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
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
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
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 (http://www.ppic.org/main/publication_show.asp?i=258) Sources: U.S. Census Bureau Decennial Censuses, American Community Survey, and the Department of Homeland Security. 4
TB in California Time to Elimination Source of TB Cases 5
TB Diagnosed in CA every 4 hours Each = 1 TB case (Total = 2147) 6
TB Diagnosed in CA every 4 hours Foreign-born: 77% US-born: 22% Each = 1 TB case (Total = 2147) 7
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. 2014 8
Number of TB Cases Tuberculosis Cases and Case Rates 6,000 5,000 4,000 3,000 2,000 1,000 0 1985 1987 California, 1985-2014 1989 5,382 1991 1993 17.4 1995 1997 TB Cases 1999 2001 2003 2005 TB Rate 2007 2009 2011 2,147 5.6 2013 2014 20 18 16 14 12 10 8 6 4 2 0 Case Rate per 100,000 9
Projected years of TB pre-elimination and elimination in California Rate per 1 Million 200 150 100 50 Actual Current decline (-3.95%) Required for 2040 Elimination (-14.35%) Pre-Elimination Elimination 2057 2114 0 1985 1995 2005 2015 2025 2035 2045 2055 Year 2065 2075 2085 2095 2105 2115 2125 10
Projected years of TB pre-elimination and elimination in California 1000 Rate per 1 Million 100 10 1 Actual Current decline (-3.95%) Required for 2040 Elimination (-14.35%) Pre-Elimination Elimination 2057 2114 0 1985 1995 2005 2015 2025 2035 2045 2055 Year 2065 2075 2085 2095 2105 2115 2125 11
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
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
How do TB Cases Occur in California? Importation TB within 1 year of US arrival 835 of 11,149 cases 2010-2014 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
7% Proportion of TB Cases among children < 5 years California, 1985-2014 % of TB cases 6% 5% 4% 3% 2% 1% 0% 2.6% 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2014 15
TB Cases within 1 year of arrival in U.S. California, 1993-2014 Number of TB Cases 800 700 600 500 400 300 200 100 0 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% % of TB Cases TB Cases % of Cases 16
TB Cases by Age Group and Median Age, California, 2010-2014 1000 0-4 5-14 15-24 25-44 45-64 65+ Number of cases 800 600 400 200 0 2010 2011 2012 2013 2014 17
TB Cases by Age Group and Median Age, California, 2010-2014 1000 0-4 5-14 15-24 25-44 45-64 65+ Number of cases 800 600 400 200 0 2010 2011 2012 2013 2014 +15% -10% -22% -14% -26% Median Age USB 40 39 42 39 37 FB 51 53 53 56 56 18
800 700 600 500 400 300 200 100 TB cases by years in US at TB report 0 California, 2010 2014 1 yr 1-10 yrs 11-20 yrs >20 yrs 2010 2011 2012 2013 2014 +5% -14% -30% -12% 19
(Sub)populations with TB Healthcare workers Corrections HIV
Number of Cases TB cases among healthcare workers, California 2010-2014 83% foreign-born 100 80 60 40 20 0 Foreign-born HCW US-born HCW % of TB Cases 2010 2011 2012 2013 2014 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Percent of TB Cases 21
TB Cases Diagnosed in Corrections California, 1993 2014 250 Corrections % of TB Cases 5.0% 4.5% 200 4.0% Number of Cases 150 100 3.5% 3.0% 2.5% 2.0% 1.5% % of All TB Cases 50 1.0% 0.5% 0 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 0.0% 22
Incidence Rate per 100,000 Population TB Incidence Rates by Type of Correctional Facility 180 160 140 120 100 80 60 40 20 0 170.0 52.5 16.8 California, 1993-2013 State Prison Incidence Rate Local Jail Incidence Rate Non-Corrections Incidence Rate 51.4 6.6 3.8 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 Slide courtesy Clinton McDaniel Year TB Diagnosed
Proportion of TB patients HIV-infected California 1993 2014 10.3% Proportion of TB-HIV 4.2% N=86 Count Year 24
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
(Sub)populations with TB Foreign-born
25 California Case Rates by Nativity 22.8 2005 2014 Foreign-born U.S.-born TB Rate per 100,000 20 15 10 5 8.1 2.5 16.1 5.6 1.6 Total 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 27
Countries of Birth for Foreign Born Persons with TB California, 2014 N=1,666 Mexico 446 Philippines 354 Vietnam Other 205 China 145 India 96 420 0% 20% 40% 60% 80% 100% 28
Years in US at TB Diagnosis California, 2010-2014 TB Cases 900 800 700 600 500 400 300 200 100 0 Years in US 29
TB Cases 900 800 700 600 500 400 300 200 100 0 Years in US at TB Diagnosis California, 2010-2014 B-notification cases* Years in US *Cases diagnosed in domestic evaluation of abnormal preimmigration CXR 30
