TB-Free California: How close are we? How can we get closer?

Transcription

1 TB-Free California: How close are we? How can we get closer? California TB Controllers Association April 21, 2015 Pennan Barry, MD, MPH Chief, Surveillance and Epidemiology Section

2 Acknowledgments Local TB Control Programs Lisa Pascopella Peter Oh Janice Westenhouse Christy Pak Phil Lowenthal Tambi Shaw Clinton McDaniel Melissa Ehman Katya Salcedo Jenny Flood 2 Graph courtesy Malcolm Barry-Kao, age 6

3 TB in California Time to Elimination Source of TB Cases Outline (Sub)Populations with TB Current TB prevention activities Getting closer to Elimination Areas for improvement in current activities Possible new TB control activities 3

4 Pop 38.8 million > 10 million immigrants (27% of CA pop.) ~25% of foreign-born in U.S. Estimated 2.5 million undocumented 50% of all children with an immigrant parent ~25% of TB in U.S. From Public Policy Institute of California ( Sources: U.S. Census Bureau Decennial Censuses, American Community Survey, and the Department of Homeland Security. 4

5 TB in California Time to Elimination Source of TB Cases 5

6 TB Diagnosed in CA every 4 hours Each = 1 TB case (Total = 2147) 6

7 TB Diagnosed in CA every 4 hours Foreign-born: 77% US-born: 22% Each = 1 TB case (Total = 2147) 7

8 Elimination Definitions Goal Goal Rate Cases in California* End of TB Epidemic <100 cases/million 3,880 Pre-elimination < 10 cases/million 388 Elimination <1 case / million 39 *Based on 2014 US Census Estimate of California Population: 38.8 million WHO. Framework towards TB Elimination in Low-Incidence Countries

9 Number of TB Cases Tuberculosis Cases and Case Rates 6,000 5,000 4,000 3,000 2,000 1, California, , TB Cases TB Rate , Case Rate per 100,000 9

10 Projected years of TB pre-elimination and elimination in California Rate per 1 Million Actual Current decline (-3.95%) Required for 2040 Elimination (-14.35%) Pre-Elimination Elimination Year

11 Projected years of TB pre-elimination and elimination in California 1000 Rate per 1 Million Actual Current decline (-3.95%) Required for 2040 Elimination (-14.35%) Pre-Elimination Elimination Year

12 How do TB Cases Occur in California? Importation TB within 1 year of US arrival Recent Transmission Reactivation of remote infection ~2,000 TB Cases Per Year 12

13 Clues to Source of TB Cases Source Importation Epidemiologic Clues Foreign-born TB diagnosed within 1 year of arrival to U.S. Recent transmission (within ~2-3 years) Reactivation of remote infection Genotype clustering Aged < 5 years TB in known contacts Linked cases on RVCT TB >5 years after arrival to U.S. TB in persons aged 65 years old Cases that are not from importation or recent transmission 13

14 How do TB Cases Occur in California? Importation TB within 1 year of US arrival 835 of 11,149 cases occurred within 1 year of arrival in US 7.5% Reactivation of remote infection Cases not from importation or recent transmission: 75.5% ~2,000 TB Cases Per Year Recent Transmission 26% genotype clustering within county (3 year window) 8% with indication of transmission within 2 years on RVCT Midpoint = 17% 14

15 7% Proportion of TB Cases among children < 5 years California, % of TB cases 6% 5% 4% 3% 2% 1% 0% 2.6%

16 TB Cases within 1 year of arrival in U.S. California, Number of TB Cases % 16% 14% 12% 10% 8% 6% 4% 2% 0% % of TB Cases TB Cases % of Cases 16

17 TB Cases by Age Group and Median Age, California, Number of cases

18 TB Cases by Age Group and Median Age, California, Number of cases % -10% -22% -14% -26% Median Age USB FB

19 TB cases by years in US at TB report 0 California, yr 1-10 yrs yrs >20 yrs % -14% -30% -12% 19

20 (Sub)populations with TB Healthcare workers Corrections HIV

21 Number of Cases TB cases among healthcare workers, California % foreign-born Foreign-born HCW US-born HCW % of TB Cases Percent of TB Cases 21

22 TB Cases Diagnosed in Corrections California, Corrections % of TB Cases 5.0% 4.5% % Number of Cases % 3.0% 2.5% 2.0% 1.5% % of All TB Cases % 0.5% % 22

23 Incidence Rate per 100,000 Population TB Incidence Rates by Type of Correctional Facility California, State Prison Incidence Rate Local Jail Incidence Rate Non-Corrections Incidence Rate Slide courtesy Clinton McDaniel Year TB Diagnosed

