2016 Annual Tuberculosis Report For Fresno County

Transcription

1 206 Annual Tuberculosis Report For Fresno County

2 Cases Rate per 00,000 people 206 Tuberculosis Annual Report Fresno County Department of Public Health (FCDPH) Tuberculosis Control Program Tuberculosis Cases and Rates in Fresno County Tuberculosis (TB) is a common communicable disease caused by the bacterium Mycobacterium tuberculosis and occasionally Mycobacterium bovis. It most commonly infects the lungs, but can infect almost any organ system. In 206, 60 new cases of active TB were diagnosed in Fresno County (6. per 00,000 population); a 42.9% increase in the annual number of cases from 205 (Figure ). Out of the 6 health jurisdictions in California, Fresno County ranked 0 th for active TB cases, representing 2.9% of all California cases Figure. Annual TB Case Counts and Rate - Fresno County, Cases Rate CA 209 Goal 0 Demographic Characteristics In 206, 44 (73.3%) cases were male and 6 (26.6%) were female. Most TB cases occur in older adults and in Fresno County, 32 (53.3%) were over the age of 50 (Figure 2). Only 3 TB patients were under the age of five. The average age of TB patients in Fresno County during 206 was 50.4 years with a range from to 95 years. In 206, 6 (26.7%) TB cases were among US-born residents, while the remaining 43 (7.7%) were among foreign-born persons (Figure 3). The nativity of (.7%) TB patient is unknown. The majority of foreign-born cases 48.8% (n=2) arrived from Mexico, and others arrived from: India 8.6% (n=8), Laos 6.3% (n=7), Philippines 7.0% (n=3), Cambodia 2.3% (n=), Vietnam 2.3%

3 Cases (n=), El Salvador 2.3% (n=), and Nigeria 2.3% (n=) (Figure 3). Foreign born TB patients spent an average of 29.3 years in the US prior to their TB diagnosis. Figure 2: Age Distrubtion of TB Cases in Fresno County Age Range (years) Figure 3: TB Cases by Nativity and Country of Origin - Fresno County, 206. Unknown.7%(n=) Nigeria 2.3%(n=) Native Born 26.7%(n=6) Mexico 48.8%(n=2) Philippines 7.0%(n=3) Vietnam 2.3%(n=) Foreign Born 7.7%(n=43) Laos 6.3%(n=7) India 8.6%(n=8) Cambodia 2.3%(n=) El Salvador 2.3%(n=)

4 Case Rate (Per 00,000 people) Racial and ethnic disparities exist among populations with TB disease in Fresno County (Figure 4 & Figure 5). The combined TB incident rate in Fresno County for 206 is 6. per 00,000 people. That rate for Asian/Pacific Islanders, Blacks/African Americans, Hispanics/Latinos, and Whites is: 25.8, 8.8, 5.7, and.3 per 00,000 people respectively (Table ). The proportion of the total Fresno County population represented by each race/ethnicity is at the far right of Table. Figure 4: TB Cases by Race/Ethnicity - Fresno County, 206. Black/African American 7%(n=4) Hispanic/Latino 46%(n=28) White 7%(n=4) Asian/Pacific Islander 40%(n=24) Figure 5: Incident Rates of TB by Race/Ethnicity - Fresno County, Asian/Pacific Islander Black/African American Hispanic/Latino White

5 Cases Table : Incident Rates of TB by Race/Ethnicity - Fresno County, 206. Race/Ethnicity Cases Incidence Rate* % Population** Asian/Pacific Islander Black/African American Hispanic/Latino White *Per 00,000 people. **Population estimates retrieved from Figure 6 shows the occupational status of those with TB disease in Fresno County during 206. Most cases, 60.0% (n=36), were not employed because they were: not seeking work 33.3% (n=20), retired 2.6% (n=3) or unemployed 5.0% (n=3). Those employed with a TB diagnosis represent 40.0% (n=24) of cases. 30 Figure 6: Occupational Status of TB Cases - Fresno County, Working Not Seeking Work Retired Unemployed 3

