TB in California: Costs, Transmission, and Selecting from the Latent Pool Pennan Barry, MD, MPH Tuberculosis Control Branch California Department of Public Health California Tuberculosis Controller s Association Conference May 15, 2012
This Presentation Review of 2011 California data Pediatric TB What proportion is from transmission? How much does managing TB cases in California cost? Can we focus prevention efforts? 2
TB in California, 2011 Janice Westenhouse Melissa Ehman 3
Final TB Case Count and Rate California, 2011 2,319 cases 0.4% decrease from 2010 (n=2,329) TB rate = 5.9 per 100,000 population 1.7% decrease from 2010 (rate = 6.0) 4
Number of Tuberculosis Cases: California, 1980 2011 12,000 10,000 6,000 5,000 4,000 8,000 6,000 4,000 2,000 0 1930 1940 1950 1960 1970 1980 3,000 2,000 1,000 0 1980 1985 1990 1995 2000 2005 2010 Year
Number of Tuberculosis Cases Case Rate per 100,000 3,400 Tuberculosis Cases and Case Rates California, 2002 2011 12 3,200 10 3,000 2,800 2,600 2,400-8.3% -5.9% -0.4% 8 6 4 2,200 2 2,000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year TB Cases TB Rate 0 6
Rate (per 100,000 TB Case Rates, California 1993 2010 7
Essential (Obvious?) Question Why a stall in the prior decline? Returning to normal after 2 larger declines? Were there increases in TB among subpopulations? 8
Number of cases TB cases by place of birth California, 2007 2011 2500 2000 1500 1000 500 0 1808 1782 2011 77% Foreign-born 494 505 2007 2008 2009 2010 2011 Foreign-born US-born 9
Number of foreign-born cases Years in US at TB diagnosis, 2007 2011 800 600 400 200 n=581 n=728 0 2007 2008 2009 2010 2011 <=1 yr 1-5 yrs 5-10 yrs 11-20 yrs 20+ yrs 10
Number of cases TB cases by age group, 2007-2011 1600 1400 1200 1000 800 600 400 200 0 2007 2008 2009 2010 2011 0-14 15-44 45+
Cases Pediatric Cases by Age Group, 100 90 80 70 60 50 40 30 20 10 0 2007 2011 2007 2008 2009 2010 2011 0-4 5-14 15-18 12
Pediatric TB Cases 0 4 yrs 7% 6% 329 California, 1993 2011 243 5% 4% 3% 190 152 132 131 85 89 70 81 2% 1% 0% 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 Cochrane-Armitage Trend Test: 1993 2011 2000 2011 2007 2011 p value <0.0001 0.0006 0.67 60 13 13
Pediatric TB (0 5 yrs) California Race/ethnicity (2011): 71% Hispanic Drug resistance (2000 2011): 27% with drug-resistance; 19% PZA mono-r US-born (2011): 93% Account for 16% of all US-born cases 14
Diagnosis (Verification) Criteria Pediatric TB Cases (0 5), 2010 2011 Criteria 2010 2011 Culture + 30% 26% NAAT or Smear + 3.3% 4.5% Clinical Case 43% 60% Provider Diagnosis 23% 10% 15
Reason for TB Evaluation: TB in Children 0 5, CA, 2010 2011 Contact investigation 37% TB symptoms 27% Abnormal CXR 30% Targeted testing 3% Immigration exam 2% 44% contact to infectious TB patient* * Evaluated in a contact investigation or linked contact to an infectious TB case 16
Sites of TB disease: Children aged 0 5 years, 2000 2011 Pulmonary TB* 78.6% Lymphatic cervical TB 11.0% CNS TB 5.5% Intrathoracic lymphatic TB 4.5% Other lymphatic TB 2.7% Bone TB 1.5% Peritoneal TB 0.5% * Pulmonary TB alone or with other sites 17
Proportion of TB Cases in Children 0 4 that are CNS TB, 1998 2011 12% 10% 8% 6% 4% 2% 0% 1998 2000 2002 2004 2006 2008 2010 18
Proportion CNS TB in Children 0 4 yrs California, 1998 2011 12% 10% 8% 6% p=.004 4% 2% 0% 1998 2000 2002 2004 2006 2008 2010 19
Deaths with TB, CA 1993 2009 12% 575 505 10% 8% 380 341 278 253 255 213 230 6% 4% 2% 0% 1993 1995 1997 1999 2001 2003 2005 2007 2009 Cochran-Armitage Trend Test: 1993 2011 2000 2009 2007 2009 p value <0.0001 0.27 0.87 20
Number of MDR TB Multidrug-resistant TB, 2002 2011 2011: 33 MDR TB cases; 1 XDR TB case 50 2.0 40 30 20 10 1.5 1.0 0.5 Percent MDR TB cases 0 42 34 41 36 37 28 32 33 25 33 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 0.0 21
MDR TB: % Foreign-born by year 100% 80% 60% 40% 20% 0% 93% 90% 97% 92% 91% 2007 2008 2009 2010 2011 22
