TB in California: Costs, Transmission, and Selecting from the Latent Pool

Transcription

1 TB in California: Costs, Transmission, and Selecting from the Latent Pool Pennan Barry, MD, MPH Tuberculosis Control Branch California Department of Public Health California Tuberculosis Controller s Association Conference May 15, 2012

2 This Presentation Review of 2011 California data Pediatric TB What proportion is from transmission? How much does managing TB cases in California cost? Can we focus prevention efforts? 2

3 TB in California, 2011 Janice Westenhouse Melissa Ehman 3

4 Final TB Case Count and Rate California, ,319 cases 0.4% decrease from 2010 (n=2,329) TB rate = 5.9 per 100,000 population 1.7% decrease from 2010 (rate = 6.0) 4

5 Number of Tuberculosis Cases: California, ,000 10,000 6,000 5,000 4,000 8,000 6,000 4,000 2, ,000 2,000 1, Year

6 Number of Tuberculosis Cases Case Rate per 100,000 3,400 Tuberculosis Cases and Case Rates California, , ,000 2,800 2,600 2, % -5.9% -0.4% , , Year TB Cases TB Rate 0 6

7 Rate (per 100,000 TB Case Rates, California

8 Essential (Obvious?) Question Why a stall in the prior decline? Returning to normal after 2 larger declines? Were there increases in TB among subpopulations? 8

9 Number of cases TB cases by place of birth California, % Foreign-born Foreign-born US-born 9

10 Number of foreign-born cases Years in US at TB diagnosis, n=581 n= <=1 yr 1-5 yrs 5-10 yrs yrs 20+ yrs 10

11 Number of cases TB cases by age group,

12 Cases Pediatric Cases by Age Group,

13 Pediatric TB Cases 0 4 yrs 7% 6% 329 California, % 4% 3% % 1% 0% Cochrane-Armitage Trend Test: p value <

14 Pediatric TB (0 5 yrs) California Race/ethnicity (2011): 71% Hispanic Drug resistance ( ): 27% with drug-resistance; 19% PZA mono-r US-born (2011): 93% Account for 16% of all US-born cases 14

15 Diagnosis (Verification) Criteria Pediatric TB Cases (0 5), Criteria Culture + 30% 26% NAAT or Smear + 3.3% 4.5% Clinical Case 43% 60% Provider Diagnosis 23% 10% 15

16 Reason for TB Evaluation: TB in Children 0 5, CA, Contact investigation 37% TB symptoms 27% Abnormal CXR 30% Targeted testing 3% Immigration exam 2% 44% contact to infectious TB patient* * Evaluated in a contact investigation or linked contact to an infectious TB case 16

17 Sites of TB disease: Children aged 0 5 years, Pulmonary TB* 78.6% Lymphatic cervical TB 11.0% CNS TB 5.5% Intrathoracic lymphatic TB 4.5% Other lymphatic TB 2.7% Bone TB 1.5% Peritoneal TB 0.5% * Pulmonary TB alone or with other sites 17

18 Proportion of TB Cases in Children 0 4 that are CNS TB, % 10% 8% 6% 4% 2% 0%

19 Proportion CNS TB in Children 0 4 yrs California, % 10% 8% 6% p=.004 4% 2% 0%

20 Deaths with TB, CA % % 8% % 4% 2% 0% Cochran-Armitage Trend Test: p value <

21 Number of MDR TB Multidrug-resistant TB, : 33 MDR TB cases; 1 XDR TB case Percent MDR TB cases

22 MDR TB: % Foreign-born by year 100% 80% 60% 40% 20% 0% 93% 90% 97% 92% 91%

23 Number and Proportion MDR TB by Country/Region of Origin, CA Country/Region No. % Former Soviet Republics Laos Burma South Korea Peru Ethiopia Philippines Vietnam Central America India Taiwan China Mexico Kampuchea United States Countries with >50 cases tested for MDR

24 TB in California, 2011 No substantial overall decline from 2010 Increases: TB in children including CNS TB (Sentinel Event) Older persons / foreign-born in US >20 years MDR case number Deaths: still nearly 1 in 10 24

