tb in north dakota: changing demographics john r. baird, md, mph fargo cass public health north...

TB in North Dakota:Changing Demographics

John R. Baird, MD, MPHFargo Cass Public Health

North Dakota Department of Health

April 11, 2012

Objectives

Shift of US TB cases to foreign born

Change in ND TB demographics

Challenges in TB evaluation and treatment in new ethnic groups

Module 1 – Transmission and Pathogenesis of Tuberculosis

• M. tuberculosis causes most TB cases in U.S.

• Mycobacteria that cause TB:– M. tuberculosis – M. bovis– M. africanum– M. microti– M. canetti

• Mycobacteria that do not cause TB– e.g., M. avium complex

M. tuberculosis

Types of Mycobacteria

Module 1 – Transmission and Pathogenesis of Tuberculosis

Sites of TB Disease

Bacilli may reach any part of the body, but common sites include:

Brain

Lym ph node

Pleura

Lung

SpineKidney

Bone

Larynx

Module 2 – Epidemiology of Tuberculosis

• TB is one of the leading causes of death due to infectious disease in the world

• Almost 2 billion people are infected with M. tuberculosis

• Each year about:

– 9 million people develop TB disease

– 2 million people die of TB

Global Epidemiology of TB

Reported TB Cases United States, 1982–2010*

*Updated as of July 21, 2011

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

0

5,000

10,000

15,000

20,000

25,000

30,000

No.

of

Case

s

Year

TB Case Rates,* United States, 2010

*Cases per 100,000.

< 3.6 (2010 national average)

>3.6

D.C.

TB cases in ND - Numbers

TB cases in ND - Rates

TB rates – US vs. ND

TB Case Rates* by Age Group United States, 1993–2010

* Updated as of July 21, 2011

1993

1995

1997

1999

2001

2003

2005

2007

2009

0.0

5.0

10.0

15.0

20.0

0- 14 15 - 24 25 - 44 45-65

Case

s p

er

10

0,0

00

Age Group (years)

TB cases in ND - Age

TB cases in ND - Sex

Reported TB Cases by Race/Ethnicity*United States, 2010

*All races are non-Hispanic. Persons reporting two or more races accounted for less than 1% of all cases.

Hispanic or Latino(30%)

Native Hawaiian or Other Pacific Is-

lander(1%)

White(16%)

Asian(28%)

American Indian or Alaska Native

(1%)

Black or African American

(24%)

TB cases in ND - Race

Number of TB Cases inU.S.-born vs. Foreign-born Persons

United States, 1993–2010*

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

5,000

10,000

15,000

20,000

U.S.-born Foreign-born

*Updated as of July 21, 2011

No. of

Case

s

>50%25%–49%<25%

2000 2010

DC

*Updated as of July 21, 2011

Percentage of TB Cases Among Foreign-born Persons, United States*

DC

TB cases in ND US vs. Foreign Born

Countries of Birth of Foreign-born Persons Reported with TB, United

States, 2010

Mexico(23%)

Philippines(11%)

India(9%)

Vietnam(8%)

China(5%)

Guatemala(3%)

Haiti(3%)

Other Countries38%

TB cases in ND - Origin Foreign Born 2007 - 2011

Africa – Somalia (5), Ethiopia (2), Kenya (2), Sudan, ZambiaSouth Asia – Bhutan (4), Nepal (2), IndiaAsia – China, Mongolia, KoreaSE Asia – Vietnam, Philippines

Refugee Arrivals North Dakota

LSS of ND

Resettlement Cities North Dakota

Countries of Origin - Refugees to ND

Maps adapted from The Perry-Castañeda Library Map Collection, The University of Texas at Austin http://www.lib.utexas.edu/maps

Latent TB Infection (LTBI)

LTBI is the presence of M. tuberculosis organisms (tubercle bacilli) without symptoms or radiographic evidence of TB disease.

25

Latent TB Infection

TST* or QFT† positive

Negative chest radiograph

No symptoms or physical findings suggestive of TB disease

Pulmonary TB Disease TST or QFT usually

positive

Chest radiograph may be abnormal

Symptoms may include one or more of the following: fever, cough, night sweats, weight loss, fatigue, hemoptysis, decreased appetite

Respiratory specimens may be smear or culture positive

*tuberculin skin test†QFT (QuantiFERON-TB and QuantiFERON-Gold) is a blood test to detect M. tuberculosis infection.

LTBI vs. Pulmonary TB Disease

Cases in ND – LTBI & TB

Challenges Language Culture Proper & prompt evaluation Care coordination Complete LTBI treatment Homeless Others?

TBNet http://www.migrantclinician.org

Case #1 4 month old – adopted from Africa Birth mother HIV+ Baby HIV neg @ 6 mo Staph skin and proctitis on US entry BCG given in Africa – no TST done is US Hospitalized at 11 mo

sore ankle, limp, temp 101-103 refused to bear weight 3 days Splinted for possible fracture

Case #1 (cont.) TST 16 mm – QuantiFERON neg Dx – abcess left distal tibia,

staph, ? TB Rx – IV Rocephen, Vacomycin,

Septra DOT – INH, RIF, EMB, PZA Daycare concerns Culture – PZA resistant – Bovine TB

http://www.heartlandntbc.org/casestudies/cs9.pdf

Case PresentationJune 2008 – Adherence Difficulties in a Child with Tuberculosis

Case History: A 15 month old child with active pulmonary tuberculosis became a significant management challenge to his public health nursing providers because of his consistent refusal to take medications.

Consultation may be requested through your state's TB Control Program or by contacting Heartland National TB Center directly at our toll-free number:

1-800-TEX-LUNG (1-800-839-5864)

Consultation line staffed Mon — Fri, from 8:00 AM until 5:00 PM, Central Time http://www.heartlandntbc.org

Questions Craig Steffens, MPH csteffens@nd.gov

TB Controller, NDDoH 701.328.2377 http://www.ndhealth.gov/disease/tb

John R. Baird, MD, MPH jbaird@nd.gov Field Med Officer, NDDoH Health Officer, FCPH 701.241.8118

http://www.heartlandntbc.org http://www.migrantclinician.org http://www.cdc.gov/tb