Years in US at TB Diagnosis California, 2010-2014 TB Cases 900 800 700 600 500 400 300 200 100 0 75% in US > 5.9 years Median 16.0 yrs 25Q 5.9 75Q 28.1 90Q 37.3 Years in US 31
Years in US at TB Diagnosis California, 2010-2014 900 800 75% in US > 5.9 years 700 TB Cases 600 500 400 300 200 50% in US >16 years Median 16.0 yrs 25Q 5.9 75Q 28.1 90Q 37.3 100 0 Years in US 32
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 2014 33
TB Prevention through screening and treatment of TB Infection Immigrants and other new arrivers 34
45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Immigration Status at First US Entry persons with TB California, 2014 41% 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
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 2013 36
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. http://www.dhs.gov/profiles-legal-permanentresidents 37
% 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% 2006 2007 2008 2009 2010 2011 2012 2013** *B1 notification arrivers: abnormal pre-immigration CXR **Jan-June only 38
100% 80% Treatment for arrivers with abnormal pre-immigration CXR California, 2012-2013 60% 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
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
TB Prevention through screening and treatment of TB Infection Longstanding Residents of California 41
20,000 Evaluation and Treatment of Contacts care cascade California, 2012 15,000 10,000 33% of infected contacts complete treatment 5,000 0 Elicited (100%) Evaluated (88%) Infected (21%) Treatment started (54%) Treatment completed (62%) 42
Evaluation and Treatment of Contacts care cascade California, 2012 20,000 2361 Contacts 15,000 Opportunity 10,000 5,000 496* 1690 757 0 Elicited (100%) Evaluated (88%) Infected (21%) Treatment started (54%) Treatment completed (62%) * Estimated based on proportion infected among those evaluated 43
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%
Who to Test for LTBI? Risk of Exposure Risk of Progression 45
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
TB Rate by Diabetes, Age, and Nativity California, 2010 2012 (Persons aged 18) Case Rate per 100,000 100 80 60 40 20 Diabetes No Diabetes 0 18-44 45-64 65-74 75+ 18-44 45-64 65-74 75+ United States or Canada Foreign-born Demlow et al, BMC Public Health 2015 Sources: Denominator: 2011-2012 California Health Interview Survey Numerator: CA TB Registry 47
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%
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 2,322,000 321,213 78,800 119,900 26,700 FB with LTBI 368,434 176,509 172,000 10,925 4,200 3,600 1,200 Total with LTBI 450,420 225,179 197,200 15,841 5,200 5,400 1,600 Relative Risk of Progression 2 3 8 16 18 20 Estimated Case number (FB) 1,090 346 506 86 66 64 24 Total Estimated Cases 1,310 426 568 118 79 90 30 Actual cases (2014) 508 144 82 86 23 Cases estimated using baseline annual rate of progression from Shea et al, 2014:.00098 for FB and.00082 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
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
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
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
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 (http://www.oshpd.ca.gov/hwdd/hwc/index.html) 53
Improvements and Possible New TB Control Activities In order to achieve elimination by 2040 54
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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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
Projected years of TB pre-elimination and elimination in California Rate per 1 Million 60 50 40 30 20 10 Current decline (-3.95%) Required for 2040 Elimination (-14.35%) Pre-Elimination Elimination 42,400 Cases averted 0 2015 2025 2035 2045 2055 2065 2075 Year 2085 2095 2105 2115 2125 58
We have done it before 59
Number of Tuberculosis Cases, California, 1980 2013 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Constant 1985 rates 1980 1985 1990 1995 2000 2005 2010 Year 2013 Projected case count calculated by applying the nativity-specific rate to population denominators 60
Number of Tuberculosis Cases, California, 1980 2013 7,000 Constant 1985 rates 6,000 5,000 4,000 3,000 Difference = 44,373 (since 1992) 2,000 1,000 0 1980 1985 1990 1995 2000 2005 2010 Year 2013 Projected case count calculated by applying the nativity-specific rate to population denominators 61
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