Epidemiology of TB: A Local and National Overview

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1 Epidemiology of TB: A Local and National Overview Sonal S. Munsiff, MD Director, Bureau of Tuberculosis Control NYC Department of Health and Mental Hygiene Medical Officer, DTBE, CDC February 4, 24 Tuberculosis in New York City: The Last Decade Tuberculosis Cases and Rates New York City, Tuberculosis rates by borough New York City, 1991 Number of cases Case Rate # Cases Rate/1, Cases per 1,/year Manhattan.8 Bronx 47.1 Brooklyn 27 Queens 9.8 Richmond NYC DOH Rates of natural resistance in M. tuberculosis soniazid 1 in 1 6 Rifampin 1 in 1 8 Ethambutol 1 in 1 6 Streptomycin 1 in 1 NH & RF 1 in 1 14 Number of organisms in a TB cavity =

2 Pathogenesis of Drug Resistance Pathogenesis of Drug Resistance R NH RF PZA R R i R NH RF NH R R R R R R R R R R R R R R How to get MDRTB Acquired resistance Non adherence to therapy inappropriate therapy Primary resistance nosocomial transmission community transmission Emergence of Resistance (nappropriate Therapy) Treatment 6/9 9/9 2/91 soniazid Rifampin Ethambutol Smear Culture Susceptibility soniazid R R R Rifampin S R R Ethambutol S S R Emergence of Resistance (Nonadherence and nappropriate Therapy) Treatment 6/9 9/9 12/9 3/91 6/91 soniazid Rifampin Ethambutol? DOT Smear Culture Susceptibility soniazid S R R R Rifampin S S S R Ethambutol S S R R Evolution of Drug Resistance in a Community First (mis) treatment 3-8 years Acquired resistance New nfection 7-12 years 1-1 years Disease with primary resistance years 2

3 Causes of resurgent tuberculosis in New York City Poverty, homelessness, crowding, substance abuse TB abroad on the rise; immigration from high prevalence countries HV/ADS epidemic Decline of public health infrastructure; lack of accessible health care Marked reduction in TB control program staff and clinic facilities By 1989, less than half of patients who began treatment were cured Percent resistant Patients with resistant isolates New York City, 1991(N=466) Any Anti-TB agent 12. NH NH/RF Never treated Previously treated Nosocomial, HV- related outbreaks of multidrug- resistant TB as of October, 1992 Facility Location Time Period Total Hospital A Miami Hospital B NYC Hospital C NYC Hospital D NYC Hospital E NYS Hospital F NYC Hospital NJ Hospital J NYC Prisons* NYS Total Cases 297 * 24 prison cases are also counted with Hospital C Prevalence of HV and mortality of patients with multidrug-resistant TB as of Oct., 1992 Facility HV+ Mortality Median nterval Hospital A 93% 72% 7 weeks Hospital B* 1% 89% 16 weeks Hospital C 9% 77% 4 weeks Hospital D 91% 83% 4 weeks Hospital E 14% 43% 4 weeks Hospital F 82% 82% 4 weeks Hospital 1% 8% 4 weeks Hospital J 96% 93% 4 weeks Prison System ** 98% 79% 4 weeks * HV infection was part of case definition ** ncludes 24 cases also counted with Hospital C Nosocomial Tuberculosis Common Characteristics Diagnosis was not considered or late diagnosis CXR often atypical for TB neffective or inadequate isolation Most cases in HV seropositive patients Multidrug-resistant strains standard treatment not effective Appropriate treatment also often ineffective for prolonged periods Laboratory results delayed A Multi-institutional Outbreak of Highly Drug-Resistant Tuberculosis Frieden et al. JAMA 1996;276:

4 Characteristics of strain W outbreak Patient Selection Patients were selected from those cared for at public and nonpublic institutions from January 1, 199 to August 1, 1993 Patients had to have isolates resistant to at least /R/E/S and RBT, if testing included it For those suspected of having strain W TB, results of isolate testing by RFLP had to have an identical or closely related pattern to strain W Characteristics of strain W outbreak Results 37 patients met case definition, 267 had isolates for RFLP 78% were sputum AFB smear positive Of 249 with known serostatus, 23 (92%) were HV+ Median survival for the 23 HV+ patients was 66 days 221 HV+ patients had positive cultures from a pulmonary source Patients with strain W had more documented HV infection than other CX+ TB patients (86% vs. 37% ; P<.1) Characteristics of strain W outbreak Epidemiological links (7%) had isolates available for RFLP testing 237 isolates had an identical RFLP pattern (strain W) 3 isolates had RFLP patterns that were very similar to strain W Patients resided in all boroughs and most zip codes in NYC Cared for at 41 hospitals and hospitalized for 19,74 days Characteristics of strain W outbreak Epidemiological links (7%) of 267 were epidemiologically linked 178 (96%) occurred in 11 different hospitals (range 1-76 case/hospital) 3 (2%) were linked in the correctional system (3%) were linked in the community Outbreaks lasted up to 38 months and most took place in 4 hospitals Median time from exposure to disease was 17 weeks Nursery exposure A MDRTB Transmission in a Hospital Nursery H B C H H TB Control: The components of DOTS Political commitment Diagnosis by microscopy Adequate supply of the right drugs Directly observed treatment Accountability TB Register 1991 Dec June 1993 Dec June 1994 Nivin et al. CD. 1998;26:33-7 4