Number and Proportion MDR TB by Country/Region of Origin, CA 2007 2011 Country/Region No. % Former Soviet Republics 7 11.7 Laos 11 9.5 Burma 3 4.7 South Korea 9 3.7 Peru 3 3.7 Ethiopia 2 3.5 Philippines 35 2.1 Vietnam 18 1.9 Central America 9 1.9 India 7 1.7 Taiwan 1 1.5 China 7 1.4 Mexico 17 0.8 Kampuchea 1 0.7 United States 10 0.5 Countries with >50 cases tested for MDR
TB in California, 2011 No substantial overall decline from 2010 Increases: TB in children including CNS TB (Sentinel Event) Older persons / foreign-born in US >20 years MDR case number Deaths: still nearly 1 in 10 24
Recent Transmission Lisa Pascopella 25
New Opportunity 26
Epi-Cluster TB case, counted in 2011 Epi-link on RVCT to at least 1 other case: Within 2 year window (report year 2009, 2010, or 2011) 27
Other RVCT indicators of transmission Additional TB Risk Factors: Contact to infectious TB case Missed contact Contact to MDR TB patient Reason for evaluation: Contact investigation Child <5 years old 28
TB cases identified in Epi-clusters, 2009 2011 255 TB cases in epi-cluster 133 in 2011 96 2-person clusters 12 3-person clusters 5 4-person clusters 1 7-person cluster 29
Recent transmission, 2011 133 (6%) in Epi-clusters 125 (5%) contacts (to infectious TB cases, or to MDR TB cases, or missed) 93 (4%) reason for evaluation = contact investigation 81 (4%) aged 0 4 years 30
At least 8% of 2011 TB Cases Involved in Recent Transmission 133 in epi-clusters -3 nonmatching genotypes +60 at least 1 RVCT transmission indicator 190 (8%) Total TB cases involved in recent transmission 31
Number of epi-linked cases is an underestimate of recent transmission In 2011, at least 5 LHJs reported outbreaks, but did not report epi-links 32
MIRU 2 clusters, 2009-2011 2,317 total TB cases in 2011 1,815 (78%) culture positive 1,406 (77%) with a genotype result 1,034 (74%) in statewide cluster 197 (14%) in LHJ cluster 33
How much does managing active TB in California cost? Peter Oh 34
Components of direct TB costs included Hospitalization Physician fees Inpatient Outpatient Outpatient case management Laboratory and imaging tests Anti-TB medications 35
Cost data sources Measure / objective Reported costs of any of the components Physician costs (fee reimbursements) Laboratory test costs (fee reimbursements) MDR TB medication costs Adjust reported health care worker salaries to California levels Source PubMed search of published articles stating costs in the U.S., 1990-2011 Medicare Physician Fee Schedule, 2011 Medicare Clinical Diagnostic Laboratory Fee Schedule, 2011 MDR Service estimate derived from CITC/CDPH, 2008 National Compensation Survey, 2010 Adjust costs to current dollars Consumer Price Index, 2011 36
MDR TB ALL CASES Assumptions Assumption Initial new patient visit, then monthly established patient visits (medium clinical complexity) $46/h salary for 152 h of NCM time during 28-week treatment period (456 hrs for MDR) Drug Prices from 340B Program 50% hospitalized 75% of MDR hospitalized; 1.7 times per patient MDR TB monitoring performed as recommended (i.e., Liver function tests baseline and monthly while on PZA, ethionamide or PAS) Treat 24 mos after culture conversion at 2 months 8 mos: CM, LNZ, LFX, CS, PZA 18 mos: PZA, LNZ, LFX, CS Source Standard practice Rubado et al, 2008; National Compensation Survey, 2010 MDR/XDR TB enhanced surveillance 2005 2007* MDR TB Service MDR TB Service 37
Estimates of Average Direct Costs Component Per Patient TB $ per patient MDR TB $ per patient Hospitalization 10,100 15,900 63,800 Physician fees 1,500 1,900 7,000 Outpatient case management Laboratory and imaging tests 8,200 24,600 1,900 4,200 TB medications 500 11,700 48,000 Total 22,200 28,400 113,100 147,600 38
Estimated Total Direct Costs of TB Care in California (2011 $) Year Total Cases MDR Cases Estimated Costs (Million $) 2006 2776 37 64.99 83.25 2007 2725 28 63.04 80.73 2008 2699 32 62.83 80.47 2009 2466 33 57.74 73.97 2010 2326 25 53.91 69.04 2011 2319 33 54.48 69.79 Total 15311 188 356.99 457.24 39
