California TB Update

Transcription

1 California TB Update Pennan Barry, MD, MPH Chief, Surveillance and Epidemiology Section California TB Controllers Association March 8,

2 Acknowledgments Local TB Programs TBCB Staff SES MDR Service Janice Westenhouse Saul Kanowitz Phil Lowenthal Varsha Hampole Clint McDaniel Melissa Ehman Lisa True Jenny Flood CTCA Organizing Committee 2

3 Outline California TB Epi Update (Preliminary 2016) Disparities Race/ethnicity Socioeconomic status MDR TB Hospitalization Health equity and TB Reporting 3

4 Reported TB in California Each = 1 TB case (Total = 2137) 2073) 4

5 Reported TB in California 2016 Elderly woman develops TB while caring for grandchildren so daughter can work. Blamed for exposure sent away Young woman in U.S. for school develops MDR TB. Cannot return home. Feels isolated, persistent nausea depression Each = 1 TB case (Total = 2073) 5

6 CA Tuberculosis Epidemic years ago: 1 in 9 died of TB 12, Number of TB Cases 10,000 8,000 6,000 4,000 2, Case Rate per 100, TB Cases TB Rate 6

7 Tuberculosis Cases and Case Rates 6,000 California, , Number of TB Cases 4,000 3,000 2,000 1, Case Rate per 100, TB Cases TB Rate 7

8 Tuberculosis Cases and Case Rates Number of TB Cases 6,000 5,000 4,000 3,000 2,000 1,000 California, Average annual change in case rate -6.2% -4.3% -3.8%? % Case Rate per 100, TB Cases TB Rate 8

9 Year of TB elimination in California Extrapolation based on current rate of decline* Rate per 1 Million Actual Current decline (-4%) 2040 Elimination (-14%) Elimination Year * Average annual decline in case rate

10 TB Case Rates by Jurisdiction, 2016 per 100, LHJs reported no cases 10

11 Demographics of TB Cases 11

12 Proportion of TB Cases by National Origin California, % U.S.-born 81% Foreign-born Mexico Philippines Vietnam China India Central America Other Countries 12

13 TB case rate by nativity California U.S.-born Foreign-born

14 TB case rate by nativity California U.S.-born Foreign-born FB:USB Ratio

15 1200 Years in U.S. at TB diagnosis by Country of Origin California, TB Cases Years in U.S. 15

16 TB Cases Years in U.S. at TB diagnosis by Country of Origin California, B-notification arrivers diagnosed during domestic evaluation >50% in US >16 yrs Years in U.S. 16

17 TB Cases Years in U.S. at TB diagnosis by Country of Origin California, Vietnam Philippines Mexico India China Others Years in U.S. 17

18 TB diagnosis within 2 years of U.S. Arrival by Country California, TB Cases Philippines 235 Mexico 147 India 135 Vietnam 128 China 71 Others 322 0% 20% 40% 60% 80% 100% 18

19 TB Rate per 100, Years in U.S. at TB diagnosis by Country of Origin California, Vietnam rate Philippines rate Mexico rate India rate China rate 0 Years in U.S. Denominator for rate is ACS data for 2014 Rates based on <10 cases not shown 19

20 100 Healthcare Workers with TB California, US born Foreign Born %hcw Number of Cases Percent HCW

21 Rate of TB among Healthcare Workers California, Rate per 100, Years Denominator from ACS surveys OCC dataset 21

22 Healthcare Workers with TB by Country of Birth and Time in US, California, cases 140 (86%) foreign-born healthcare workers Philippines (n=111, 79%) Mexico (n=8) India (n=6) 13 other countries Time in US Median= 14.5 years (IQ range = years) 22

23 Recent Transmission (RT) of TB Culture positive cases identified as potentially a recipient of recent transmission Cases (%) 236 (13.5) 239 (13.6) 238 (13.8) 247 (14.0) 190 (11.4) France, et al. Am J Epidemiol

24 25% % plausible source cases by nativity California, % 15% 10% 5% 0% 22% 11% US Born Foreign Born *CDC recent transmission algorithm (unrevised) from France et al Am J Epidemiol

25 Age at TB Diagnosis California, 2016 Median age continues to increase: 53 (2015) 54 (2016) 2016: Foreign-born=57 years US-born=38 years 0 4 n= n= n= n= n= n=690 0% 20% 40% 60% 80% 100% 25

26 Median Age of TB Cases by Nativity California Median Age at Report of TB (years) US-born Foreign-born

27 Pediatric Cases <5yrs California, % Number of Cases % Percent of Cases

28 Epi Update Summary 3.8% decline better; not on track for elimination Birth outside U.S. vulnerable to TB? Less likely to be source of transmission Adults >45 years account for 65% of cases Only 34 cases under 5 Little transmission 28

