Substance Abuse and Tuberculosis Oklahoma City, Oklahoma November 17, 2010

Substance Abuse and Tuberculosis Oklahoma City, Oklahoma November 17, 2010 Epidemiology of Substance Abuse and Tuberculosis: Where is the Problem? Mary Long, MPSH; Heartland Phillip Lindsey, MD; OK State HD Diane Wermy; OK City County HD November 17, 2010 Epidemiology of TB Mary Long, MSPH Heartland National TB Center November 17, 2010

Objectives 1. TB Epidemiology in the World 2. TB Epidemiology in the U.S. 3. TB Epidemiology in the Heartland Region Estimated TB Incidence by Country, 2009 Global Tuberculosis Control 2010 Report, WHO

Global Epidemiology of TB - 2009 High burden areas: Asia 55% Africa 30% Eastern Mediterranean Region 7% European Region 4% Region of Americas 3% Global Epidemiology of TB - 2009 Countries with the largest number of incident cases: India (1.6 2.4 million) China (1.1 1.5 million) South Africa (0.40 0.59 million) Nigeria (0.37 0.55 million) Indonesia (0.35 0.52 million) India alone accounts for an estimated one fifth (21%) of all TB cases worldwide China and India combined account for 35%

Global Epidemiology of TB - 2009 Top 10 Countries with the highest NEW TB CASES per 100,000: Worldwide 137 Swaziland 1,257 South Africa 971 Zimbabwe 742 Namibia 727 Botswana 694 Sierra Leone 644 Lesotho 634 Djibouti 620 Gabon 501 Timor Leste 498 Togo 446 All in Africa! #56 India 168/100,00 #78 China 96/100,000 #15 Myanmar (Burma): 404/100,100 Global Epidemiology of TB - 2009 There were 9.4 million new TB cases (including 3.3 million women), including 1.1 million cases among people with HIV 1.7 million people died from TB (including 380 000 women), including 380 000 people with HIV, equal to 4700 deaths a day TB is among the three greatest causes of death among women aged 15-44

Global Epidemiology of TB The TB death rate has fallen by 35% since 1990, and the number of deaths is also declining The estimated global incidence rate fell to 137 cases per 100 000 population in 2009, after peaking in 2004 at 142 cases per 100 000 Global Epidemiology of TB There were an estimated 440 000 new MDR-TB cases in 2008 and 150 000 deaths from MDR-TB It was estimated that in 2009, 3.3% of all new TB cases had MDR-TB In 2010, the largest WHO MDR-TB survey reported the highest rates ever of MDR-TB, with peaks of up to 28% of new TB cases in some settings of the former Soviet Union

Tuberculosis in the United States National Tuberculosis Surveillance System Highlights from 2009 Division of Tuberculosis Elimination Centers for Disease Control and Prevention Reported TB Cases* United States, 1982 2009 No. of Cases *Updated as of July 1, 2010. Year

TB Morbidity United States, 2003 2009 Year No. Rate* 2003 14,836 5.1 2004 14,499 4.9 2005 14,064 4.8 2006 13,734 4.6 2007 13,280 4.4 2008 12,906 4.2 2009 11,545 3.8 *Cases per 100,000, updated as of July 1, 2010. TB Case Rates,* United States, 2009 D.C. *Cases per 100,000. < 3.5 (year 2000 target) 3.6 3.8 > 3.8 (national average)

TB Case Rates* by Age Group United States, 1993 2009 Cases per 100,000 *Updated as of July 1, 2010. Age Group (years) Reported TB Cases by Age Group, United States, 2009 >65 yrs (20%) <15 yrs (6%) 15 24 yrs (11%) 45 64 yrs (30%) 25 44 yrs (34%)

TB Case Rates by Age Group and Sex, United States, 2009 Cases per 100,000 TB Case Rates by Race/Ethnicity* United States, 1993 2009** Cases per 100,000 Asian/Pacific Islander Black or African-American Hispanic American Indian/Alaska Native White *All races are non-hispanic. In 2003, Asian/Pacific Islander category includes persons who reported race as Asian only and/or Native Hawaiian or Other Pacific Islander only. **Updated as of July 1, 2010.

Reported TB Cases by Race/Ethnicity* United States, 2009 Native Hawaiian or Other Pacific Islander (1%) White (16%) Asian (28%) Hispanic or Latino (29%) American Indian or Alaska Native (1%) Black or African-American (25%) *All races are non-hispanic. Persons reporting two or more races accounted for less than 1% of all cases. Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, 1993 2009* No. of Cases *Updated as of July 1, 2010.

