TB Infection Who is Testing and Treating? TB Control and Elimination: Current Dilemma. Span of TB Control: 2010

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1 TB Infection Who is Testing and Treating? Jennifer Flood, M.D., M.P.H. California Department of Public Health Tuberculosis Control Branch 1 TB Control and Elimination: Current Dilemma How many are infected with TB in the U.S.? Who is identifying i and treating ti TB infection? How can we make the best use of opportunities to prevent TB? 2 Span of TB Control: ,182 U.S. residents with tuberculosis Over 50,000 TB suspects 75, ,000 contacts ~15 million Americans infected 312 million Americans who breathe Provider Demographics: Who is Screening for and Treating LTBI? 1of 5

2 Too Busy Fighting Alligators to Drain the Swamp? 4 How Many People are Infected with Mycobacterium Tuberculosis? Latent tuberculosis infection (LTBI) is NOT reportable Diagnostics for TB infection are imprecise Number with TB infection is estimated 5 National Health and Nutrition Examination Survey (NHANES) Representative U.S. survey: 1999/2000 7,386 individuals had TST placed/read LTBI defined as TST = 10 mm RESULTS 4.2% = 11,213,000 with LTBI in U.S. 18.7% with TB infection among foreign-born Provider Demographics: Who is Screening for and Treating LTBI? 2of 5

3 How Many Know They are Infected? How Many Receive Treatment? Of the 11,213,000 patients infected with TB: 1 in 4 knew they were infected 1 in 9 infected had received treatment Source: Bennett, et al, Am J Resp Crit Care Med; 177: Where is Testing and Treatment Occurring? Results 37,857 patients were started on LTBI treatment 79% public health clinic 6.1% correctional 6.4% immigrant /refugee clinic 2% private Conclusions LTBI treatment is started in substantial numbers, primarily in public sector Extrapolated to U.S: 4-11,000 cases prevented 8 Source: Sterling,et al. Am J Respir Crit Care Med 2006;173 How Do You Search for and Treat Those at Highest Risk? >10 million with TB infection in the U.S. One in 10 progress to disease 9 of 10 never develop TB Universal testing and treatment is not warranted Risk-based approach is called for Provider Demographics: Who is Screening for and Treating LTBI? 3of 5

4 Risk for TB Progression Risk Factor Relative Risk Advanced untreated HIV Close contact 6.1 Radiographic evidence 5.2 Prednisone treatment Chronic Renal Failure 2.4 TNF inhibitor use 2.0 Diabetes Mellitus 1.7 Weight <10% 1.6 Smoking Source: Horsburgh, et al. NEJM, 2011; LTBI and Medical Risk in California Medical Condition Estimated LTBI in population Diabetes Rheumatoid Arthritis HIV/AIDS Renal dialysis Crohn s Disease Organ transplant recipients Population size 1,835, ,000 95, ,087 3,297 Foreign-born 35% 17% 14% 25% 4% 22% With LTBI 119,000 6,000 2,500 2, Total LTBI ,050 Proportions of TB Disease Attributable to Medical Risk Factors, California Factor RR if factor present Prevalence of factor Population attributable risk percent (PAR%) Smoking % 18.3% Diabetes % % ESRD % % HIV/AIDS % 1.8% Organ transplant Rheumatoid arthritis % % % % 12 Estimated total population attributable risk %: 29 45% 2012 Provider Demographics: Who is Screening for and Treating LTBI? 4of 5

5 LTBI Acceptance and Completion in the U.S. and Canada Fewer than half of the people starting treatment of LTBI completed therapy Risk factors for failure to complete treatment included: Longer regimen, injection drug use, incarceration, and being a health care worker Source: Horsburgh,et al. Chest 2010; 137(2): Opportunities to Prevent TB Shorter regimens have the potential to make treatment more successful 4 month daily rifampin i 12 dose INH/Rifapentine weekly regimen Source: Bindman AB, Schneider AG. N Engl J Med April 21, 2011; 2012 Provider Demographics: Who is Screening for and Treating LTBI? 5of 5

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