5 Programmatic measures used to control TB in NYC DOT as standard of care ntensive case management Detention until cure for least adherent mproved nfection Control Hospitals Correctional facilities Changes in empiric treatment regimens Mandatory susceptibility testing and reporting 3, 3, 2, 2, 1, 1, Tuberculosis Cases and Rates New York City, * Rate/1, 4, Case Rate 4, # Cases * Rates since are based on Census data. Trends in Tuberculosis - 1 New York City, % fewer cases since % fewer MDRTB cases 88.4% fewer US-born cases 76.9% fewer cases in 2-44 year age group Trends in Tuberculosis - 2 New York City, HV-infected cases decreased from 34% in 1992 to 1% in 21, increasing to 18% in 22 Females increased from 28% in 1986 to 39% in 22 Non-US-born cases increased from 18% in 1992 to 66% in 21, decreasing to 6% in 22 Tuberculosis Cases New York City, Cases Patients on DOT Federal Budget $ in Millions

6 Cluster size among NYC TB patients during three surveys Clustering among NYC TB patients during three surveys Number of clusters Number of patients per cluster Percentage Clustered US born Non US born % 32% 18 18% Percent Clustered Risk factors associated with clustering of TB in NYC MDRTB Black Race Homeless US Born HV Positive DNA Clustering by country of origin, NYC US-Born Patients Non US-Born Patients Clustered Total Culture Clustered Cases Total Culture Overall Cases No. Positive No. (%) Positive % Clustering (%) Cross-Sectional Surveys (NYC April Studies) 1991* % % 37% 1994** % % 32% 1997** % % 18% NYC ncident ME Project cases (2 years) RFLP alone for cases >3 bands % % 29% RFLP and Spoligo for ALL Cases % % 33% * Frieden, et al, 199: includes only cases with strains of >3 RFLP bands. **Unpublished study includes only cases with strains of >3 RFLP bands. Number and Size of DNA Clusters (N=132 clusters) Multivariate Analysis Clustering Number of Clusters Variable Age <6 US-Born Asian History of TB or LTB Low band RFLP OR Adjusted (9% C) Cluster Size (Patients per Cluster) 6

7 Reported TB Cases United States, TB Case Rates, United States, 22 No. of Cases Rate: cases per 1, D.C. < 3. (year target) >.2 (national average) Cases per 1, 2 TB Case Rates by Age Group United States, TB Case Rates by Age Group and Sex, United States, < Age Group (years) Cases per 1, <1 yrs 1-24 yrs 2-44 yrs 4-64 yrs 6+ yrs Male Female Cases per 1, TB Case Rates by Race/Ethnicity United States, Crude Case Rates by Borough New York City, Crude rate/1, New York City Staten sland Queens Bronx Brooklyn Manhattan Asian/Pacific slander Black, non-hispanic Hispanic American ndian/alaska Native White, non-hispanic

8 Health Districts with Case Rate* $2 New York City, 22 Case rates per 1, Central Harlem Manhattan Queens Brooklyn Corona L East Side Bushwick Astoria-LC Fort Greene * Rates per 1, based on Census data. Percent of Eligible* Tuberculosis Patients on Directly Observed Therapy** New York City, 21 % on DOT MDR 7.1 Pulm. smearpositive 82.6 Any DOHMH Rx * Eligible patients were those diagnosed while alive and who received some treatment on an outpatient basis. ** Ever on DOT as of March of the year after being confirmed as a case of tuberculosis All 4 2 Trend in HV-nfection and TB New York City, % of Cases TB/HV nfected 1,4 % TB/HV+ 34% 1,2 33% 34% 33% # TB/HV+ 31% 4 1, 26% 8 22% 22% 3 18% 18% 6 1% HV nfection and Tuberculosis New York City, 22 % of Cases 2.4% 13.7% Males (N = 667) Females (N = 417) 47.2% 48.2% 38.1% 32.4% HV+ HV- Unknown % Coinfection Estimated HV Coinfection in Persons Reported with TB United States, All Ages Aged 2-44 Note: Minimum estimates based on reported HV-positive status among all TB cases in the age group. All 21 cases from California have an unknown HV status. 8

9 HV-nfected US-Born TB Cases New York City, ,4 1,2 1, % nfected # TB/HV Multidrug-Resistant TB* New York City, * *1991 data are incomplete **multidrug-resistant TB or MDRTB: resistant to at last NH & RF W and related strain epidemic curve in NYC, MDRTB Strain W and Variants Number of strains Major multidrug-resistant strains in New York City, W W1 H AB P AU C P1 Other Unique Drug Resistance in New York City, Primary Anti-TB Drug Resistance United States, % of all Cx+ cases with susceptibility results who had drug resistance MDR-TB: resistant to at least NH & RF ODR-TB: resistance to other first-line drugs MDRTB Non MDRTB % Resistant soniazid MDR TB Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin. 9