Trends in TB Cases in Foreign-born Persons, United States, 1989 2009* No. of Cases Percentage *Updated as of July 1, 2010. Reported TB Cases by Origin and Race/Ethnicity,* United States, 2009 Native Hawaiian/ Other Pacific Islander (<1%) Hispanic or Latino (19%) White (32%) U.S.-born American Indian or Alaska Native (2%) Hispanic or Latino (36%) Black or African American (42%) Foreign-born** White (5%) Asian (44%) Asian (3%) Black or African American (14%) *All races are non-hispanic. Persons reporting two or more races accounted for less than 1% of all cases. **American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander accounted for less than 1% of foreign-born cases and are not shown.

Percentage of TB Cases Among Foreign-born Persons, United States* 1999 2009 DC DC *Updated as of July 1, 2010. >50% 25% 49% <25% Countries of Birth of Foreign-born Persons Reported with TB United States, 2009 Other Countries (38%) Mexico (23%) Philippines (12%) Haiti (3%) Guatemala (3%) China (5%) Vietnam (8%) India (8%)

Primary Anti-TB Drug Resistance United States, 1993 2009* % Resistant *Updated as of July 1, 2010. Note: Based on initial isolates from persons with no prior history of TB. Multidrug resistant TB (MDR TB) is defined as resistance to at least isoniazid and rifampin. No. of Cases Primary MDR TB United States, 1993 2009* Percentage *Updated as of July 1, 2010. Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.

Primary Isoniazid Resistance in U.S.-born vs. Foreign-born Persons United States, 1993 2009* % Resistant *Updated as of July 1, 2010. Note: Based on initial isolates from persons with no prior history of TB. Primary MDR TB in U.S.-born vs. Foreign-born Persons, United States, 1993 2009* % Resistant *Updated as of July 1, 2010. Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.

XDR TB Case Count defined on Initial DST by Year, 1993 2009* Case Count Year of Diagnosis Drug susceptibility test. *Reported incident cases as of July 1, 2010. Extensively drug-resistant TB (XDR TB) is defined as resistance to isoniazid and rifampin, plus resistance to any fluoroquinolone and at least one of three injectable second-line anti-tb drugs. Reporting of HIV Test Results in Persons with TB by Age Group United States, 1993 2009* % with Test Results *Updated as of July 1, 2010. Note: Includes TB patients with positive, negative, or indeterminate HIV test results. Persons from California reported with AIDS only through 2004. (HIV test results are not reported from California)

Estimated HIV Coinfection in Persons Reported with TB, United States, 1993 2009* % Coinfection *Updated as of July 1, 2010. Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group. Completion of TB Therapy United States, 1993 2007* Percentage ** *Updated as of July 1, 2010. **Healthy People 2010 target: 90% completed in 1 yr or less. Note: Excludes persons with initial isolate rifampin resistant, or patient with meningeal disease, or pediatric patient (aged <15) with miliary disease or positive blood culture.

Cases Case Rates Rank by Rate Population Estimates Reporting Area 2009 2008 2009 2008 09 08 July 1, 2009 United States 11,545 12,906 3.8 4.2 -- -- 307,006,550 Arizona 232 227 3.5 3.5 17 21 6,595,778 Illinois 418 466 3.2 3.6 19 19 12,910,409 Iowa 42 49 1.4 1.6 39 40 3,007,856 Kansas 64 57 2.3 2 29 32 2,818,747 Minnesota 161 211 3.1 4 21 13 5,266,214 Missouri 80 107 1.3 1.8 40 39 5,987,580 Nebraska 32 33 1.8 1.9 35 36 1,796,619 New Mexico 48 60 2.4 3 26 25 2,009,671 North Dakota 5 3 0.8 0.5 48 50 646,844 Oklahoma 102 100 2.8 2.7 23 28 3,687,050 South Dakota 18 16 2.2 2 30 33 812,383 Texas 1,501 1,501 6.1 6.2 3 4 24,782,302 Wisconsin 67 68 1.2 1.2 43 43 5,654,774

Cases with Known Homeless Status Cases Reported Being Homeless Reporting Area Total Cases No. (%) No. (%) United States 10,893 10,729 (98.5) 567 (5.3) Arizona 216 194 (89.8) 8 (4.1) Illinois 402 393 (97.8) 25 (6.4) Iowa 40 40 (100.0) 0 (0.0) Kansas 59 58 (98.3) 6 (10.3) Minnesota 142 142 (100.0) 4 (2.8) Missouri 74 69 (93.2) 3 (4.3) Nebraska 29 29 (100.0) 1 (3.4) New Mexico 48 48 (100.0) 2 (4.2) North Dakota 5 5 (100.0) 0 (0.0) Oklahoma 85 78 (91.8) 6 (7.7) South Dakota 18 18 (100.0) 1 (5.6) Texas 1,395 1,395 (100.0) 39 (2.8) Wisconsin 66 65 (98.5) 5 (7.7) Total Cases with IVDU Info Cases Reporting IVDU Reporting Area Cases No. (%) No. (%) United States 10,893 10,590 (97.2) 152 (1.4) Arizona 216 187 (86.6) 3 (1.6) Illinois 402 380 (94.5) 7 (1.8) Iowa 40 40 (100.0) 1 (2.5) Kansas 59 56 (94.9) 0 (0.0) Minnesota 142 142 (100.0) 0 (0.0) Missouri 74 73 (98.6) 0 (0.0) Nebraska 29 27 (93.1) 0 (0.0) New Mexico 48 47 (97.9) 2 (4.3) North Dakota 5 5 (100.0) 0 (0.0) Oklahoma 85 74 (87.1) 4 (5.4) South Dakota 18 18 (100.0) 0 (0.0) Texas 1,395 1,391 (99.7) 32 (2.3) Wisconsin 66 66 (100.0) 1 (1.5)