25 Recent Transmission Lisa Pascopella 25

26 New Opportunity 26

27 Epi-Cluster TB case, counted in 2011 Epi-link on RVCT to at least 1 other case: Within 2 year window (report year 2009, 2010, or 2011) 27

28 Other RVCT indicators of transmission Additional TB Risk Factors: Contact to infectious TB case Missed contact Contact to MDR TB patient Reason for evaluation: Contact investigation Child <5 years old 28

29 TB cases identified in Epi-clusters, TB cases in epi-cluster 133 in person clusters 12 3-person clusters 5 4-person clusters 1 7-person cluster 29

30 Recent transmission, (6%) in Epi-clusters 125 (5%) contacts (to infectious TB cases, or to MDR TB cases, or missed) 93 (4%) reason for evaluation = contact investigation 81 (4%) aged 0 4 years 30

31 At least 8% of 2011 TB Cases Involved in Recent Transmission 133 in epi-clusters -3 nonmatching genotypes +60 at least 1 RVCT transmission indicator 190 (8%) Total TB cases involved in recent transmission 31

32 Number of epi-linked cases is an underestimate of recent transmission In 2011, at least 5 LHJs reported outbreaks, but did not report epi-links 32

33 MIRU 2 clusters, ,317 total TB cases in ,815 (78%) culture positive 1,406 (77%) with a genotype result 1,034 (74%) in statewide cluster 197 (14%) in LHJ cluster 33

34 How much does managing active TB in California cost? Peter Oh 34

35 Components of direct TB costs included Hospitalization Physician fees Inpatient Outpatient Outpatient case management Laboratory and imaging tests Anti-TB medications 35

36 Cost data sources Measure / objective Reported costs of any of the components Physician costs (fee reimbursements) Laboratory test costs (fee reimbursements) MDR TB medication costs Adjust reported health care worker salaries to California levels Source PubMed search of published articles stating costs in the U.S., Medicare Physician Fee Schedule, 2011 Medicare Clinical Diagnostic Laboratory Fee Schedule, 2011 MDR Service estimate derived from CITC/CDPH, 2008 National Compensation Survey, 2010 Adjust costs to current dollars Consumer Price Index,

37 MDR TB ALL CASES Assumptions Assumption Initial new patient visit, then monthly established patient visits (medium clinical complexity) $46/h salary for 152 h of NCM time during 28-week treatment period (456 hrs for MDR) Drug Prices from 340B Program 50% hospitalized 75% of MDR hospitalized; 1.7 times per patient MDR TB monitoring performed as recommended (i.e., Liver function tests baseline and monthly while on PZA, ethionamide or PAS) Treat 24 mos after culture conversion at 2 months 8 mos: CM, LNZ, LFX, CS, PZA 18 mos: PZA, LNZ, LFX, CS Source Standard practice Rubado et al, 2008; National Compensation Survey, 2010 MDR/XDR TB enhanced surveillance * MDR TB Service MDR TB Service 37

38 Estimates of Average Direct Costs Component Per Patient TB $ per patient MDR TB $ per patient Hospitalization 10,100 15,900 63,800 Physician fees 1,500 1,900 7,000 Outpatient case management Laboratory and imaging tests 8,200 24,600 1,900 4,200 TB medications ,700 48,000 Total 22,200 28, , ,600 38

39 Estimated Total Direct Costs of TB Care in California (2011 $) Year Total Cases MDR Cases Estimated Costs (Million $) Total

40 Limitations Perspective Health care system perspective does not include societal costs of TB Private sector costs not measured Public health costs not directly related to care not included contact investigation / treatment of contacts 40

41 Medical risk factors: Can we focus prevention efforts? Ellen Demlow Peter Oh Janice Westenhouse

42 Medical risk factors among TB cases >15 years of age, 2011 Risk Factor All Cases USborn Foreign-born All 10+ yrs in US Diabetes 24% 15% 27% 34% End stage renal disease 3.8% 3.8% 3.9% 5% HIV-positive* 4.5% 6.9% 4.0% 4.0% Other immunosuppression 7% 6% 7% 9% Post-organ transplant <1% <1% <1% 1% One or more risk factor 35% 29% 36% 42% *HIV-positive among all cases, including those not tested, etc. 42