6 Figure 7: TB Cases by Zip Code - Fresno County, 206.

7 Case Referral by Source Cases of TB were referred to the Fresno County Department of Public Health from different sources. Of the 60 cases, 80% (n=48) were referred by hospitals, 3% (n=8) by private doctors, 5% (n=3) by contact investigation, and 2% (n=) as lab referrals (Figure 8). Figure 8: Referral Souces for TB Cases - Fresno County, 206. Contact Investigation 5%(n=3) Hospital 80%(n=48) Lab 2%(n=) Private Doctor 3%(n=8) Pathology and Organism Characteristics Forty-eight (80.0%) patients had lung involvement, of which 45 (75.0%) had lung involvement only. Of these 48, three had pulmonary infection combined with infection in: bone in case (.7%), cervical lymph nodes in case (.7%), and genitourinary involvement in case (.7%). Twelve patients (20.0%) had extrapulmonary infection in the: cervical lymph nodes 5 (8.3%), lung pleura 4 (6.7%), axillary lymph nodes (.7%), and bone (.7%) tissues (Table 2). Table 2: Cases of TB by Site of infection Fresno County, 206. Infection Site* Cases Pulmonary Cervical Pleural Axillary Bone Peritoneal Genitourinary *A blue box indicates infection and a grey box indicates no infection.

8 Culture positive results were obtained on 78.3% (n=47) of the 60 TB patients. Of these, drug susceptibility results are available for 87.2% (n=4) cases. No drug resistance was observed in 80.4% (n=33) of cases, while the remaining 9.5% (n=8) of cases showed resistance to: Isoniazid 7.3% (n=3), Isoniazid + Streptomycin 2.4% (n=), Isoniazid + Ethionamide 2.4% (n=), Rifampin 2.4% (n=), Streptomycin 2.4% (n=), and Pyrazinamide 2.4% (n=) (Table 3). No cases of TB in 206 were multi-drug resistant (MDR) or extensively drug resistant (XDR). Table 3: Drug Resistance Profile for TB Cases - Fresno County, 206. Tuberculosis Drug* Cases Isoniazid Rifampin Streptomycin Ethionamide Pyrazinamide 33 3 *A blue box indicates resistance and a grey box indicates no resistance. Tuberculosis has different strains or lineages that can be determined through genotyping. When two or more TB cases share the same genetic strain or lineage, they potentially became infected through a common source. The TB program can use genetic links between TB cases to investigate and stop common sources of transmission. Figure 9 shows the proportion of each lineage in TB cases sent for genotyping from During 206, 85% (n=5) of cases were genotyped and composed of four lineages: EuroAmerican 58.8% (n=30), IndoOceanic 7.6% (n=9), East Asian 5.6% (n=8), and East African Indian 7.8% (n=4). 00% 80% 60% 40% 20% Figure 9: Proportion of Different TB Lineages - Fresno County, % EuroAmerican East Asian IndoOceanic East African Indian Bovis

9 Contributing Risk Factors During 206, 55 (9.6%) of the 60 TB cases had at least one or more underlying factor that increased risk for TB infection or progression of infection to disease whether it be occupational, social, or medical (Tables 4 & Table 5). For those TB patients with chronic medical issues, 28.0% (n=7) had at least one or more comorbidity. Other known risk factors for TB disease not present in the 206 cases include: Prednisone treatment, TNF-α antagonist treatment, smoking, being underweight and incarceration. Table 4: Occupational and Social Risk Factors that Increase Risk for TB Infection by Nativity - Fresno County, 206. Risk Characteristic U.S. Born N Foreign Total N (%) (%) Born N (%) Health Care Worker 0 (0.0%) (.6%) (.6%) Migrant/Seasonal Worker 0 (0.0%) 0 (6.6%) 0 (6.6%) Homeless 2 (3.3%) 3 (5.0%) 5 (8.3%) Resident Long Term Care 4 (6.6%) 0 (0.0%) 4 (6.6%) Facility Contact To Infectious TB 6 (0.0%) 0 (0.0%) 6 (0.0%) Table 5: Medical Risk Factors that Increase Risk for TB Infection Progressing to TB Disease - Fresno County, 206. Comorbidity U.S. Born N Foreign Total N (%) (%) Born N (%) Diabetes (.6%) 0 (6.6%) (8.3%) End Stage Renal Disease 0 (0.0%) 2 (3.3%) 2 (3.3%) HIV Positive (.6%) (.6%) 2 (3.3%) Immunosuppression (.6%) 0 (0.0%) (.6%) Alcohol Abuse 0 (0.0%) 5 (8.3%) 5 (8.3%) Drug Abuse 0 (0.0%) (.6%) (.6%) TB Reactivation 0 (0.0%) (.6%) (.6%)