Total Cases w/ Info Non IVDU Cases Reporting Non IDVU Reporting Area Cases No. (%) No. (%) United States 10,893 10,571 (97.0) 828 (7.8) Arizona 216 187 (86.6) 17 (9.1) Illinois 402 378 (94.0) 37 (9.8) Iowa 40 40 (100.0) 1 (2.5) Kansas 59 58 (98.3) 5 (8.6) Minnesota 142 142 (100.0) 6 (4.2) Missouri 74 70 (94.6) 3 (4.3) Nebraska 29 27 (93.1) 0 (0.0) New Mexico 48 48 (100.0) 4 (8.3) North Dakota 5 5 (100.0) 0 (0.0) Oklahoma 85 74 (87.1) 10 (13.5) South Dakota 18 18 (100.0) 0 (0.0) Texas 1,395 1,386 (99.4) 107 (7.7) Wisconsin 66 66 (100.0) 3 (4.5) Cases w/ info Excess Alcohol Use Cases Reporting Excess Alcohol Use Reporting Area Total Cases No. (%) No. (%) United States 10,893 10,609 (97.4) 1,382 (13.0) Arizona 216 186 (86.1) 16 (8.6) Illinois 402 379 (94.3) 55 (14.5) Iowa 40 40 (100.0) 5 (12.5) Kansas 59 58 (98.3) 9 (15.5) Minnesota 142 142 (100.0) 7 (4.9) Missouri 74 74 (100.0) 2 (2.7) Nebraska 29 27 (93.1) 1 (3.7) New Mexico 48 47 (97.9) 5 (10.6) North Dakota 5 5 (100.0) 0 (0.0) Oklahoma 85 76 (89.4) 14 (18.4) South Dakota 18 18 (100.0) 5 (27.8) Texas 1,395 1,392 (99.8) 263 (18.9) Wisconsin 66 65 (98.5) 9 (13.8)

Cases w/ info HIV Status Cases w/ HIV+ Results Reporting Area Total Cases No. (%) No. (%) United States 3,893 2,754 (70.7) -- -- Arizona 82 75 (91.5) 13 (17.3) Illinois 145 132 (91.0) 11 (8.3) Iowa 18 17 (94.4) 1 (5.9) Kansas 20 20 (100.0) 0 (0.0) Minnesota 68 63 (92.6) 5 (7.9) Missouri 28 23 (82.1) 3 (13.0) Nebraska 10 7 (70.0) -- -- New Mexico 10 10 (100.0) 0 (0.0) North Dakota 3 3 (100.0) 0 (0.0) Oklahoma 23 19 (82.6) 2 (10.5) South Dakota 6 6 (100.0) 0 (0.0) Texas 549 423 (77.0) 74 (17.5) Wisconsin 23 21 (91.3) 3 (14.3) Epidemiology of Tuberculosis in Oklahoma Substance Abuse and Tuberculosis November 17, 2010 Phillip H. Lindsey, M.D Medical Consultant/Associate Tuberculosis Control Officer Oklahoma State Department of Health

2.8 14.8 10.3 State Rate: 2.8 47.7

Tuberculosis Rates Oklahoma and U.S., 2003 2009 3.8 Reported Tuberculosis Cases Oklahoma, 2001-2009 2009 194 190 163 178 144 144 149 100 102 2010 to date: 78

Active TB Case Count, OK 1994-2009 280 260 240 220 Number of Cases 200 180 160 140 120 100 80 60 40 20 0 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Year y = -8.2857x + 16762 R 2 = 0.8208 TB Morbidity and Mortality Oklahoma, 2007-2010 2010 Estimated 152,000 people in Oklahoma currently infected with MTB 102 new cases of active TB in 2009 (up from 100 in 2008) Thirty-two two (32) cases of active TB with prolonged health provider-based diagnostic delay,, Jan 2007- June 2010 (1 every 39 days) Eight deaths directly due to TB, Jan 2008- June 2010. Six following health provider-based diagnostic delay,, two following prolonged patient-based delay Ten additional deaths with TB as a contributing or co- morbid factor (2008-2009) 2009) Am J Resp Crit Care Med 2008; 177 OSDH TB Division data