24 Proportion of TB patients HIV-infected California % Proportion of TB-HIV 4.2% N=86 Count Year 24

25 Healthcare workers, HIV infected, corrections residents Historical intense focus for TB control Now declining or stable TB (each <5% of TB) Not main drivers of current TB cases 25

26 (Sub)populations with TB Foreign-born

27 25 California Case Rates by Nativity Foreign-born U.S.-born TB Rate per 100, Total

28 Countries of Birth for Foreign Born Persons with TB California, 2014 N=1,666 Mexico 446 Philippines 354 Vietnam Other 205 China 145 India % 20% 40% 60% 80% 100% 28

29 Years in US at TB Diagnosis California, TB Cases Years in US 29

30 TB Cases Years in US at TB Diagnosis California, B-notification cases* Years in US *Cases diagnosed in domestic evaluation of abnormal preimmigration CXR 30

31 Years in US at TB Diagnosis California, TB Cases % in US > 5.9 years Median 16.0 yrs 25Q Q Q 37.3 Years in US 31

32 Years in US at TB Diagnosis California, % in US > 5.9 years 700 TB Cases % in US >16 years Median 16.0 yrs 25Q Q Q Years in US 32

33 Constant rate of reactivation from TB infection after immigration Avg rate per 100,000 = 31.8 Years after immigration with a normal pre-immigration chest radiograph Filipino immigrants to California Walter et al AJRCC

34 TB Prevention through screening and treatment of TB Infection Immigrants and other new arrivers 34

35 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Immigration Status at First US Entry persons with TB California, % Immigrant Visa n=683 Screened (for active disease) 9% Refugee/Asylee /Family n=150 5% Student/Worker n=74 Not screened * Includes persons from counties with policies against collecting immigration status information 3% Tourist n=45 23% Other (includes undocumented) n=383 Probably Not screened 18% Unknown* n=300 35

36 Newcomers to California Examples Number per year TB screening required? New immigrants Green Card holders Refugees 200,000 Nonimmigrant Admissions Tourists Students Workers 11,000,000 (640,000 students/ workers) No legal status Undocumented Yes No N/A? Source: US Dept of Homeland Security. Yearbook of Immigration Statistics

37 TB Screening of New Immigrants Legal Permanent Residents B-notification Apply Overseas N=100,000 / year Active case finding only Evaluated overseas CXR (TST for children) Abnormal CXR 3 sputa smear and cx If no active TB Domestic follow-up by health department Data easily available Status adjustors Apply in US N=100,000/year Active and latent testing Evaluated by civil surgeons TST or IGRA CXR for positives (>5mm) No requirement for treatment or referral if no active TB Is LTBI treatment given? Data not available Source: U.S. Dept of Homeland Security. 37

38 % of Arrivers* with active TB within 6 mos of arrival California 4.5% 4.0% 4.1% 3.5% 3.4% 3.0% Pre-immigration sputum culture 2.5% 2.0% 1.5% 1.0% 1.6% 1.2% 1.7% 1.4% 0.9% 1.3% 0.5% 0.0% ** *B1 notification arrivers: abnormal pre-immigration CXR **Jan-June only 38

39 100% 80% Treatment for arrivers with abnormal pre-immigration CXR California, % 40% 20% Unknown No treatment LTBI treatment 0% ATS Class 2 n=1191 ATS Class 4 n=2505 Persons evaluated in California including with a CXR 39

40 New Arriver Screening Gaps Many not screened at all (visitors, undocumented) Of those screened great majority not screened for LTBI Even among those screened by health departments >40% don t start treatment No data from civil surgeons 40

41 TB Prevention through screening and treatment of TB Infection Longstanding Residents of California 41

42 20,000 Evaluation and Treatment of Contacts care cascade California, ,000 10,000 33% of infected contacts complete treatment 5,000 0 Elicited (100%) Evaluated (88%) Infected (21%) Treatment started (54%) Treatment completed (62%) 42

43 Evaluation and Treatment of Contacts care cascade California, , Contacts 15,000 Opportunity 10,000 5, * Elicited (100%) Evaluated (88%) Infected (21%) Treatment started (54%) Treatment completed (62%) * Estimated based on proportion infected among those evaluated 43

44 TBI infections estimated by applying nativity and race/ethnicity-specific TB infection rates from 44 NHANES (Bennett et al 2008 and Shea et al 2014) to the California population 2.5 Million Estimated TB Infections California US Born 0.5 Million Foreign Born 2 Million 0% 20% 40% 60% 80% 100%

