Tuberculosis Mortality Risk Factors in New Mexico. NM Dept of Health/UNM Brown University

Transcription

1 Tuberculosis Mortality Risk Factors in New Mexico NM Dept of Health/UNM Brown University

2 Objectives Background of TB landscape nationally and locally Methods Preliminary results

3 TB Incidence Rates 2016 ~3/100,000 22/100,000 WHO. Global Tb Report

4 Not much change over last few years CDC. TB Incidence in the United States,

5 NM is a lower incidence state (~2/100,000) National average ~3/100, rd /50 Light green= <2.9 (2016 national average Dark green= >2.9 Cases per 100,000

6 National TB Mortality Rate ~5% case fatality rate CDC. Reported Tb in the United States. Div of Tb Elimination

7 Tb Mortality Data New Mexico 1 Year Tb Cases Reported Deaths Crude Death Rate Population Adjusted Death Rate % case fatality adjusted mortality rate per 100, % California case fatality 2006 (268/2778) 2 1 New Mexico Dept of Health. Tb Division J. Fournier, J Sprinson et al. TB Death Assessment Tool in California: Development and Pilot Test. CA dept public health.

8 Previous U.S. TB Mortality Studies Beavers et al. TB mortality in the U.S.: Epidemiology and Prevention Opportunities. Annals ATS. June 2018 Hannah et al. Sociodemographic and clinical risk factors assoc. w/tb mortality in the US, Public Health Reports Waitt et al. A systematic review of risk factors for death in adults during and after tuberculosis treatment. Int J Tuberc Lung Disease. Apr Bailey et al. Missed Opps for TB Diagnosis. Int J Tuberc Lung Disease. August 2011

9 TB Mortality in the U.S adults w/tb who died before therapy completion 1039 frequency matched controls who completed TB treatment 13 states (65% total U.S. burden) RVCT data Blue=TB unrelated death Red= TB related death Beavers et al. TB mortality in the US. Epidemiology and prevention opportunities. Annals ATS. June 2018 (15);

10 Methods 11 year retrospective chart review ( ) Public health records Inpatient/outpatient records Death certificates All mortality charts reviewed by pulm/ccm PGY 6 Controls reviewed by pulm/ccm PGY 4 All TB relatedness of death and Missed Opps confirmed by 2 TB experts

11 Methods Primary analysis 2:1 age, gender, ethnicity matched case/control analysis Report of verified cases of tuberculosis Secondary analysis using mortality cases (n=83) TB relatedness of death Missed opportunities in diagnosis Patient delays Provider delays Treatment delays Accuracy of death certificate Tool to Assess Missed Prevention Opportunities of TB Related Deaths CDC recommends evaluation for missed opportunities 1 No gold standard for defining TB related death 1 CDC essential components of TB prevention and control program. Recommendations of the Advisory Group for the Elimination of TB. MMWR 1995;44 (No. RR 11).

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13 Definition of TB relatedness Using extent and severity and consequences of TB disease: Definitely Possibly Unlikely Definitely Not

14 4 points triggers TB index of suspicion (+time criteria =delay) Step 1 (Index of TB Suspicion)

15 Step 2 Inpatients treatment delay = >3 days from the date that the total score on Prelim 1 + Prelim 3 was first > 7 Outpatient treatment delay = initiation of treatment >7 days from the date that the total score on Prelim 1 + Prelim 3 was first at least 7 Do not need AFB or culture positivity Step 3

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17 Where are our TB cases reported from?

18 County # County # Sandoval 17 Rio Arriba 6 Dona Ana 29 Eddy 2 Lea 6 Roosevelt 1 Bernalillo 59 Socorro 6 Cibola 7 Otero 2 Valencia 10 Mora 1 McKinley 26 Chaves 5 San Juan 29 Curry 3 Santa Fe 13 Luna 2 Taos 1 San Miguel 2 Includes cases and some controls (n=227) Cases: Bernalillo (19), Dona Ana (14), McKinley (9), San Juan (9), Sandoval (9)

19 Tb Rate Border Region NM Dept of Health. Border Health Report

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22 Heinsius, Ryan. Federal Report Shows Poor Tribal Road Conditions Contribute to Student Absenteeism. NPR. Arizona Public Radio. May 23, 2017.

23 Age Distribution Male: 50 of 83 (60.2%) Female: 33 of 83 (39.8%)

24 Mortality by Race/Ethnicity Hisp n=37 (44%) Native American n=31 (37%) Non Hisp White n=7 Asian n=7 Black n=2 Race Percentage of state pop Black 2.5 White 37.5 Asian 1.7 Hispanic 48.8 Native American 10.6 Native Hawaiian/Pacific 0.2 Islander U.S. Census Bureau. Population Estimates Jul 2017.