Limitations Perspective Health care system perspective does not include societal costs of TB Private sector costs not measured Public health costs not directly related to care not included contact investigation / treatment of contacts 40
Medical risk factors: Can we focus prevention efforts? Ellen Demlow Peter Oh Janice Westenhouse
Medical risk factors among TB cases >15 years of age, 2011 Risk Factor All Cases USborn Foreign-born All 10+ yrs in US Diabetes 24% 15% 27% 34% End stage renal disease 3.8% 3.8% 3.9% 5% HIV-positive* 4.5% 6.9% 4.0% 4.0% Other immunosuppression 7% 6% 7% 9% Post-organ transplant <1% <1% <1% 1% One or more risk factor 35% 29% 36% 42% *HIV-positive among all cases, including those not tested, etc. 42
TB Population Attributable Risk % 20 by Co-Morbidity, 2010 2011 15 % 10 5 0 Cases Attributed 0.6 3.5 4.2 16.4 Organ Transplant POT ESRD HIV Diabetes 14 81 97 380 PAR%: the proportion of TB in the overall population that is attributable to the medical risk and could be eliminated if the risk were eliminated 43
DM/TB Rates by Nativity Adults, CA, 2010 2011 Categories Total Cases TB Cases among diabetics * (%) 1014 (23.4) TB Rate per 100,000 Diabetics TB Cases among nondiabetics (%) 21.8 3329 (77.0) 6.6 Risk Difference per 100,000 (95% CI) 15.2 (13.8, 16.5) Relative Risk (95% CI) 3.3 (3.1, 3.5) U.S.-born 117 (11.5) 4.2 657 (19.7) 1.9 TB Rate per 100,000 nondiabetics Foreignborn 885 (87.3) 46.7 2605 (78.3) 16.0 2.3 (1.8, 3.1) 30.7 (27.6, 33.8) 2.2 (1.8, 2.7) 2.9 (2.7, 3.2) *All cases are among the adult population 18 years of age 44
DM/TB Rates by Race/Ethnicity White Not Hispanic Black Not Hispanic Adults, CA, 2010 2011 TB Cases among diabetics*(%) TB Rate per 100,000 diabetics TB Cases among nondiabetics (%) TB Rate per 100,000 nondiabetics 47 (4.6) 2.9 323 (9.7) 1.3 33 (3.3) 8.5 235 (7.1) 8.7 Hispanic 405 (40.0) 21.1 1121 (33.7) 7.0 Relative Risk (95% CI) 2.2 (1.6, 2.9) 1.0 (0.7, 1.4) 3.0 (2.7, 3.4) US Born 56 (13.8) 8.8 216 (19.3) 3.1 2.8 (2.1, 3.8) F-Born 341 (84.2) 26.6 844 (75.3) 9.3 2.8 (2.5, 3.2) 3.9 (3.5, 4.3) US Born 10 (1.9) 6.0 56 (3.5) 2.9 2.1 (1.1, 4.1) Asian/PI 526 (51.9) 92.6 1611 (48.4) 24.0 F-Born 513 (97.5) 128.3 1544 (46.4) 32.4 4.0 (3.6, 4.4) *All cases are among the adult population 18 years of age 45
DM/TB: Reason for Evaluation, Adults, CA, 2010 2011 Reason for Evaluation TB- No Co-Morbidity n=3313 (%) TB-DM n=1014 (%)* TB Symptoms 2017 (60.9) 705 (69.5) Abnormal Chest Radiograph 600 (18.1) 187 (18.4) Incidental Lab Result 262 (7.9) 75 (7.4) Total Passive Case Finding 2879 (86.9) 967 (95.4) Contact Investigation 164 (5.0) 11 (1.1) Targeted Testing 74 (2.2) 8 (0.8) Healthcare Worker 11 (0.3) 1 (0.1) Employment/Admin Testing 37 (1.1) 3 (0.3) Immigration Medical Exam 133 (4.0) 19 (1.9) Total Active Case Finding 419 (12.6) 42 (4.1) Unknown 15 (0.5) 3 (0.3) *All cases are among the adult population 18 years of age 46
Benefits of Screening Foreign-born Persons with Diabetes Focus on persons in US for >10 years Many/most accessing healthcare Not being done now Screening foreign-born cost effective Plausible biologic basis of increased risk IFN-γ, IL-12, Th1 response Linas, et al. Am J Respir Crit Care Med. 2011 Sep 1;184(5):590-601. Jeon et al. PLoS Med. 2008 Jul 15;5(7):e152. 47
TB Control Strategies Quickly diagnose and treat active cases Priority 1 Activity Expensive Stop transmission Effective treatment of active cases Contact Investigation, treatment of infected contacts Prevent pediatric cases Treat latent pool of infections 3HP Foreign-born diabetics 48
Summary More than 8% involved in recent transmission (known underestimate) Repeat analysis planned Nearly $0.5 Billion estimated direct healthcare costs of TB in California over 6 yrs Baseline for cost effectiveness analyses 1/3 of foreign born TB cases with DM Can we focus screening for TB infection? 49
Acknowledgments Surveillance and Epidemiology Section TB Registry Allison Kelley Jenny Flood Local TB Control Programs Pennan Barry, MD, MPH pennan.barry@cdph.ca.gov