Tuberculosis Elimination Jennifer Flood, MD, MPH Pennan Barry, MD, MPH NAR-NTCA February 25, 2016

Transcription

1 Tuberculosis Elimination Jennifer Flood, MD, MPH Pennan Barry, MD, MPH NAR-NTCA February 25, 2016 Picture source:

2 Questions What is the California dream? What is our current reality? Can the dream come true? 2

3 California > 1,000 miles of beach, 1100 surfers 310 days of sunshine, 110 state parks Opportunities: gold rush, free speech, tech boom >200 airports: ports of entry >100 million passengers/yr

4 Population: 39 million > 10 million immigrants ~25% of foreignborn in U.S. ~25% of TB in U.S. From Public Policy Institute of California ( Sources: U.S. Census Bureau Decennial Censuses, American Community Survey, and the Department of Homeland Security. 4

5 CA Tuberculosis Epidemic ,000 10,000 Number of TB Cases Case Rate per 100, years ago 1 in 9 died of TB at age 30 8,000 6,000 4,000 2, TB Cases TB Rate 5

6 Why aren t we satisfied? TB is diagnosed every four hours Every other day a Californian dies with TB Each week at least one child under 5 found to have TB 6

7 Elimination Definitions Status Rate Cases in California* Current (2015) 56 cases/million 2,147 Elimination <1 case / million 39 *Based on 2014 US Census Estimate of California Population: 38.8 million WHO. Framework towards TB Elimination in Low-Incidence Countries

8 Rate per 1 Million Year of TB elimination in California Extrapolation based on current rate of decline* Actual Current decline (-4%) 2040 Elimination (-14%) Elimination Year * Average annual decline in case rate

9 2015: Young Californian with TB disease 28 year old male with TB disease TB caused neck and chest lymph nodes to enlarge around his airway With treatment his lymph nodes may get larger before they resolve He asks: Is there anything he could have done to prevent this from happening? 9

10 Preventing TB 10

11 How do TB Cases Occur in California? 7.5% Importation 835 of 11,149 cases occurred within 1 year of arrival in U.S. ( ) 79.5% Reactivation of remote infection Cases not from importation or recent transmission ~2,100 TB Cases Per Year 13% Recent Transmission CDC plausible source case method* * France et al, Am J Epidemiol

12 Reported TB in California, 2015 Foreign-born 81% US-born 19% Each = 1 TB case (Total = 2137) 12

13 Median Age at Report of TB (years) Median Age of TB Cases by Nativity California US-born Foreign-born

14 Medical Risk Factors Adult TB cases (Age 15+) California or more risk DM, ESRD, HIV, TNF-α, organ transplant, steroids, immunosuppression Total n (%) US-born % Foreign-born % 757 (37%) 23.1% 39.4% Diabetes 585 (28%) 13.6% 31.2%

15 Only ~1/3 of TB Cases are Foreign-Born with Medical Risk (Age 15+) California, 2015 US Born Foreign Born 2,069 TB Cases 780 (38%) 936 (45%) Medical Risk 0% 20% 40% 60% 80% 100% medical risk: current smoking, DM, HIV, ESRD, organ transplant, TNF-alpha, other immunosuppression 15

16 2.1 Million Estimated TB Infections, California 2014 U.S. Born Foreign Born 0.5 Million 1.6 Million 0% 20% 40% 60% 80% 100% Estimated by applying nativity and race/ethnicity-specific TB infection prevalence from NHANES (Miramontes, 2015) to the California CPS population estimates using TST for US born and IGRA for foreign born 16

17 Millions of persons Estimated TB Infection prevalence, awareness, treatment California, 2014 NHANES applied to California population U.S.-born Foreign-born M 20% 12% LTBI prevalence Aware of LTBI Treated for LTBI 17

18 How many Californians are being Group tested for TB Infection now? Estimated Number tested annually TB risk Healthcare workers 1,443,000 Low State prison inmates 130,000 Low Status adjusters (civil surgeon screening) 105,000 HIV infection 18,000 High Contacts 17,000 High Moderate-High Refugees 8,000 Moderate-High B-notification arrivers 5,000 High Very High Others? varied Total 1,726,000 * 18