Tuberculosis Cases and Deaths Oklahoma, 1945 1963 792 OK TB deaths in 1945 155 OK TB deaths in 1963 19,707 US TB deaths in 1953 Tuberculosis Cases by Origin of Birth Oklahoma, 2003 2009

Rates of Tuberculosis by Race/Ethnicity Oklahoma, 2005 2009 RACE** 2005 2006 2007 2008 2009 American Indian/Alaska Native 12 8 11 6.7 4.5 Asian 30 43 17 11.2 19.1 Black 8 8 8 8 4.5 Native Hawaiian/ Pacific Islander -- -- 210 164.3 129.4 White 3 3 3 1.6 1.8 Muliple Races 4 0.6 -- -- 4.7 ***Hispanic 7 13 14 5 5.7 *Rate is 100,000 per population **Race and Age calculations using census data ***Persons of Hispanic ethnicity may be represented in other races. INH mono resistance and MDR Oklahoma, 2003 2009

Tuberculosis Cases and HIV Co Infection Oklahoma, 2003 2009 TB/AIDS Co-Diseased Oklahoma, 1999-2009 Number of Cases 14 12 10 8 6 4 2 0 12 10 10 6 5 5 4 4 3 3 1 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year OSDH/TB Division

Tuberculosis Cases by Housing Status Oklahoma, 2003 2009 Tuberculosis Cases (12+ y/o) Oklahoma 1/1/09-10/31/10 (N=156) Current smokers 64 (41%) Current smokers, 12+ Oklahoma (24.5%) * Current/recent alcohol abuse 48 (31%) Past year alcohol dependence or abuse 12+ Oklahoma (7%)** *Behavioral Risk Factor Surveillance System (BRFSS) 2009 **National Surveys on Drug Use and Health NSDUH 2007-2008

Tuberculosis Cases (12+ y/o) Oklahoma 1/1/09-10/31/10 (N=156) Intravenous drug use 13 (8%) Non- IV illicit drug abuse 15 (10%) Past year illicit drug dependence or abuse 12+ Oklahoma (2.66%)* *National Surveys on Drug Use and Health NSDUH 2007-2008

Prescription Drugs Fatal poisonings involving opioid analgesics in in US 2006: Oklahoma ranked 4 th in the nation* In 2007, Oklahoma was 232% above the national average in consumption of prescription painkillers* In 2007-2008, 2008, 6.9% of all Oklahomans 12+ y/o used prescription opioid analgesics for non-medical purposes. This ranks #1 among all states** *CDC,National Center for Health Statistics **NSDUH 2008-2008 Prescription Drugs CDC, National Center for Health Statistics. Multiple Causes of Death,1999-2006

Contact Info/Helpful Websites Oklahoma State Department of Health TB Division 405-271-4060 (on-call 24/7) Oklahoma County TB Control Center - 405-419 419-40004000 Tulsa City-County County TB Program - 918-595 595-4103 OSDH Tuberculosis Laboratory - 405-271 271-5070 Oklahoma State Department of Health Website - www.ok.gov/health CDC Division of TB Elimination - www.cdc.gov/tb Heartland National TB Center- San Antonio, TX - www.heartlandntbc.org Questions?

Substance Abuse Issues in Oklahoma City/County Diane Wermy BA, BS Disease Investigator OCCHD Signs of Meth

The Face of Meth ** Maintain current photo for patient s chart ** What We See in Oklahoma City/County ETOH Marijuana Cocaine Huffers American Indians Meth few seen in clinic

Working With Cases With Substance Abuse Issues Patients may not use/abuse but are some how involved in the drug culture Children Other relatives Legal system ( I( I just sell it but don t t use it ) Some don t t believe they have a a problem so the actual total may be higher Working With Cases With Substance Abuse Issues May find them under bridges, camped by the road Live in their own time; will call when they want Moody, angry, depressed Contact Investigation can be difficult

Oklahoma Cases With Abuse Issues 140 120 125 133 100 87 85 80 60 # of TB Cases Inj ecti ng Dr ug Use Non Inj ecting Dr ug Use Excess Alcohol Use 40 20 14 12 25 8 20 31 13 14 10 10 4 4 0 2005 2006 2008 2009 Year OKC/County Case Stats 35 30 28 26 25 22 17 Abusers Total Cases 14 10 8 11 4 2005 2006 2007 2008 2009 2010

Patterns Most cases with substance abuse issues are American born ETOH is drug of choice Foreign born cases are not abusers Most cases also tobacco smokers Majority are male Couch homeless DOC or jail visit Unnecessary End 2005 1 death 2006 2 deaths 2007 1 death 2008 1 death 2009 1 death 2010 1 death so far