TB Notes Newsletter
No. 2, 2005
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
Misdiagnosis in Rural
Background. Colorado is a low-incidence state, with a 2004
tuberculosis (TB) case rate of 2.8 per 100,000 population. However,
the number of reported cases increased from 111 cases in 2003 to
127 in 2004. The Denver metro area typically reports 70% to 75%
of the state’s active TB cases each year. Though the metro area
accounts for most of the cases, misdiagnosis still occurs if physicians
do not “think TB” or if they have never seen a TB case before.
In 2004 three rural counties in Colorado reported at least one active
case of TB for the first time in at least 8 years. These counties
have few health care facilities available and no TB expertise locally.
Case Report. On April 29, 2004, the Colorado Department
of Public Health and Environment TB Program (CDPHE) received a call
from an infectious disease (ID) physician in Denver. The physician
was very concerned after diagnosing TB in a patient referred to
her from a rural community clinic. This patient had sought care
repeatedly and was misdiagnosed over a 4-month period of time. A
discussion with the physician ensued regarding the consequences
of the loss of TB diagnostic expertise in low-incidence areas such
as Colorado, but especially in rural communities.
The patient was a 35-year-old female who had traveled to the United
States from Uganda
with an 18-month worker’s visa. She arrived in a rural county in
the Rocky Mountains of Colorado in December 2003. Her employer’s
international office actively recruits employees from around the
world, including many from countries with a high incidence of TB.
No health screening or tuberculin testing is required upon employment.
The patient sought care with the community clinic 11 times from
December 2003 through April 2004. The clinician at this rural community
clinic treated the patient repeatedly for pneumonia. The patient
received several rounds of antibiotics and inhalers before being
referred to the ID physician in Denver. The patient’s symptoms included
cough, chest pain, weight loss, and fever. The patient states her
symptoms started approximately 1 week after arrival in Colorado,
although she did not feel well on the flight over. Chest x-rays
of December 2003 and March 2004 showed left upper and lower lobe
infiltrates. The chest x-ray of April 2004 exhibited worsening infiltrates
with cavitation. The patient had a history of a negative HIV test
The ID physician immediately hospitalized the patient in Denver
after her evaluation. Sputa collected were reported as 4+ on smear
and four-drug therapy with INH, rifampin, ethambutol, and PZA was
initiated. The rural county nursing service was contacted and the
suspected TB case was reported to the nursing director and the public
health nurse on April 29, 2004. The public health nurse, though
experienced in nursing, was new to public health and had just finished
her tenth day on the job. This rural county had not reported an
active case of TB in over 10 years.
The CDPHE TB program nurse consultant immediately provided the
community clinic staff with an educational inservice training; information
included TB diagnosis and treatment and the contact investigation
process. TB educational materials, including the CDC tuberculin
skin testing video, guidelines for the treatment of TB, and the
Colorado State TB Manual, were distributed during this session.
A county commissioner was noted among the audience. Discussions
took place to answer questions and alleviate concerns. The TB program
nurse consultant found that meeting with the community clinic staff
was useful in the long and arduous process of contact investigation
and case management of patients.
Many concerns and questions came from the private clinicians and
public health staff, as well as the community. The CDPHE TB program
nurse consultant made many trips to the county (a 200-mile round
trip) to provide assistance and consultation. Building relationships
improved the comfort level of the providers in the community to
ask questions and follow recommendations. However, it was difficult
for a low-incidence state such as Colorado to provide the assistance
required to a small rural county and maintain all program functions.
The patient completed 6 months of directly observed therapy for
culture-confirmed and drug-susceptible Mycobacterium tuberculosis
on November 5, 2004. She exhibited severe joint and muscle pain
at times while on treatment, although this did not interrupt her
therapy. The patient was determined to complete her therapy regardless
of side effects. The public health nurse offered encouragement to
the patient and arranged appointments with the patient’s private
care provider for evaluation of symptoms and follow-up. As treatment
continued, the patient regained 20 pounds of her weight loss and
other TB symptoms resolved. She was extremely thankful for the treatment
and care she received from the public health nursing service. She
refused HIV testing though it was offered several times. Her reasoning
was that she could not handle any additional bad news and would
refuse treatment even if the test proved positive. The patient recounted
knowing others who had died of HIV/AIDS in Uganda.
