California TB program updates

Transcription

1 California TB program updates CAPHLD Conference Nov 6, 2017 Pennan Barry, M.D., M.P.H. Chief, Surveillance and Epidemiology Section Lead MD, California MDR TB Service

2 Outline California TB Epidemiology California TB Elimination Plan Electronic reporting of IGRA results Vision for LTBI surveillance system Work with commercial laboratories Other brief updates Molecular DSTs by ELR Universal WGS 2

3 California TB Epidemiology Review 3

4 CA Tuberculosis Epidemic years ago: 1 in 9 died of TB 12, Number of TB Cases 10,000 8,000 6,000 4,000 2, Case Rate per 100, TB Cases TB Rate 4

5 Tuberculosis Cases and Case Rates 6,000 California, , Number of TB Cases 4,000 3,000 2,000 1, Case Rate per 100, TB Cases TB Rate 5

6 Tuberculosis Cases and Case Rates Number of TB Cases 6,000 5,000 4,000 3,000 2,000 1,000 California, Average annual change in case rate -6.2% -4.3% % Case Rate per 100, TB Cases TB Rate 6

7 Why aren t we satisfied? Decline has slowed TB is diagnosed every four hours Every other day a Californian dies with TB Each week at least one child under 5 found to have TB 7

8 Human impact of TB disease 20 year old foreign-born man with smear positive pulmonary TB Transmitted to niece and nephew 6 yo with pulmonary and bone TB 1 yo with pulmonary and meningeal TB poor neurologic outcome, now in long term care facility far from family >20 other infected persons (12 children) in 2 households This is preventable! 8

9 Year of TB elimination in California Extrapolation based on current rate of decline* Rate per 1 Million Actual Current decline (-4%) 2040 Elimination (-14%) Elimination Year * Average annual decline in case rate

10 California Tuberculosis Elimination Plan A Five-Year Action Plan Document%20Library/TBCB-TB-Elimination-Plan pdf

11 California TB Elimination Task Force Insert photo of task force meeting 11

12 TB Elimination Plan Recommendations Focus on Latent TB Infection (LTBI) PRIORITIZE screening and testing for LTBI Find and engage populations at risk for TB Use Risk Assessment; IGRA for BCG vaccinated OPTIMIZE treatment for LTBI Treat routinely; Use shorter regimens PARTNER and EDUCATE Public and private; providers and community groups MEASURE monitor and evaluate screening and treatment LTBI reportable? RESOURCE Funding, drug supply, expertise

13 TB Risk Assessment at 13

14 TB Elimination Plan Recommendations Focus on Latent TB Infection (LTBI) PRIORITIZE screening and testing for LTBI Find and engage populations at risk for TB Use Risk Assessment; IGRA for BCG vaccinated OPTIMIZE treatment for LTBI Treat routinely; Use shorter regimens PARTNER and EDUCATE Public and private; providers and community groups MEASURE monitor and evaluate screening and treatment LTBI reportable? RESOURCE Funding, drug supply, expertise

15 California TB Elimination Plan: LTBI Reporting

16 Current Status of IGRA Reporting IGRA can be reported by ELR (not required) Available to local and state TB programs for: following up contact investigation IGRA results for active TB cases (required for CDC reporting) following up on LTBI cases

17 IGRA by ELR July 2016 June laboratories; 43 jurisdictions; 230 healthcare facilities, 754 ordering providers >10,000 results reported Nearly 5,000 positive results Among laboratories reporting all results: positivity 17% (n=7162) (likely not testing a low risk population) 17

18 Survey of CA TB Programs IGRA by ELR Of respondents aware of IGRAs in CalREDIE: 36% reported use for public health action Of all respondents: 75% support mandatory reporting 62.5% support reporting of positive and negative results 18

19 Adding IGRA by ELR to 2505 PROS Feasible Uses existing system Little burden on programs/providers: Electronic Can be ignored by LHJ until needed Enough data for Suspected LTBI case definition Increasing IGRA use CONS Ignores TST results Limited patient data Less than needed for LTBI confirmed case definition

20 Principles for developing LTBI surveillance in California Minimize work of reporting for LHJs and providers Build on existing systems and efforts Incremental work toward reportability and complete surveillance Sync (as much as reasonable) with national surveillance to allow reporting to CDC

