Tuberculosis Epidemiology TB CLINICAL INTENSIVE COURSE Curry International Tuberculosis Center October 18, 2017 Varsha Hampole, MPH Tuberculosis Control Branch California Department Of Public Health Outline TB epidemiology Global burden United States California Summary of surveillance data Demographic characteristics Clinical characteristics Summary Tuberculosis Epidemiology 1
Estimated Global TB Burden, 2015 10.4 million incident cases; 1.2 million HIV positive 142 cases per 100,000 1.8 million deaths 400,000 deaths among HIV+ 480,000 developed MDR WHO, Global Tuberculosis Control 2016 WHO, Global Tuberculosis Control 2016 4 Tuberculosis Epidemiology 2
TB Epidemiology United States 5 Reported Tuberculosis Cases United States, 1982 2015* No. of Cases *Cases per 100,000 population; as of June 9, 2016. Tuberculosis Epidemiology 3
TB Morbidity United States, 2010 2015 *Cases per 100,000; as of June 9, 2016 TB Case Rates,* United States, 2015 *Cases per 100,000 population; as of June 9, 2016. Tuberculosis Epidemiology 4
Which populations in the U.S. developed TB? Reported TB Cases by Age Group, United States, 2015* *As of June 9, 2016. Tuberculosis Epidemiology 5
TB Case Rates by Age Group and Sex, United States, 2015* Cases per 100,000 Population Age Group (Years) Reported TB Cases by Race/Ethnicity,* United States, 2015 *All races are non Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin. Unknown race consisted of 0.3% and is not shown. As of June 9, 2016. Tuberculosis Epidemiology 6
Number of TB Cases Among U.S. born vs. Non U.S. born Persons, United States, 1993 2015* No. of Cases *As of June 9, 2016. TB Case Rates in U.S. born vs. Non U.S. born Persons, United States,1993 2015* Cases per Cases 100,000 per Population 100,000 *As of June 9, 2016. Tuberculosis Epidemiology 7
Countries of Birth of Non U.S. born Persons Reported with TB, United States, 2015* *As of June 9, 2016. What is the prevalence of TB drug resistance in U.S.? 16 Tuberculosis Epidemiology 8
Primary Anti TB Drug Resistance, United States, 1993 2015* Resistant % Resistant (%) *As of June 9, 2016. 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. Primary MDR TB, United States, 1993 2015* No. of cases % Resistant Percentage *As of June 9, 2016. Note: Based on initial isolates from persons with no prior history of TB; multidrug resistant TB (MDR TB) defined as resistance to at least isoniazid and rifampin. Tuberculosis Epidemiology 9
Primary MDR TB Among U.S. born vs. Non U.S. born Persons United States, 1993 2015* % Resistant *As of June 9, 2016. Note: Based on initial isolates from persons with no prior history of TB; multidrug resistant TB (MDR TB) defined as resistance to at least isoniazid and rifampin. TB Epidemiology California Tuberculosis Epidemiology 10
Number of Tuberculosis Cases: California, 1988 2016 2,062 California Department of Public Health, Tuberculosis Control Branch Number of Tuberculosis Cases and Case Rates: California, 2006 2016 Case Rate per 100,000 California Department of Public Health, Tuberculosis Control Branch Tuberculosis Epidemiology 11
Tuberculosis in California, 2016 >= 5.2 (state average) 3.0 5.1 <= 2.9 (national average) < 5 cases California Department of Public Health, Tuberculosis Control Branch CA Epidemiology Reflects Global Epidemiology Tuberculosis Epidemiology 12
7 U.S.-born 463 (21.6%) Tuberculosis Cases by Country of Origin: Unknown 14 ( 0.7%) California, 2016* Foreign-born 1,670 (77.8%) All Others 404 (24.2%) Mexico 450 (26.9%) India 96 (5.7%) China 160 (9.6%) Vietnam 205 (12.3%) Philippines 355 (21.3%) California Department of Public Health, Tuberculosis Control Branch Tuberculosis Cases by Race/Ethnicity: California, 2016 White Non- White, Non Hispanic (7.1%) 165 (7.7%) Black 118 Black (5.5%) (5.2%) American Indian/ American Alaska Indian/ Native Alaska 4 (0.2%) Native (0.2%) Asian/Pacific Islander 1,081 (50.3%) Hispanic 776 (36.1%) Hispanic (34.3%) Asian/Pacific Islander (53.2%) California Department of Public Health, Tuberculosis Control Branch Tuberculosis Epidemiology 13