43 TB Population Attributable Risk % 20 by Co-Morbidity, % Cases Attributed Organ Transplant POT ESRD HIV Diabetes PAR%: the proportion of TB in the overall population that is attributable to the medical risk and could be eliminated if the risk were eliminated 43

44 DM/TB Rates by Nativity Adults, CA, Categories Total Cases TB Cases among diabetics * (%) 1014 (23.4) TB Rate per 100,000 Diabetics TB Cases among nondiabetics (%) (77.0) 6.6 Risk Difference per 100,000 (95% CI) 15.2 (13.8, 16.5) Relative Risk (95% CI) 3.3 (3.1, 3.5) U.S.-born 117 (11.5) (19.7) 1.9 TB Rate per 100,000 nondiabetics Foreignborn 885 (87.3) (78.3) (1.8, 3.1) 30.7 (27.6, 33.8) 2.2 (1.8, 2.7) 2.9 (2.7, 3.2) *All cases are among the adult population 18 years of age 44

45 DM/TB Rates by Race/Ethnicity White Not Hispanic Black Not Hispanic Adults, CA, TB Cases among diabetics*(%) TB Rate per 100,000 diabetics TB Cases among nondiabetics (%) TB Rate per 100,000 nondiabetics 47 (4.6) (9.7) (3.3) (7.1) 8.7 Hispanic 405 (40.0) (33.7) 7.0 Relative Risk (95% CI) 2.2 (1.6, 2.9) 1.0 (0.7, 1.4) 3.0 (2.7, 3.4) US Born 56 (13.8) (19.3) (2.1, 3.8) F-Born 341 (84.2) (75.3) (2.5, 3.2) 3.9 (3.5, 4.3) US Born 10 (1.9) (3.5) (1.1, 4.1) Asian/PI 526 (51.9) (48.4) 24.0 F-Born 513 (97.5) (46.4) (3.6, 4.4) *All cases are among the adult population 18 years of age 45

46 DM/TB: Reason for Evaluation, Adults, CA, Reason for Evaluation TB- No Co-Morbidity n=3313 (%) TB-DM n=1014 (%)* TB Symptoms 2017 (60.9) 705 (69.5) Abnormal Chest Radiograph 600 (18.1) 187 (18.4) Incidental Lab Result 262 (7.9) 75 (7.4) Total Passive Case Finding 2879 (86.9) 967 (95.4) Contact Investigation 164 (5.0) 11 (1.1) Targeted Testing 74 (2.2) 8 (0.8) Healthcare Worker 11 (0.3) 1 (0.1) Employment/Admin Testing 37 (1.1) 3 (0.3) Immigration Medical Exam 133 (4.0) 19 (1.9) Total Active Case Finding 419 (12.6) 42 (4.1) Unknown 15 (0.5) 3 (0.3) *All cases are among the adult population 18 years of age 46

47 Benefits of Screening Foreign-born Persons with Diabetes Focus on persons in US for >10 years Many/most accessing healthcare Not being done now Screening foreign-born cost effective Plausible biologic basis of increased risk IFN-γ, IL-12, Th1 response Linas, et al. Am J Respir Crit Care Med Sep 1;184(5): Jeon et al. PLoS Med Jul 15;5(7):e

48 TB Control Strategies Quickly diagnose and treat active cases Priority 1 Activity Expensive Stop transmission Effective treatment of active cases Contact Investigation, treatment of infected contacts Prevent pediatric cases Treat latent pool of infections 3HP Foreign-born diabetics 48

49 Summary More than 8% involved in recent transmission (known underestimate) Repeat analysis planned Nearly $0.5 Billion estimated direct healthcare costs of TB in California over 6 yrs Baseline for cost effectiveness analyses 1/3 of foreign born TB cases with DM Can we focus screening for TB infection? 49

50 Acknowledgments Surveillance and Epidemiology Section TB Registry Allison Kelley Jenny Flood Local TB Control Programs Pennan Barry, MD, MPH