10 US* and Non-US Born TB Cases New York City, , 3, US-Born Non-US-Born 3,132 2, 2, 1, 1, 7 1, Puerto Rico and U.S. Virgin slands are included as U.S.-born There were 22 cases with unknown country of birth Non-US Born Tuberculosis Cases New York City, % of NYC Cases Percent (66%) 12 1 # of Cases *NYC cases with known country of birth Tuberculosis Cases by Area of Birth and Borough, New York City, Unknown Non-US Born U.S.-born Manhattan Queens Brooklyn Bronx Staten sland 14.9* 14.3* 14.* 12.*.6* *Rate per 1, based on Census High-Burden TB Countries* 1. ndia 12. Kenya 2. China 13. Vietnam 3. ndonesia 14. Tanzania 4. Nigeria 1. Brazil. Bangladesh 16. Thailand 6. Ethiopia 17. Uganda 7. Philippines 18. Myanmar 8. Pakistan 19. Mozambique 9. South Africa 2. Cambodia 1. Russian Federation 21. Zimbabwe 11. DR Congo 22. Afghanistan *As per the World Health Organization Top 1 Countries of Birth NYC TB Cases 22 China Ecuador Dominican Republic ndia Haiti Mexico Republic of Korea Bangladesh Pakistan Russia No. of Cases Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, U.S.-born Foreign-born 1

11 Percentage of TB Cases Among Foreign-born Persons, US >% 2%-49% <2% Cases per 1, TB Case Rates in U.S.-born vs. Foreign-born Persons, United States, U.S. Overall U.S.-born Foreign-born Countries of Birth for Foreign-born Persons Reported with TB United States, 22 Length of U.S. Residence Prior to TB Diagnosis, United States, 22 Other Countries (38%) S. Korea (3%) Haiti (3%) China (%) Mexico (2%) Philippines (11%) Vietnam ndia (8%) (7%) 1% 8% 6% 4% 2% % All Philippines Mexico Vietnam <1 yr 1-4 yrs > yrs New York City Population, 199 and NYC non-us Born Population by Borough % Native non-us Born Non-English speaking 1 Bronx Brooklyn Manhattan Queens Staten sland Source: 199 and Census Profiles Population Division, NYC Department of City Planning Source: 199 and Census Profiles, Population Division, NYC Department of City Planning 11

12 Percent NYC non-us born Population Entering US in Past Ten s Bronx Brooklyn Manhattan Queens Staten sland Source: 199 and Census Profiles Population Division, NYC Department of City Planning NYC non-us born Population by Region Europe Asia Africa Oceania Latin Region America* Northern America 199 Not Reported *ncludes Mexico and Caribbean Source: 199 and Census Profiles, Population Division, NYC Department of City Planning NYC Population and TB Case Rates: Top 12 Countries of Origin for TB cases NYC population 1,222,737 n US <1 years* 384,226 Expected TB cases using: Total population 1,839 n US <1 years 617 Actual 21 Cases in NYC 6 *Estimate applying regional % in US <1 yrs to country-specific population Sources: US Census and WHO estimated TB case rates Limitations of Census Data 199 Census denominators - overestimate incidence rate Time spent outside US for US-born, and reentry for non-us born unavailable mmigration status of non-us born TB cases not available Current Prevention Strategies mproving LTB treatment completion for high risk individuals Targeted testing in high risk communities Screening of immigrants dentifying missed opportunities for TB prevention LTB Treatment Treatment for LTB is resource intensive and has limited success soniazid treatment for 9-12 months is 7% effective Cost per case prevented $14,8 Cost per TB case $16,391 But if completion rate is %, it is not cost effective Source: nstitute of Medicine, Ending Neglect, 12

13 7% 6% % 4% 3% 2% 1% % LTB Treatment Completion Rates DOHMH Chest Centers Contacts Medical Population Yield of targeted tuberculin testing is low Results of targeted testing in Haitian and Ecuadorian communities, NYC (n=38) TST positive (n=116) 38% Completed medical evaluation 9% Started treatment for LTB 33% Completed treatment 13% *21 data are preliminary Screening of mmigrants/refugees mmigrants/refugees (>1 years of age) are screened by chest x-ray and sputa before entry Non-infectious disease - required to report to health department at destination Account for small proportion of foreign-born cases n NYC, on average 2/year 2% of FB cases in 21 Excludes majority of foreign-born (tourists, students, temporary workers, undocumented) Will there always be 1 TB cases per year in NYC? Non-US born population increasing in NYC Prevention strategies are resource intensive and have limited success mmigrant screening abroad covers small proportion of cases in non-us born Case rates in country of origin and recent arrival in US strongest predictors of disease mported TB likely to continue to contribute significantly to NYC cases in near future Challenges in the Future HV infection and congregate settings Continued high immigration from high incidence countries Potential for decreased vigilance in hospitals Decreased funding nternational TB efforts not moving at the pace needed to fulfill WHO goals 13

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