TB Nurse Case Management San Antonio, Texas July 18 20, 2012 TB Epidemiology Robert Petrossian July 18, 2012 Robert Petrossian has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1
TB Nurse Case Management San Antonio, Texas Epidemiology of TB Robert Petrossian Robert Petrossian has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity. 2
Today s Discussion (Objectives) Epidemiology of TB in the world Epidemiology of TB in the United States Epidemiology of TB in Texas and the Heartland Region Global Epidemiology of TB 2010 The Bad News 2 Billion people with LTBI worldwide There were 8.8-9.2 million new TB cases worldwide. 1.5 million people died from TB, including 350,000 people with HIV. In 2009 there were almost 10 million children who were orphans as a result of parental deaths caused by TB. 3
Global Tuberculosis Control WHO Report 2011 India and China accounted for 40% of the world s notified TB cases in 2010, Africa an additional 24% Approximately 13% of TB cases occur among HIV co-infected individuals Global Epidemiology of TB 2010 The Good News TB incidence rates have been falling since 2002 Between 1995 and 2010, 55 million TB patients were treated by DOT 46 million were successfully treated. These treatments saved almost 7 million lives. 4
Worldwide TB What s fueling this epidemic Risk factors associated with TB Malnutrition, vitamin deficiencies, overcrowded living conditions, genetic susceptibility, sex, age:?x HIV 20-37X (#1 risk factor LTBI to active disease) Diabetes 3X Smoking 2X Indoor air pollution?2x Silicosis 3X Alcohol 3X End-stage renal disease 10X Malignancy?X Corticosteroid therapy 2X TNF alpha inhibitor?x (>risk TNF antibodies vs soluble TNF receptor) Lawn and Zumia, Lancet e-pub 3/18/11 Worldwide TB Lawn and Zumia, Lancet e-pub 3/18/11 Approximately 12% worldwide TB caseload HIVassociated 4/5 HIV co-infected cases in sub-saharan Africa In the worst affected countries of South Africa and Swaziland about 1% of the population develops TB each year. 5
Estimated TB Incidence by Country, 2010 Global Tuberculosis Control 2011, WHO More Bad News Drug Resistant Tuberculosis MDR and XDR TB results from TB control practices in most of the world that would not be acceptable in US Case identification and treatment response are based on AFB smears without confirmatory cultures or susceptibility testing. Retreatment for treatment failure not based on in vitro susceptibility studies, rather, on fixed retreatment regimens. 6
Extensively drug-resistant TB: There must be some kind of way out of here Unlike in affluent countries the large majority of persons with MDR-TB worldwide do not receive a diagnosis and remain untreated. Sophisticated microbiology laboratories and complex combinations of expensive second-line drugs are not available to them, and the disease spreads unchecked. Cegielski 2010, CID; 50: S195 Global Tuberculosis Control WHO Report 2011 In 2010, 8/22 high burden countries did not have 1 microscopy center/100,000 population. Among 36 high burden and high MDR countries, 20 had less than 1 lab capable of performing culture and DST/5 million pop 7
Steps that can be taken to combat the TB epidemic Case identification Early recognition of drug resistant disease Availability of appropriate TB meds Administration of adequate TB regimens Treatment of co-existing medical problems Administrative and engineering controls to prevent TB transmission Isolation of contagious cases Quarantine for nonadherent patients Contact investigation/treatment of LTBI Worldwide TB and the United States Foreign born persons account for the majority of TB cases in the U.S. Foreign born persons account for the majority of drug resistance cases in the US 8
TB IN THE UNITED STATES 30,000 Reported TB Cases United States, 1982 2010 25,000 20,000 15,000 10,000 5,000 0 9
What caused an increase in TB Morbidity: 1985-1992 Deterioration of the TB public health infrastructure Immigration from countries where TB is common The Development of MDR and XDR TB HIV/AIDS epidemic Homelessness, drug and alcohol abuse TB Case Rates,* United States, 2010 D.C. < 3.6 (2010 national average) >3.6 *Cases per 100,000. 10
Decrease in Reported Tuberculosis Case U.S. More good news For 2010: 11,182 TB cases reported in U.S. TB case rate: 3.6 cases/100,000 14.3% decrease in TB case rate of 4.2/100,000 from 2008 The 2009 rate showed the greatest single-year decrease ever recorded and was the lowest recorded rate since national TB surveillance began in 1953. Trends in Tuberculosis-United States, 2010 (MMWR 3/24/11) CA, TX, NY, FL all had more than 500 cases/state. U.S. born 1.6 cases/100,000 C/W whites, TB rates 7X higher in Hispanics, 8X higher in Blacks, 25X higher in Asians Among U.S. born, blacks 40% of all cases 9% TB patients co-infected with HIV 11
Steps that can be taken to combat the TB epidemic in the US Case identification Early recognition of drug resistant disease Availability of appropriate TB meds Administration of adequate TB regimens Treatment of co-existing medical problems Administrative and engineering controls to prevent TB transmission Isolation of contagious cases Quarantine for nonadherent patients Contact investigation/treatment of LTBI Trends in Tuberculosis-United States, 2010 (MMWR 3/24/11) Foreign born 60% TB cases, 18 cases/100,000 TB rates for foreign born 11X higher than U.S. born 4 countries 50% of TB morbidity in foreign born: Mexico, Philippines, India, Vietnam Foreign born account for 90% of MDR cases in the U.S. Rate of MDR-TB 5X higher in previously treated patients than patients without previous history of TB. 12
TUBERCULOSIS IN THE HEARTLAND REGION 13
TB Cases in the Heartland Region, 2009 Arizona 232 South Dakota 18 Illinois 418 Texas 1501 Iowa 42 Wisconsin 67 Kansas 64 Minnesota 161 HTNC Region 2770 Missouri 80 Oklahoma 102 Nebraska 32 New Mexico 48 North Dakota 5 TB Cases in the Heartland Region, 2010 Arizona 283 South Dakota 15 Illinois 372 Texas 1,385 Iowa 48 Wisconsin 55 Kansas 46 Minnesota 135 HTNC Region 2622 Missouri 107 Oklahoma 86 Nebraska 27 New Mexico 51 North Dakota 12 14
TB INCIDENCE IN TEXAS 2008 1501 cases 2009 1501 cases 2010 1385 cases In Heartland Region, metropolitan areas with highest TB case rates Houston Dallas San Antonio Austin Chicago, OKC, Tulsa, Twin Cities Estimated Migrants Entering U.S. Visitors without visas ~ 30,000,000 Non-immigrant visas 27,907,139 Immigrants and refugees 411,266 Undocumented migrants ~ 275,000???? N= ~ 59,000,000 Status adjusters in U.S.: 679,305 Source: U.S. Department of Homeland Security, 2003 (2002 data) 15
What we discussed (Review) Epidemiology of TB in the world Epidemiology of TB in the United States Epidemiology of TB in Texas and the Heartland Region QUESTIONS? 16