10 Percent Percent Of the 60 TB patients in 206, 54 were eligible for HIV testing and all of them completed testing. Six cases (0%) were excluded from HIV testing because they either died before testing (n=4), or were younger than age five without risk factors for HIV (n=2) (Figure 0) Figure 0: Proportion of TB Patients with Known HIV Status (Positive or Negative) Fresno County, % Reported Positive or Negative CA 209 Goal Treatment Outcomes Of the 60 cases of TB in Fresno County during 206, 28 had positive sputum culture results at the time of treament initation. After 60 days of treament, 20 (7.4%) patients had sputum-culture negative results indicating they were no longer contagious for TB (Figure ) Figure : Proportion of TB Patients with Sputum Culture Conversion Within 60 Days - Fresno County, % Converted 60 Days CA 209 Goal

11 Percent Treatment courses for TB are long and standard treatment regimens are 6-2 months; furthermore, drug resistant TB patients may be treated for up to two years. Due to the long time frame for treatment, data for 206 treatment completion is not available at the time of this report; however, this information is available for the 205 TB cohort. During 205, 85.7% (n=36) of the 42 TB patients were eligible to complete their treatment within a 2 month period. Of these 36 patients, 9.7% (n=33) completed their treatment within one year (Figure 2). The remaining nine TB patients: completed treatment after 2 months.9% (n=5), 7.% (n=3) died, and 2.3% (n=) were unable to complete therapy. The one patient that did not complete therapy left the United States before treatment completion. Delays or intermittent interruptions in treatment can result from factors such as: multidrugresistant TB, patient non-compliance, underlying health conditions, and adverse effects of medication. Figure 2: Proportion of Fresno County TB Patients Completing Treatment in 2 Months or Less, * Completed Treatment 2 Months CA 209 Goal % *For patients with TB in which 2 months or less of treatment was indicated. In late 205, the TB Control Program began documenting 3HP treatment completion in LTBI patients (Figure 3). 3HP treatment is one treatment method for LTBI and requires patients take Isoniazid and Rifapentine antibiotics once weekly for twelve weeks. Between September December of 205, LTBI patients began treatment, 8.8% (n=9) finished treatment, and 8.2% (n=2) did not finish treatment. In 206, 40 LTBI patients began 3HP treatment. Of these 90.7% (n=27) finished treatment and 9.3% (n=3) did not finish treatment.

12 Percent Percent Figure 3: Proportion of LTBI Patients with 3HP* Treatment Completion - Fresno County, Completed Treatment Completed Treatment 2 Weeks Did Not Complete *3HP treatment consists of a once weekly dose of Isoniazid and Rifapentine for 2 weeks. 9.3 Contact Investigation Contact investigation data for 206 is not available at the time of this report; however, this information is available for the 205. During 205, 52.3% (n=22) of 42 TB cases were AFB smear-positive and 00% of these cases had contacts elicited for investigation. Out of the 56 AFB smear-positive contacts elicited, 76.6% (n=395) were examined for TB infection (Figure 4). Of the AFB smearpositive contacts examined in 205, 8.2% (n=72) were discovered to have LTBI infection and 73.6% (n=53) of these patients began treatment (Figure 5) Figure 4: Contacts to AFB Smear Positive Cases Examined for TB - Fresno County, % AFB Smear + Contacts Examined CA 209 Goal