TB Case Rates by Race/Ethnicity: California, 2007 2016 California Department of Public Health, Tuberculosis Control Branch Tuberculosis Cases by HIV/AIDS Diagnosis: California, 2011 2016 Number of Cases with HIV/AIDS California Department of Public Health, Tuberculosis Control Branch Tuberculosis Epidemiology 14
Tuberculosis Cases with Multidrug Resistance (MDR)*: California, 2005 2016 Number of MDR Tuberculosis Cases 34 41 36 37 28 32 33 25 36 16 *Cases with resistance to at least isoniazid and rifampin reported on the Initial Drug Susceptibility Report (Follow up 1) or on the Case Completion Report (Follow up 2) California Department of Public Health, Tuberculosis Control Branch Deaths in Persons with Tuberculosis: California, 2005 2014 Number of Deaths Percent of Cases California Department of Public Health, Tuberculosis Control Branch Tuberculosis Epidemiology 15
What are the implications for public health practice? Continued vigilance, surveillance, and active prevention measures are needed to reach the TB elimination. To continue making strides toward elimination, alignment of domestic TB control activities with international TB control initiatives is needed to address increasing disparities between U.S. born and foreign born persons. Treatment of persons at high risk with latent Mycobacterium tuberculosis infection is also needed to address this disparity. CDC MMWR 2015; 64(10); 265 269 The Challenges of Latent TB Infection Preventing TB disease by detecting and treating those with latent TB infection (LTBI) is a cornerstone of the U.S. strategy for TB elimination. TB infection is not currently reportable. It is estimated that more than 2 million Californians have latent TB infection (~13 million people in the U.S.) If not treated, persons with TB infection have a 5 10% lifetime risk of developing TB disease. Tuberculosis Epidemiology 16
California Department of Public Health, Tuberculosis Control Branch Plan to Eliminate TB California Tuberculosis Elimination Plan TB Free California California TB risk assessment Tuberculosis Epidemiology 17
Summary Case count ~ Over 9,000 new cases of TB per year in the U.S. ~ ¼ of cases in the U.S. occur in California Disease incident rate Declining, but the pace of decline has slowed since ~2000 California s TB incidence rate nearly twice that of the U.S. Certain groups disproportionately affected Men (e.g., among 45+ years) Persons born outside the U.S. Race/ethnicity disparities TB Deaths ~9 10% of TB case patients die in California Summary HIV ~6% of TB cases in the U.S. and 4% of cases in CA are HIV positive Drug Resistance Multidrug resistance in 1 2% of TB cases Isoniazid and multidrug resistance are higher among non U.S. born than among U.S. born LTBI An estimated 13 million people in the U.S. (2.4 million in CA) have LTBI Prioritizing TB screening for groups with elevated LTBI prevalence and medical risk of progression from LTBI to TB may help prevent future TB cases Tuberculosis Epidemiology 18
References Centers for Disease Control and Prevention. Reported Tuberculosis in the United States, 2016. Atlanta, GA: U.S. Department of Health and Human Services, CDC Tuberculosis Control Branch. Report on Tuberculosis in California, 2017. Richmond, CA: California Department of Public Health World Health Organization. Global Tuberculosis Report, 2016. Geneva, Switzerland Tuberculosis Epidemiology 19