45 Who to Test for LTBI? Risk of Exposure Risk of Progression 45

46 Medical Risk Factors among persons with TB by nativity California, 2014 Total n (%) US-born % Foreign-born % Diabetes 508 (24.7) 13.9% 27.3% ESRD 82 (4.0) 2.9% 4.2% HIV positive 86 (4.2) 9.9% 3.5% Other immunosuppression Post-organ transplantation 124 (6.0) 5.0% 6.3% 23 (1.0) 0.5% 1.3% TNF-antagonist rx 20 (1.0) 0.5% 1.1% 1+ co-morbidity 723 (35.2) 30.2% 36.5% Persons aged 15 46

47 TB Rate by Diabetes, Age, and Nativity California, (Persons aged 18) Case Rate per 100, Diabetes No Diabetes United States or Canada Foreign-born Demlow et al, BMC Public Health 2015 Sources: Denominator: California Health Interview Survey Numerator: CA TB Registry 47

48 TBI infections estimated by applying nativity and race/ethnicity-specific TB infection rates from 48 NHANES (Bennett et al 2008 and Shea et al 2014) to the California population 2.5 Million Estimated TB Infections California US Born 0.5 Million Foreign Born 2 Million 0% 20% 40% 60% 80% 100%

49 Estimated TB Infections and Cases Among Selected Medical Risk Groups California Medical Risk Total Current smokers* Diabetes Immune suppression** ESRD*** HIV/AIDS Organ transplant Total Population 6,518,613 3,650,000 2,322, ,213 78, ,900 26,700 FB with LTBI 368, , ,000 10,925 4,200 3,600 1,200 Total with LTBI 450, , ,200 15,841 5,200 5,400 1,600 Relative Risk of Progression Estimated Case number (FB) 1, Total Estimated Cases 1, Actual cases (2014) Cases estimated using baseline annual rate of progression from Shea et al, 2014: for FB and for USB FB = foreign-born * Excludes 93,000 smokers that have diabetes ** Includes only estimates of total population with inflammatory bowel disease and rheumatoid arthritis ***Includes all patients including those s/p kidney transplant 49

50 Estimated TB Infections and Cases California US Born Foreign Born 38 M Populatn. 1,970,238 (5%) Medical Risk medical risk: current smoking, DM, HIV, ESRD, organ transplant, and those having another indication for immunosuppression (inflammatory bowel disease or rheumatoid arthritis) 50

51 Estimated TB Infections and Cases California US Born Foreign Born 38 M Populatn. 1,970,238 (5%) Medical Risk 2.5 M TB infections 368,434 (14%) medical risk: current smoking, DM, HIV, ESRD, organ transplant, and those having another indication for immunosuppression (inflammatory bowel disease or rheumatoid arthritis) 51

52 Estimated TB Infections and Cases California US Born Foreign Born 38 M Populatn. 1,970,238 (5%) Medical Risk 2.5 M TB infections 368,434 (15%) Medical Risk 2,147 TB Cases 1,098 (51%) 0% 20% 40% 60% 80% 100% medical risk: current smoking, DM, HIV, ESRD, organ transplant, and those having another indication for immunosuppression (inflammatory bowel disease or rheumatoid arthritis) 52

53 How many Californians are being Group tested for TB Infection now? Estimated Number tested annually TB risk Healthcare workers 1,443,000 Low Status adjusters (civil surgeons) 105,000 Moderate-High Contacts 17,000 High B-notification arrivers 5,000 High Very High Others? varied Total 1,570,000 *Source for healthcare worker data: California Healthcare Workforce Clearinghouse ( 53

54 Improvements and Possible New TB Control Activities In order to achieve elimination by

55 Areas for Improvement in Current Activities In order to achieve elimination by 2040 Treat higher proportion of persons known to have TB infection: Contacts B-notification arrivers Status adjusters More testing of highest risk Risk assessment Get highest risk patients through LTBI care cascade 55

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57 Possible New Activities Alter new arriver screening? Identify TB infection in overseas evaluations Expand to other types of arrivers Linkage to TB infection treatment for domestic evaluation Make latent TB infection reportable? 57

58 Projected years of TB pre-elimination and elimination in California Rate per 1 Million Current decline (-3.95%) Required for 2040 Elimination (-14.35%) Pre-Elimination Elimination 42,400 Cases averted Year

59 We have done it before 59

60 Number of Tuberculosis Cases, California, ,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Constant 1985 rates Year 2013 Projected case count calculated by applying the nativity-specific rate to population denominators 60

61 Number of Tuberculosis Cases, California, ,000 Constant 1985 rates 6,000 5,000 4,000 3,000 Difference = 44,373 (since 1992) 2,000 1, Year 2013 Projected case count calculated by applying the nativity-specific rate to population denominators 61

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