Contact Investigation. Owing to the length of time the case
was misdiagnosed and to the patient’s work and living environment,
an extensive contact investigation was performed. It quickly became
apparent that the patient had become very involved in the community
since her arrival. The investigation included the work site, on-site
housing, work site day care, high-risk patients from the clinic
waiting room, the patient’s church, and a Girl Scout troop. The
public health nurse began tuberculin testing of the contacts; however,
the need for support was soon recognized. As the numbers of contacts
and sites increased, the state TB program offered assistance. Several
CDPHE TB program staff assisted, as did a communicable disease epidemiologist.
The CDPHE TB program nurse consultant’s visits to the county provided
opportunities for additional education to those who needed it, including
local public health staff, contacts, providers, and community members.
Being on site was invaluable in understanding the anxiety created
as the numbers of sites and contacts grew. It also provided the
opportunity to assess new problems as they arose, make quick decisions,
and give directions. The CDPHE TB program nurse consultant was able
to obtain immediate guidance while on site from the expert physicians
at Denver Public Health when needed.
A total of 321 people were initially tested, and a list of 267
true contacts was developed for the follow-up testing. A large number
of the contacts were foreign-born persons, coming from many countries
around the world, including high-incidence countries. This added
confusion to the task of determining transmission and controlling
the scope of the investigation.
Local clinicians were contacted and given recommendations regarding
follow-up of their patients who were named as contacts. Questions
and discussion were encouraged.
Results of the contact investigation identified one additional
person with active TB. She was treated by DOT with 4 months of therapy
since she had a negative culture but clinical improvement. This
patient was also from Uganda
and traveled with the index case.
There were 56 contacts identified with latent TB infection (LTBI),
of which 38 were started on treatment with INH; 39 of these contacts
were foreign-born persons. To date, 30 contacts continue their therapy.
Several patients returned to their home countries during the investigation.
Referrals were made where possible.
The local public health nursing director requested assistance from
the bioterrorism (BT) program in conducting the contact investigation.
The bioterrorism (BT) program felt the follow-up tuberculin testing
would be an excellent opportunity to carry out a response exercise.
Testing was accomplished at several clinics set up at the sites
where contacts were identified. The BT program and rural public
health agency gained experience in putting a plan together, initiating
the plan, and making calls for assistance from the community, the
surrounding counties, and the State TB and BT Programs. Public health
nurses as well as support staff from many surrounding counties and
the state responded to help with the testing clinics.
The nurses who responded not only received updated information
on tuberculosis and testing procedures, but also were able to fulfill
many objectives related to bioterrorism grant funding. The responders
gained experience in how an actual event could evolve and a response
would occur. The community and surrounding counties were able to
practice the ability to put a plan together and modify it as the
event progressed. The members of the BT exercise planning team gained
experience in working together. It was beneficial for all involved
to appreciate the effectiveness of program and regional collaborations.
One caveat or limitation of the TB/BT collaboration was that participating
in the planning, initiation, and execution of the exercise increased
the workload of both the CDPHE TB Program and the local public health
agency. Those responders who were assigned to place and read skin
tests were trained appropriately and monitored, with adjustments
in assignments made as needed. The local public health nurse was
responsible for arranging the clinics and making staffing assignments
as responders volunteered. The public health nurse, who was assigned
the role of incident commander, was responsible for the adjustment
of staff before and during the clinics.
The participants in the event came away with new skills, new associates,
and a sense of collaboration within public health and the community.
Submitted by Gayle M. Schack, RN,
Nurse Consultant and
Juli Bettridge, Health Professional III
Colorado Department of Public Health and Environment