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20 Risk Assessment For use by primary care providers Influenced by CA TB Elimination Task Force Extensive feedback from diverse providers Simplicity, clarity over detail Companion Fact Sheet Customizable for local programs

21 Who should I test for TB Infection? 21

22 Who should I test for TB Infection? 22

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24 ~90% of Adult TB Cases Would be tested by Risk Assessment (Age 15+) California, 2015 US Born Foreign Born 2,059 TB Cases Covered by California Risk Assessment (88%) 0% 20% 40% 60% 80% 100% medical risk: current smoking, DM, HIV, ESRD, organ transplant, TNF-alpha, other immunosuppression 24

25 Migration to California Persons in U.S. for <1 yr 160, , , ,000 80,000 60,000 40,000 20, Others India Vietnam Philippines China Mexico Source: ACS surveys

26 Why now? Expanded access to care focused on prevention 12 dose regimen has very high completion rates TB transmission at nadir so re-infection unlikely IGRAs can weed out BCG false positives International focus on LTBI contribution to end TB Economic benefit of TB prevention clearer 26

27 Challenges Engage those at risk and their providers? Not all individuals at risk are in care Care delivery system is complex Primary care clinicians overwhelmed Out-of-pocket costs for TB services for some Drug supply not continuous Limited health department resources 27

28 California TB Elimination Task Force Recommendations Insert photo of task force meeting 28

29 Find and engage persons with TB risk and their providers Create epidemiologic profiles of populations at high risk for infection and disease and providers who serve them Ensure foreign birth/ birth country are included in EMR 29

30 85, 731 patients: 81% Hispanic 21% diabetes High % with foreign birth FQHCs: % foreign birth Risk characteristics TB cases 30

31 Apply effective strategies for LTBI testing Focus testing on foreign-born persons Use IGRAs for BCG-vaccinated persons Reduce testing of low-risk persons Update California laws to risk-based testing: teachers, parks and rec workers students, healthcare workers 31

32 Optimize treatment for LTBI Maximize treatment of routinely tested Use shortest effective LTBI treatment and new adherence technologies Civil surgeons to refer/treat status adjusters who test positive for TB infection Jail setting: 9H replaced with 12 dose regimen achieved > 85% treatment completion 32

33 Make TB prevention routine Build strong public/private partnerships Motivate community providers serving key populations to test and treat US Preventive Services Task Force A/B Rating? Create simple messages for providers and public 3 risk groups Implement system to measure and track progress with least burden report LTBI 33

34 North East Medical Services San Francisco, California 62,035 patients: majority from China, uninsured, limited English Account for 5% of SF TB cases each year Focused on young with diabetes, smoking Change process: standing orders, training, provider report cards, auto-reminders for appointments Courtesy of Dr. Jerry Jew (Medical Director, NEMS) 34

35 Courtesy of Dr. Jerry Jew (Medical Director, NEMS) 87.5% 78.3%

36 Remove financial impediments for providers and patients Ensure access to 12 dose regimen on formularies Remove patient share of cost for TB service Letter to Covered California/Medi-Cal Make an serious investment in prevention CA TB Elimination Challenge 2040 Fund Fully appropriate U.S. Comprehensive Elimination Act 36

37 Summary /Next Steps The California dream is a big dream: TB elimination by 2040 Current reality: sluggish decline and preventable TB and deaths We are optimistic dream can come true Focus = prevention (while maintaining strong case detection and rx) Normalize testing and treating high risk populations NEXT STEPS : Elimination Plan will be set into action in 2016! 37

38 2 year old male fever, weight loss, seizures meningitis with brain and lung TB

39 Acknowledgments CA TB Survivors Local TB Control Programs CA TB Controllers Association Curry International TB Center CA TB Control Branch Staff TB Elimination Task Force and Coalition Task Force Report 2015 and CA TB Risk Assessment /tb/pages/default.aspx 39

