTBI. Furthermore, our findings indicate that tuberculin testing of low-risk persons has low yield and thus is not an effective use of limited public health resources. 

Several significant challenges have been encountered during the early phases of this program. While a large number of high-risk persons were identified and provided services, over 17,000 low-risk persons were also provided TB or LTBI screening and education and over 10,000 of these were given tuberculin skin tests. Public health workers were initially resistant to the idea of refusing to provide requested services such as skin tests, even to persons with no apparent risk for LTBI or TB. However, the extremely low rate of tuberculin positivity among low-risk persons has slowly convinced our staff that limiting testing of low-risk persons is unlikely to result in a missed opportunity to detect or prevent active TB. Another barrier to reducing skin testing of low-risk persons is the existence of various licensure rules and broad administrative policies that require tuberculin testing regardless of TB or LTBI risk. For example, TSTs have routinely been required for school teachers, bus drivers, day care workers, foster care parents and children, and volunteers who provide nonmedical personal services for the elderly, among others. In addition, some large employers have required skin testing for employment. Even though the targeted tuberculin testing and treatment guidelines published by CDC in 2000 recommend that routine testing for administrative purposes be discontinued,2 current regulations are difficult to change. To date we have had to address this problem one group at a time. In 2002, we implemented a joint policy with the Department of Education to discontinue required skin testing of teachers and bus drivers, and in 2003 we implemented similar policies at the Department of Human Services and the Tennessee Commission on Aging and Disability.

Another unanticipated challenge we have encountered has been defining the concepts of high- vs. low-risk and determining who should have a tuberculin skin test. Frequently, health department personnel who provide tuberculin testing are not designated TB staff but rather work in other programs such as WIC, immunization or primary care. We have recently determined that some staff do not understand what factors determine whether a person has increased risk of LTBI or TB disease and symptoms that are more likely attributable to causes other than pulmonary TB may be overreported (i.e., chronic cough of COPD or acute symptoms of upper respiratory infections).  In addition, risk factors such as “travel to high-TB risk areas,” “children exposed to adults in high-risk categories,” “patients receiving immunosuppressive therapy,” and “residents and employees of high-risk congregate settings” are hard to define for persons who infrequently perform TTI services.  We are currently revising our state guidelines and providing more specific written protocols to enable all public health personnel to better identify persons who would benefit from TB testing and treatment versus those who should be counseled and dismissed.  In addition, we hope that statewide retraining and a highly coordinated “train-the-trainer” approach will help us overcome these problems to provide more effective TTI services to the appropriate populations statewide.

A final limitation to implementing a statewide targeted tuberculin testing and treatment program is certainly the high cost and large number of staff required to deliver the needed services. However, by reallocating the cost and staff time that are currently expended providing TST and other preventive services to low-risk persons, perhaps local TB control programs can accomplish targeted testing of a specific high-risk group.  Given the great success of our TTI during the initial year, we are optimistic that this statewide initiative will reduce the incidence of active TB among Tennessee residents, particularly the foreign-born. Implementation of this program is thus a big step toward our goal of TB elimination in Tennessee.

—Reported by Connie Haley, MD, MPH
TB Control Officer, and
Katie Garman, MPH, CHES, Epidemiologist
Tennessee Department of Health


1. Title VI of the 1964 Civil Rights Act (42 U.S.C. 2000d-1) states that "No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." Title VI bars intentional discrimination as well as disparate impact discrimination (i.e., a neutral policy or practice that has a disparate impact on protected groups).

2. CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49(No. RR-6):1-51.


The Renovation of Hawaii’s Lanakila TB Clinic

In many areas, TB control has been neglected with diminished funding, support, and interest. The Hawaii (HI) State TB Control Program is uniquely fortunate to be supported by the State Legislature, Governor, health partners, community, and CDC to aggressively address the state’s continued high TB morbidity.

After 15 months, the Lanakila Tuberculosis Clinic returned from temporary quarters to a completely renovated 13,000-square-foot headquarters in Honolulu.  A dedication ceremony celebrated on August 7, 2003, began with a beautiful Hawaiian chant by Makia Malo, a local Hawaiian storyteller. Dr. Chiyome Fukino, Director of the Hawaii State Department of Health, hosted the ceremony with several distinguished guests, including Dr. Ken Castro of CDC, HI Representative Dennis Arakaki, HI Senator Suzanne Chun-Oakland, and HI Representative Felipe Abinsay. The Honorable U.S. Representative Neil Abercrombie gave poignant remarks on the achievements and dedication of the U.S. Public Health Service in public health and TB control in Hawaii and the United States. 