13 Percent Figure 5: Contacts to Sputum AFB Smear Positive TB Cases with LTBI Treatment Status Fresno County, Started Treatment Did Not Start Treatment CA 209 Goal %

14 Tuberculosis Burden in Fresno County In 206, the Fresno County Health Department s TB Control Program provided treatment, contact investigation, and follow-up for all the 60 newly diagnosed active TB cases. The TB program staff continued to simultaneously provide care for patients diagnosed prior to 206 who had not yet completed treatment (standard treatment regimens are 6-2 months; drug resistant TB patients may be treated for two years and all require at least monthly visits). To ensure TB medication is taken correctly, department staff visit pulmonary TB patients daily to observe them take their medications; this is also known as Direct Observed Therapy (DOT). Tuberculosis Burden at Global, National and State Levels Global Tuberculosis (TB) is one of the world s deadliest diseases and one-third of the population has latent TB infection. During 205, 0.4 million people developed active TB resulting in.8 million deaths from the illness. TB is especially known to impact low and middle income countries where 95 percent of cases occur. TB is a leading killer of people who are HIV infected, and in 205, 35% of HIV deaths were due to TB complications globally. National A total of 9,557 TB cases (a rate of 3.0 cases per 00,000 persons) were reported in the United States in 205. This is a.6% increase in TB cases from 204, however; the incident rate has remained stable at around 3.0 cases per 00,000 people since 203. TB persists at greater incidence rates in specific populations such as those who are foreign born and in racial/ethnic minorities. California In 205, a total of 2,33 cases were reported compared to 234 cases in 204. Twenty percent of the nation s TB cases were reported from California during 205. The decrease in the TB incident rate in California has slowed over the past decade and flattened during 205. During , the annual TB rate remained at 5.5 cases per 00,000 people. Tuberculosis cases were reported in 42 of California s 6 (69%) local health jurisdictions. Twelve of 27 (44%) local health jurisdictions with at least 5 cases in 205, had an increase in cases compared to 204 An estimated 2.4 million Californians (6%) are infected with latent TB and at risk of developing active TB if not properly diagnosed and treated. Among this group,

15 only 3% have been treated and only 23% are aware of their infection. Latent TB treatment is critical because an estimated 80% of active TB cases develop from latent TB infections. Multidrug-resistant TB (MDR TB) is resistant to the strongest two primary antituberculosis medications (isoniazid and rifampin), and extensively drug resistant TB (XDR TB) organisms are resistant to these medications plus at least two of the principal secondary medications. Patients with XDR TB have few treatment options because the drugs most effective against TB are ineffective against their disease. In California, MDR TB has remained a small proportion of TB cases (- 2%) during despite the growth of MDR TB cases throughout the world. The majority (85%) of California counties with reported TB cases have had at least one MDR TB case in the last 7 years ( ). No Extensively Drug Resistant (XDR) TB cases were reported in California during 205 and only 3 XDR TB cases were reported in California during Sources: World Health Organization: Centers for Disease Control: California Tuberculosis Control Branch: Public Health Strategies to Control, Prevent, and Eliminate Tuberculosis Include: - Finding and adequately treating persons that have active disease 2- Identifying individuals who have been exposed to someone with TB disease, evaluating them for TB infection or TB disease, and treating them if they have either of these. 3- Screening individuals for TB infection that are known to be at higher risk for infection with TB or at higher risk for developing TB disease if infected. 4- Applying control measures in high risk settings. The FCDPH Chest Clinic Program identifies and treats TB disease, identifies and evaluates exposures to TB and offers treatment if needed, screens certain high risk populations, and assists the public with the application of control measures in high risk environments. Title 7 of California Code of Regulations requires that notification be given to the county health department of all diagnosed or suspicious cases of tuberculosis by telephone or fax within one working day of identification. California Health and Safety Code 2362 also require that providers treating persons with active TB report to the local health officer any pertinent information the health officer requests. Additional Information Available If you have any questions regarding TB infection or disease or the control of TB in Fresno County please contact our Community Liaison Nurse at