40 EXTRA SLIDES 40

41 California Dreamin All the leaves are brown (all the leaves are brown) And the sky is grey (and the sky is grey) I've been for a walk (I've been for a walk) On a winter's day (on a winter's day) I'd be safe and warm (I'd be safe and warm) If I was in L.A. (if I was in L.A.) California dreamin' (California dreamin') On such a winter's day The Mamas and the Papas

42 TB Cases in California Testing Foreign Born Interventions Base case (4% tested) Use QFT/3HP 2x testing (FB) 4x testing (FB) ~1.6M 10x testing (FB) Year 42 2x, 4x, 10x use QFT/3HP Dotted lines represent pre-elimination and elimination

43 Newcomers to California Examples Number per year TB screening before entry? TB screening later? New permanent immigrants Immigrants Refugees Nonimmigrant Admissions Tourist/ Business Entries Students Workers No legal status Undocumented 100,000 10,400, ,000? Active Disease No N/A Active and latent 7,000 with abnormal CXR Active and latent 100,000 applying for permanent residency N/A Source: US Dept of Homeland Security. Yearbook of Immigration Statistics

44 Mean Life Expectancy (years) Mean Age and Life Expectancy by risk group Foreign born adults Bubble size=number with LTBI BMI <18.5 All Foreign Born IVDU Adults Alcohol TNF Alpha Tobacco HIV+ Recent SOT Steroids Post SOT Diabetes Heme Cancer ESRD Solid Organ Cancer Mean Age Source: Yeats 2015 RAND Dissertation: Priorities for Targeted Testing for Latent Tuberculosis Infection among Foreign Born Adults in the United States, Table (

45 Medical Risk Factors Adult TB cases (Age 15+) California 2015 Total n (%) US-born % Foreign-born % Diabetes 585 (28%) 13.6% 31.2% ESRD 83 (4%) 2.0% 4.4% HIV positive 62 (3%) 5.2% 2.6% Other immunosuppression Post-organ transplantation 113 (5%) 4.3% 5.7% 9 (0.5%) 0.6% 0.4% TNF-antagonist rx 13 (0.6) 0.6% 0.6% 1 or more risk 757 (37%) 23.1% 39.4%

46 How do TB Cases Occur in California? Importation TB within 1 year of US arrival Recent Transmission CDC plausible source case method Reactivation of remote infection ~2,100 TB Cases Per Year France et al, Am J Epidemiol

47 Rate per 1 Million Years of TB elimination in California Extrapolation based on current rate of decline* Actual Current decline (-4%) 2040 Elimination (-14%) Elimination Year * Average annual decline in case rate

48 Cases per 100,000 TB case rate by nativity California U.S.-born Foreign-born Year

49 Adult Tuberculosis Cases California, , N(%) Total Cases Aged 15 yrs 8482 Foreign Born 6901 (81.4) US Born 1569 (18.5) Recent US arrival <1yr 925 (13.4) RT 450 (6.5) Reactivation 5526 (80) Reactivation 1284 (81.8) RT 285 (18.2) RT = recent transmission Medical risk 2073 (37.5) No medical risk 3453 (62.5) ~1350 smokers also included here No Medical medical risk risk (69) (30.5) Immuno- suppressed 584 (28.2) Not immunosuppressed 1489 (71.8) Medical Risk: Immunosuppressed: HIV, organ transplant, TNF-alpha, other immunosuppression Not immunosuppressed: DM, ESRD Not Immunosuppressed 204 (52.5) Immunosuppressed 187 (47.8)

50 100% Foreign-born Reactivation TB cases Percent without medical risk factor* California, % 60% 40% 20% 0% 94% 89% 72% 54% 52% 50% 53% 57% 65% Age Group *Does not include smoking Total N=

51 Foreign-born Reactivation TB cases Number without medical risk factor* California, Age Group *Does not include smoking Total N=

52 Foreign-born Reactivation TB cases Cumulative percent without medical risk factor* California, % 80% 60% 40% 20% 0% 8% 27% 43% 57% 71% 83% 95% 100% 100% Age Group *Does not include smoking Total N=