25 All TB deaths, Native American TB deaths

26 Native American TB deaths by TB relatedness

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28 Occupation

29 32.5% 8.4% Reactivation? (from MEX w/ hx previously treated TB, RA on pred 5 qd, MTX and adalimumab) 12% 7.2% 13.3% 28.9% 31.3%

30 Other interesting variables # Hypothyroid 22 Not a previously described mortality risk factor significance? Cognitive impairment/ Depression 17 Hyponatremia 41 HIV # POS 6 NEG 38 Not offered 36 Unknown 2 Refused 1 Inability to SA meds probably not a factor due to DOT Na<135 on admission poor prognostic marker of pulmonary TB? SIADH mechanism? CD4 counts HAART compliance Increased mortality OR? (Total) 83

31 Duration of TB Symptoms Prior to Diagnosis or Treatment 25 Case Patients Average = 27 weeks 20 Patient ID number Duration of Symptoms (weeks) mortality data (Richter, Burgos) Average 27 weeks (9.5 wks if 2 largest outliers thrown out)

32 25 Length of TB Treatment Prior to Death Case Patients Average = 7 weeks 20 Patient ID number Length of TB Treatment (weeks) late starts Average ~7 weeks mortality data (Richter, Burgos)

33 Competing Diagnosis before TB? Competing Diagnosis AWS/SBP/ AAH Competing Diagnosis 2 Lymphoma 3 CAP/HAP/LRTI 35 Sarcoid/neurosarcoid 2 AE COPD 4 Nocardia 1 Acute PE 1 Cellulitis (neck) 1 Lung 1 Bacterial meningitis 2 abscess Influenza 1 UTI 2 Cancer 6 Depression 1 Renal 2 Seizure 1 failure Chronic vertebral osteo NOS 1 CHF 1

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35 Pulmonary vs Extra pulmonary Extrapulmonary site # Extrapulmonary site # Pleural 6 Peritoneal 4 Lymphatic 4 Subcutaneous 1 Bone 2 Spinal cord 2 Genitourinary 1 Brain 2 Meningeal 2 Duodenum 1 Pericardium 1 Jejunum 1 Other 1 (Total) 28

36 Death Certificates Line on death certificate TB mentioned TB relatedness of death Primary 16 Definitely: 13 Possibly: 1 Unlikely: 1 Definitely Not: 1 Secondary 6 Definitely: 5 Possibly: 2 Unlikely: 1 Definitely Not: 0 Tertiary 3 Definitely: 3 Possibly: 0 Unlikely: 0 Definitely Not: 0 Line on death certificate TB mentioned TB relatedness of death Quaternary 2 Definitely: 1 Possibly: 0 Unlikely: 1 Definitely Not: 0 Other 11 Definitely: 5 Possibly: 4 Unlikely: 2 Definitely Not: 0 Total % concordance for TB related deaths CA DOH 53% 1 J. Fournier, J Sprinson et al. TB Death Assessment Tool in California: Development and Pilot Test. CA dept public health

37 TB Relatedness of death NM DOH: 79.5% California DOH: 85% 1 J. Fournier, J Sprinson et al. TB Death Assessment Tool in California: Development and Pilot Test. CA dept public health

38 Susceptibility data

39 Provider Delay for TB in New Mexico ( ) 45.8% Native American cohort experienced a higher rate of provider delays (51%) J. Fournier, J Sprinson et al. TB Death Assessment Tool in California: Development and Pilot Test. CA dept public health

40 Patient Delay for TB in New Mexico ( ) 42.2% Native American cohort experienced a lower rate of patient delays (39%)

41 Conclusions Forthcoming Vulnerable populations at the U.S./Mexico border Disproportionately high TB mortality rate amongst Native Americans Increased provider delay rate amongst the Native American cohort compared to all comers Sub analysis

42 Future Directions Continued use of the TB mortality risk assessment tool for future mortality cases GIS mapping genotypes to look for clusters of TB infection Distribution of REDCap database

43 Thank you! Anna Makaretz MS MPH Diana Fortune RN TB nurse consultants Nick Villalobos MD Marcos Burgos MD Jane Carter MD Sam Rosenthal MPH

44 Rajiv Patel PGY 6 Pulmonary/critical care medicine rajiv_patel@brown.edu