21 LTBI Surveillance: Vision Current LTBI Data Streams EDN (Immigrants - B notification) RHEIS (refugee health) CAIR/RIDE (immunization registry) IGRA by ELR CalREDIE Contacts -- CalREDIE (new tab) STEMS (CDC/TBESC LTBI Case management) Future LTBI Data Streams LTBI report form -- CalREDIE Electronic case reporting from EHRs -- CalREDIE Civil surgeon data Harmonization Deduplication CDPH LTBI Surveillance Registry (SQL) Identifiers TB risks LTBI test results CXR LTBI treatment LTBI treatment outcome CDC TBLISS US LTBI Surveillance Analysis /Reports Performance measures State and local use Program improvement

22 If Vision Realized Data-Driven: Accurate estimates of untreated LTBI burden Increased awareness of LTBI and treatment Metrics for improvement Progress toward elimination

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24 Work with Commercial Laboratories 24

25 Pulmonary sputum culture positive TB cases by laboratory type % Cases Commercial & Other Public Health Year 25

26 What Could Go Wrong is not unique Santa Clara County data, (n=148): TAT from specimen to DST results Regional labs days (median) National/commercial labs days (median) Data courtesy Wen Lin 26

27 Contributors to delays Delays reporting Not reporting results to health department, only to provider* Not reporting preliminary results Complex communication procedures Logistical procedures Transport between facilities Batching of cultures and DSTs Sub-culturing each time isolates arrive Not performing DSTs unless ordered* Underutilization of rapid tests such as molecular detection of drug resistance *Required by CA Code of Regulations 27

28 How to address challenges Improve communication Establish direct lines of communication Exchange challenges and contact info Provide information to labs (webinar Nov 2016) Regulations Role of public health programs Resources in public health labs Assist local TB programs Toolkit with information and tips for communicating with commercial labs Case by case assistance 28

29 CDPH and CDC Molecular Testing for Drug Resistance Known or suspected drug-resistant TB Pyrosequencing (PSQ) at CA lab detect resistance to INH, rifampin, fluoroquinolones, or injectable drugs culture or smear-positive specimen MDDR at CDC (PSQ and Sanger) Adds ethambutol and pyrazinamide Both 1-2 day turnaround time Provided without charge

30 Pyrosequencing Speeds time to effective MDR treatment PSQ done (n=60) PSQ not done (n=38) Days from specimen collection to MDR treatment California MDR cases August 2012-December

31 Indication for Pyrosequencing: Higher Risk of MDR-TB Xpert with RIF resistant result History of previous TB treatment Known exposure to MDR-TB case HIV (+)

32 Indication for Pyrosequencing: Higher Risk of MDR-TB Arrival in U.S. within last 2 years Immigration /recent extended travel to country with > 2% MDR among cases diagnosed in California/U.S.: India Laos Russia and other former Soviet states Korea Peru Central America Burma Ecuador Dominican Republic Other state or locally identified risk groups, including: Hmong refugees Persons of Tibetan origin *California data from and U.S. data from Current U.S. data are available from the CDC, Division of TB Elimination (DTBE) ( 32

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34 Other Brief Updates 34

35 Universal WGS in 2018 New National Tuberculosis Molecular Surveillance Center at Michigan PHL Universal WGS start in 2018 Both conventional and WGS for 3 years No change in shipping processing practices Complete submission of isolates important 35

36 Molecular Susceptibility Reporting Voluntary CDC reporting now APHL/CDC collaboration for ELR of Xpert MTB/RIF results Required CDC reporting in

37 Summary Working toward TB Elimination Vision: LTBI reporting / surveillance system including ELR for IGRA results Ongoing work between public health and commercial labs Universal WGS for TB in 2018 Reporting of molecular tests for resistance including Xpert 37

38 Acknowledgments Jenny Flood Christy Pak Grace Lin Ed Desmond Wen Lin Lisa True Carol Greene Donald Baird Hava Phillips Neha Shah Yasser Bakhsh Varsha Hampole Phil Lowenthal California TB Elimination Advisory Committee California TB Controller s Association Commercial laboratory partners Dale Schwab, Kamran Azad Adam Readhead Janice Westenhouse Tessa Mochizuki Lisa Pascopella Melissa Ehman 38

39 Resources Local TB Program Directory Local Public Health Lab Directory under laboratory listing Microbial Diseases Laboratory (MDL) TBCB Website: MDR TB Service: Risk Assessments: TB Data: APHL mycobacteriology best practices Assessing-Your-Laboratory.pdf Laboratory reporting regulations Curry International TB Center Warmline: Drug Resistant TB Survival Guide (Lab Chapter) Pennan Barry: 39