This grand opening celebration showcased over 2 years of detailed planning toward the development of a model TB Clinic with separate clinics for screening and treatment. Two capital improvement bills totaling over $3 million dollars were approved in 2000 by the Hawaii State Legislature and former Governor Ben Cayetano to completely demolish and renovate the old TB clinic and procure a digital X-ray imaging system.  The TB Program worked closely with Teresa Seitz and Ken Martinez of the National Institute for Occupational Safety and Health to optimize infection control features. Highlights of the renovation include the following:

  • Dual TB clinics: The Screening Clinic and Chest Clinic are separated, with independent ventilation and air conditioning systems to prevent potential mixing of air between low-risk and high-risk populations.

  • Negative air pressure clinic: The entire Chest Clinic (including all waiting rooms and examination rooms) is under negative air pressure and is serviced by a one-pass ventilation system that exhausts HEPA filtered air externally. These engineering controls are augmented by the use of stand-alone HEPA filters and wall-mounted ultraviolet germicidal irradiation lamps which offer optimal infection control for clients and staff.

  • Computed radiography: A complete digital X-ray and image database system was installed. This state-of-the-art system offers rapid processing of X-rays; decreases radiation exposure for clients and staff; and eliminates the need for film, chemical film processing, and storage of analog films for the approximately 16,000 X-rays taken annually, with the ease of computer access, manipulation, interpretation, and storage of electronic images.

  • The Bishop Museum installed a permanent exhibit chronicling the history of TB in Hawaii (done in partnership with Leahi Hospital and the American Lung Association of Hawaii). The exhibit presents a timeline beginning in January, 1778, when Captain Cook brought two shipmates with TB to Waimea, Kauai. In the early 20th century, TB sanatoriums and preventoriums for children were established on each island before widespread use of surgery and antibiotics.

  • The Hawaii State Art Museum’s Art in Public Places Programs loaned over 20 pieces of original art, including paintings, statues, photographs, and ceramics from local artists for display in public areas throughout the clinic. A noted Hawaiian artist with family ties to the TB Program also loaned several of his pieces for display.

Several hundred people enjoyed the grand opening festivities, which included an open house, tours, Hawaiian story telling, local food, and entertainment. The event was covered by all local television news stations and documented for video presentation by community access television.

A small team of visitors from the CDC’s Division of TB Elimination was led by Dr. Ken Castro. The team met with Dr. Boz Tucker of the Pacific Island Health Officers Association, representatives of Pacific Resources for Education and Learning, and the Hawaii State TB Laboratory Staff. Dr. Zachary Taylor provided an in-service training session to TB Program staff. Dr. Castro was the featured speaker in a presentation on international TB issues, teleconferenced live to Bangkok from Tripler Army Medical Center. In partnership with the American Lung Association of Hawaii and the Hawaii Thoracic Society, Dr. Castro also inaugurated the new TB conference room with a presentation on the new ATS/CDC/IDSA TB Treatment Guidelines to a large group of physicians and nurses.

The CDC Team also reviewed program data with local CDC personnel (Dr. Jessie Wing, CDC Medical Officer and Hawaii TB Program Chief, and Jason Nehal, CDC public health advisor) and TB Program staff in Honolulu, Maui, and the Big Island of Hawaii. The State of Hawaii has reported the highest annual state TB incidence rate for most of the past decade (11.9/100,000 in 2002) with over 80% of its cases in foreign-born persons each year.

The busy CDC team visit was capped off by a very enlightening visit to Kalaupapa Settlement for Hanson’s Disease on the island of Molokai, hosted by Mike Maruyama, Branch Chief of the Hanson’s Disease (HD) Program. In the World Health Organization model, TB and HD are placed under the same program. Closer collaboration with the HD program is helpful since HD and TB have similar at-risk populations in Hawaii and the Pacific region.

The Hawaii TB Control Program plans to build on the momentum afforded by this new beginning to maintain a high profile in the community and with the legislature. The program will continue to work collaboratively with its partners to promote engagement, collaboration, and funding to advance the goals of TB elimination. Ninety-three years after the Hawaii Bureau of TB was established, the Hawaii TB Control Program is proud to have a cutting-edge facility to develop more responsive and progressive initiatives for Hawaii and the Pacific region and go forward in the 21st century.

I mua a lanakila:  Go forward to victory.

—Submitted by Rachel Blair, Ricardo Silva, Dzung Thai, Jason Nehal, and Jessie S. Wing
Hawaii State TB Control Program


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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