4/25/2012. The information on patterns of infection and disease can assist in: Assessing current and evolving trends in TB

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1 Sindy M. Paul, MD, MPH, FACPM May 1, 2012 The information on patterns of infection and disease can assist in: Assessing current and evolving trends in TB morbidity, including resistance Identifying people or groups of people at risk for TB Understanding how the disease is transmitted Prioritizing cases Planning appropriate use of staff and resources Human disease since antiquity Egyptian mummy from 2400 BC shows pathology of spinal column decay due to TB Term phthisis (consumption) in Greek literature Hippocrates identifies it as the most widespread disease of the time with death thinevitable it when patient t in late stages 17th century pathologic and anatomic description 1679 Sylvius in Opera Medica described tubercules in lungs and other areas and described their progression to abscesses and cavities 17th 18th centuries: TB took 1 in 5 adult lives : 1 billion died of TB 1882: Robert Koch discovered the TB bacillus (7 million deaths) : Sanatorium treatment 1944: Development of Streptomycin 1952: Development of Isoniazid 1

2 TB decreased incidence in industrialized countries until mid 1980s when increase observed Immigration from high incidence countries HIV/AIDS epidemic Increasing resistance What is the epidemiology of TB today Global United States Where are TB cases coming from? Domestic, foreign born, travel What are the populations within your area? When to contact the health department? What services are available through public health? DOT, meds, clinics, expert consultation, transportation When to seek consultation from an expert and who to call? What drives di the global l TB epidemic? 1 Afghanistan 2 Bangladesh 3 Brazil 4 Cambodia 5 China 6 DR Congo 7 Ethiopia 8 India 9 Indonesia 10 Kenya 11 Mozambique 12 Myanmar 13 Nigeria 14 Pakistan 15 Philippines 16 Russian Federation 17 South Africa 18 Tanzania 19 Thailand 20 Uganda 21 Vietnam 22 Zimbabwe 80% of Global TB Cases come from 22 countries 2

3 Who carries the burden of Tuberculosis? Largely, the most vulnerable TB spreads in poor, crowded & poorly ventilated settings 700,000/yr women die of TB more suffer due to illness, stigma, infertility TB orphans are also a consequence Migrant workers, prisoners, minorities, refugees suffer from barriers to care Over 25% of TB disease may be attributable to poor nutrition; 25% to HIV infection; TB rates are linked to tobacco & alcohol use as well as diabetes All forms of TB HIV associated TB Multidrug resistant TB (MDR TB) Estimated number of cases 9.4 million 440,000 Estimated number of deaths 1.7 million* 1.1 million (12%) 380,000 ~150,000 Co infection between TB and HIV Multidrug resistant TB (MDR TB) Resistance to Isoniazid and Rifampin the 2 most powerful anti TB drugs Extensively drug resistant TB (XDR TB) MDR TB plus resistance to any fluoroquinolone and at least 1 second line injectable (amikacin, kanamycin, capreomycin) Totally drug resistant TB?? Approx. 1/3 of the world (2 billion people) is infected with M.tb *including deaths among PLHIV 3

4 Armenia Azerbaijan Bangladesh Belarus Bulgaria China DR Congo Estonia Ethiopia Georgia India Indonesia Kazakhstan Kyrgyzstan Latvia Lithuania Myanmar Nigeria Pakistan Philippines Rep of Moldova Russian Federation South Africa Tajikistan Ukraine Uzbekistan Vietnam 27 high MDR TB burden countries are those estimated by WHO in 2008 to have had at least 4000 MDR TB cases arising annually and/or at least 10% of newly registered TB cases with MDR TB CA * Per 100, 000 population Data are provisional CA, TX, NY, & FL = about half of all TB cases reported in 2011 Year No. of Cases Rate (per 100,000) , , , , , , , , , , Lowest since % decline 4

5 TB disproportionately affects foreign born persons, Asians, blacks, and people with HIV Compared with whites, TB is 25 times higher for Asians, 8 times higher for blacks and 7 times higher for Hispanics More TB cases reported among Asians than any other racial/ethnic group in the US in 2011 Multidrug resistant TB (MDR TB) cases accounted for 109 of all US TB cases in cases of extensively drug resistant (XDR TB), all among foreign born persons HIV status known for 81% of TB cases 7.9 % co infected with HIV TB incidence in foreign born persons was 12 times greater than US born Number and rate of TB among foreign born persons in the US declined in 2011 More than 50% of foreign born TB cases were from 5 countries: Mexico (21.3%) Philippines (11.5%) Vietnam (8.2%) India (7.6%) China (5.6%) Addressing the increasing difference between TB rates in foreign born and USborn persons is critical for TB elimination, CDC said. At the current rate, it would take until 2100 for the United States to eliminate TB, which is defined as less than one case per 1 million people, CDC noted Have germs, will travel Migrating populations in the 1990s *Updated March 2012 with provisional 2011 data Compared 4 x increase to , in volume four fold as compared increase in to migration Source: Population Action International

6 Immigration has played an important role in American history, and the US continues to have the most open immigration policy in the world US immigrant population reached 40 million in 2010, highest in nation s history Immigrants account for 1 in8 US residents 2010 census 309,349,689 US pop 39,955,854 FB (12.9%) Who is required to have a medical examination for migration to the United States? Category Medical Examination Examination Site Examination Location Immigrants Yes Panel physicians Overseas Refugees Yes Panel physicians Overseas Status Adjuster Yes Civil surgeons U.S. Non immigrants No Short term Transit No Others No CDC Immigration Requirements: 2007 Technical Instructions for TB Screening & Treatment No TB classification normal TB screening exam Class A TB disease, smear and/or culture positive Class B1 TB Pulmonary No treatment: abnormal CXR, smear & culture negative Completed TB treatment Class B1 TB Extrapulmonary Class B2 TB LTBI evaluation TST 10mm or positive IGRA Class B3 TB Contact evaluation 6

7 Insufficient financial and human resources Inadequate healthcare infrastructure Weak laboratory capacity and lack of new rapid diagnostic tools Smear negative and drug susceptibility testing Lack of new drugs that would cure TB in a shorter time Lack of effective vaccine that would prevent spread of infection Minimal social mobilization for TB control and minimal population awareness stigma HIV and MDR/XDR threats Office of Travel and Tourism Industries Need to know epidemiology to know who may be infected & risk of resistant strains Local risk groups differ based on geographic region, migration, and travel TB cases can come from an area not listed as a high burden TB country Most focus is on non US born populations but also consider overseas travel Need to consider co infection with HIV Determine HIV status within minutes using Pointof care rapid HIV test Affect treatment options for both active TB and LTBI Don t go it alone! Seek expert consultation Coordinate with public health for services and reporting 7