53 TB Cases Years in US at TB Diagnosis California, % in US > 5.9 years 50% in US >16 years Median 16.0 yrs 30 25Q Q Q Years in US 53

54 Percent cases Time in US by Country of Origin, < 1 year in US 5+ years in US % % China India Mexico Philippines Vietnam

55 Time in US by Country of Origin, 2015 <1 year 5+ years China 7% 81% India 20% 57% Mexico 6% 89% Philippines 9% 82% Vietnam 8% 79%

56 Immigration Status, 2015 Impact of student and employee overseas screening may not be evident for a few years following implementation. 750 (44%) of foreign-born TB cases entered the US with an immigration visa. 53 (3%) cases had student visas 39 (2%) cases had employee visas Time in US for TB cases entering US with student or employee visa, 2015 Visa Type <1 year 1-2 years 2-5 years 5+ years Student 18 (35%) 6 (12%) 11 (22%) 16 (31%) Employee 6 (16%) 4 (11%) 7 (19%) 19 (53%)

57 Migration to California from 250, , , ,000 50,000 0 Top 5 countries of origin Persons in U.S. for <2 yrs India Vietnam Philippines China Mexico Source: ACS surveys

58 Average population Thousands Foreign born: Years in U.S. California, Years in US 58

59 Average Annual Population (Thousands) Foreign born: Years in U.S. California, China N=797,046 Philippines N=869,649 Vietnam N=511,264 India N=493, <=

60 Average Annual Population (Thousands) Foreign born: Years in U.S. California, Mexico N=4,344, <=1954 Source: ACS surveys 60

61 Mean Life Expectancy (years) Mean Age and Life Expectancy by risk group Foreign born adults BMI <18.5 All Foreign Born IVDU Adults Alcohol TNF Alpha Tobacco HIV+ Recent SOT Steroids Post SOT Diabetes Heme Cancer ESRD Solid Organ Cancer Mean Age Source: Yeats 2015 RAND Dissertation: Priorities for Targeted Testing for Latent Tuberculosis Infection among Foreign Born Adults in the United States, Table 12 61

62 Mean Life Expectancy (years) Mean Age and Life Expectancy by risk group Foreign born adults Bubble size=number with LTBI BMI <18.5 All Foreign Born IVDU Adults Alcohol TNF Alpha Tobacco HIV+ Recent SOT Steroids Post SOT Diabetes Heme Cancer ESRD Solid Organ Cancer Mean Age Source: Yeats 2015 RAND Dissertation: Priorities for Targeted Testing for Latent Tuberculosis Infection among Foreign Born Adults in the United States, Table (

63 Mean Life Expectancy (years) Mean Age and Life Expectancy by risk group Foreign born adults Bubble size=number with LTBI BMI <18.5 IVDU Alcohol TNF Alpha Tobacco HIV+ Recent SOT Steroids Post SOT Diabetes Heme Cancer ESRD Diabetes Average: Age: 59 Life expectancy: 12.5 Lifetime TB risk: 3.4% Solid Organ Cancer Mean Age Source: Yeats 2015 RAND Dissertation: Priorities for Targeted Testing for Latent Tuberculosis Infection among Foreign Born Adults in the United States, Table (

64 Mean Life Expectancy (years) Mean Age and Life Expectancy by risk group 30 Foreign born adults Bubble size=number with LTBI Age Age Age Age Age Age Mean Age Source: Yeats 2015 RAND Dissertation: Priorities for Targeted Testing for Latent Tuberculosis Infection among Foreign Born Adults in the United States, Table 12 64

65 2 5 Y E A R S Modeling TB Elimination Slides courtesy Alex Goodell, Jim Kahn and UCSF/Berkeley/Stanford CAPE Investigators

66 TB Cases in California Testing overall population Interventions Base case (4% tested) Use QFT/3HP 2x testing (all) 4x testing (all) ~6.8M 10x testing (all) 2x, 4x, 10x use QFT/3HP Dotted line represent elimination Year Estimated with 10x testing: 64 cases / year Elimination: 59 cases / year

67 Selected TB Prevention Activities in California 67