california update : tb epidemiology and indicators ctca october 22, 2010 jennifer flood md mph...
TRANSCRIPT
California Update: TB Epidemiology
and Indicators
CTCAOctober 22, 2010
Jennifer Flood MD MPHChief, Surveillance and Epidemiology
Tuberculosis Control BranchCalifornia Department of Public Health
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Objectives
Epidemiology• Are we on our way… towards TB elimination…
finally?• How has the TB case population changed?
TB Control Indicators• Has California successfully deployed available
TB control strategies? Compared to the nation?
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Longview: 80 Years of TB Control in California
YEAR TB Cases Case rate
1930 11,293 199/100,000
2009 2500 6.7/100,000
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Hierarchy of TB Case Rate Disparities,
California, 2009Case rate Nativity and race/ethnicity1.2 U.S.-born White2.7 U.S.-born Hispanic3.8 National case rate4.1 Foreign-born White4.2 U.S.-born Asian6.7 U.S.-born Black12.9 Foreign-born Hispanic35.2 Foreign-born Asian99.0 Foreign-born Black
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U.S.-born Homeless TB Cases in California, Then and Now
1994 vs. 2009
Total homeless 390 (8%) 103 (4%)
U.S.-born TB cases
Homeless 274 (17%) 55 (9.5%)
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U.S. and Foreign-born TB Cases in California, 2009
65%
24%
11%
0% 20% 40% 60% 80%
Foreignborn recentTB cases 256
US born TB cases(583)
Foreign-born remoteTB cases (1543)
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Changes in arrivals by overseas TB classification, 2009-2010
TB Class 2009 Jan-Jun2010
B1 (TI 07) 2557(40%) 1790 (54%)
B1/B2 (TI 91) 1530 (24%) 170 (5%)___________________________________
B2 LTBI (TI 07) 2366 (37%) 1353 (41%)
• Over 6,000 B-notification arrivers in 2009!• 60% of arrivers from Philippines
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TB cases among recent B-notification arrivers from Mexico, the Philippines, or Vietnam
Is the revised overseas screening preventing TB importation into California?
0
5001000
15002000
25003000
3500
2002 2003 2004 2005 2006 2007 2008
B-n
oti
fica
tio
n a
rriv
als
0.0
1.0
2.0
3.0
4.0
5.0
6.0
% r
epo
rted
as
TB
cas
es
B1/B2 (TI 91) & B1 (TI 07) TB cases <6 months after U.S. arrival
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Who are California’s HIV co-infected TB cases?
1993 (501) 2008 (126)Median age 36 40Female 6% 17%Hispanic 37% 57% Black 33% 22%White 25% 12%Asian 4% 8% Foreign birth 34% 60% PZA mono-resistance 1.8% to 14%
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How many with AIDS/TB die?
1994 2007
140 (31%) 18 (14%)
Source: California AIDS/TB registry match
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Has the pathogen changed?Anti-TB Drug Resistance,
California 2009
• Pansusceptible 85%
• INH 8%
• Mono-PZA 3.6% ------Increasing!
• Polydrug 2.9%
• MDR 1.7%
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Summary: TB Epidemiology in California is Changing
• TB now affects much fewer CaliforniansWho has TB Disease in 2009?• Prominent race and nativity disparities• Homeless TB cases shrinking • Foreign-born remote arrivers = largest case group• Growth of immigrant group with B-notification; marked
decline in disease post-arrival• Striking changes in HIV/TB intersection and mortalityIs the pathogen more difficult to treat? • Drug resistance unchanged except climb in M. bovis
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TB Control Indicators
• How successful are we in implementing TB control strategies and driving TB morbidity downward?
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TB Control Indicators: California SHORT LIST
SurveillanceTB case rate
US-born TB case rateGenotyped cases
TB Treatment Inappropriate SAT
TB disease outcomes Culture conversion Completion of therapy ever TB deaths
Case-finding Contacts evaluated B-notification evaluated
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Selected TB Control Indicators:California compared to Nation
Better• Culture conversion within 60 days (2008) 64%• Universal genotyping (2009) 78%
Same as National Average• Contact evaluation (2007) 83%
Worse• TB case rate (2009) 6.7
• US born case rate (2009) 2.2
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California Cases Recommended for DOT Receiving SAT only,
by provider type
0
10
20
30
40
50
60
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90
100
1994 1996 1998 2000 2002 2004 2006 2008Year
Per
cen
t
PMD All HD
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SAT and risk of acquired drug resistance
Of 2,315 TB cases in 2008,
• 350 (15%) were on SAT throughout therapy• 77 (22%) of the 350 patients had 1 or more risk factors for acquired drug resistance:
HIV infectiondrug resistance smear positive cavitary CXR
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Trends: Cases with no documented conversion ever, 1994-2008
(private vs. public)
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10
20
30
40
50
60
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Per
cen
t
Health Department
Private Provider
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Tuberculosis Cases1 by Outcome of Therapy, Excluding Deaths: California, 2008
Completed Therapy 2,250 (91.5%)
Moved112 (4.6%)
Refused/Lost48 (1.9%)
Missing/Other49 (2.0%)
1 Patient alive at diagnosis, started treatment and did not die during therapy.
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Death by Consumption 2009
Died with TB 218 (8.8%)
• Deaths during therapy 177 (7.2%)
• Dead at diagnosis 42 (1.7%)
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TB Deaths during Therapy, by Provider Type, 1994-2009
0
2
4
6
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10
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18
20
Year
Per
cen
t
Private Provider
Health Department
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Case-finding and Prevention: Evaluation of TB suspects and contacts
How many were evaluated in California?
• 2767 (73%) persons with abnormal overseas CXR (B1 and old B1/B2) evaluated in 2008
• 12,380 (83%) contacts to smear positive pulmonary TB cases in 2007
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What is not measured in our indicator sets?
• Time to TB diagnosis (delays in diagnosis)
• TB transmission events
• Acquired drug resistance
• TB treatment failure and relapse
_______________________________
• Which interventions are most important and most effective not clearly defined
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Summary: How successful are TB control efforts in California?
• California has reaped huge benefit from TB control efforts • Use of recommended strategies has improved dramatically• Vast majority of patients complete TB therapy• Fraction who die has not changed • More attention needed for those at highest risk for adverse
outcomes • Private sector lags behind in best practices • Improvements suggest private-public collaboration can work • Challenge: treatment, case-finding and prevention needs
remain very large • California without TB: a wellness and prevention expectation
for health care reform!
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Questions?