29 Infographic: Multidrug-resistant TB 29

30 Primary Multidrug-resistant TB Cases California, MDR Case Number MDR Percent MDR Cases MDR Percent 0 30

31 MDR Cases by Country of Origin, California, Number or MDR cases Other countries Philippines Vietnam United States Mexico 31

32 60 50 Foreign-born MDR Cases by Time in US California, >5 years Percent MDR cases <1 year 2 5 years 1 2 years 32

33 Number and Proportion MDR-TB by Country/Region of Origin, CA Country/Region No. % Former Soviet Republics Laos Burma India Guatemala Korea (N&S) Peru Ethiopia Philippines Vietnam China (incl Taiwan) United States Cambodia Mexico Countries with >35 cases tested for MDR 33

34 Number and Proportion MDR-TB by Country/Region of Origin, CA Country/Region No. % PPV (99% spec) PPV (98% spec) Former Soviet Republics % 87% Laos % 72% Burma % 63% India % 60% Guatemala % 60% Korea (N&S) % 59% Peru % 56% Ethiopia % 50% Philippines % 45% Vietnam % 40% China (incl Taiwan) % 37% United States % 28% Cambodia % 25% Mexico % 22% Countries with >35 cases tested for MDR 34

35 MDR-TB Cases by Country/Region of Origin and Years in the US, CA Country/Region Total MDR TB cases 2 years in US No. (%) >2 years in US No. (%) All Countries* (excl U.S.) (3.7) 71 (1.2) Vietnam* 13 9 (7.9) 3 (0.4) China* (incl Taiwan) 7 5 (8.8) 2 (0.4) Philippines* 27 8 (4.0) 19 (1.4) * Difference is statistically significant 35

36 California MDR Outcomes All MDR Cases n=195 Off Treatment 132 On Treatment 52 Moved 11 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Failure (micro)=1 Death=4 Failure(ADR)=4 Default/LTFU=5 Off Treatment n=132 Cure/Complete 118 0% 20% 40% 60% 80% 100% Includes consult and nonconsult cases by year of MDR Service notification MDR by MDR Service definition: includes molecular susceptibility tests and clinical cases 36

37 Are we ready to try the Short(er) Course Regimen for MDR-TB? Initial Phase (7 drugs) Continuation Phase (4 drugs) Moxifloxacin* Ethambutol Pyrazinamide Clofazimine Ethionamide Isoniazid* Amikacin *High dose months 37

38 MDR TB Summary Recent increase in cases Overall demographics stable Risk of MDR can guide Xpert RIF results Outcomes are good Short course? 38

39 Interaction Institute for Social Change Artist: Angus Maguire. and 39

40 TB Rates and Disparities between Race/Ethnic Groups, Rate per 100, x 4.5x White Black Hispanic Asian/PI 40

41 Health Disparity: TB rate by race/ethnicity and nativity CA rate: 5.3 California 2016 Overall Asian Black Hispanic White Foreign born US born Rate (per 100,000) Sources: American Community Survey and CA Department of Finance population data, RVCT case data 41

42 HIV Inequities California, 2016 % HIV positive, n=

43 Measures of socio-economic status (SES) American Community Survey: (U.S. Census Bureau) Poverty, Household size, Education, Health insurance Census tract level, 5 year average Matched to RVCT data Created dichotomous variables using California average as cutpoint Example: Average census tract has 16% poverty: Poverty above or Poverty below CA average 43

44 Caution: Ecologic Analysis Race/ethnicity Hispanic Age 32 Nativity Foreign-born Avg Household size 4.5 % Medi-Cal 15% % Poverty 21% RVCT; patient ACS; census tract ACS data represent patient residential community, not individual characteristics 44

45 TB Cases by Poverty and Race/Ethnicity and Place of Birth, California, 2016 Race/ethnicity US-born Foreign-born Percent* RR (95% CI) Percent* RR (95% CI) White 30% Reference 33% Reference Black 68% % 1.5 Hispanic 59% % 2.1 Asian/Pacific Islander 30% % 1.2 * Percent of cases in census tract with > 16% poverty (state average) Bold indicates 95% CI does not cross

46 Risk of Cavitary TB and Community Measures of SES California, 2016 Relative Risk Medicaid (>22%) Uninsured (>15%) Poverty (>16%) Bachelor's Degree (>31%) Mantel-Haenszel RR. Based on characteristics of residential census tract from ACS. 46

47 Risk of Death on TB Treatment and Community Measures of SES California, Uninsured (>15%) Poverty (>16%) Bachelor's Degree (>31%) Relative Risk Mantel-Haenszel RR. Based on characteristics of residential census tract from ACS. 47

48 Rural Outcomes California, No different than nonrural outcomes Total cases (%) Rural (%) Urban (%) Total California 15, (0.6) 15,112 (99.4) Poor outcome 1,829 (12) 13(13.5) 1,816 (12) Good outcome 13,379 (88) 83 (86.5) 13,296 (88) Rural aor for poor outcome = 1.0 (0.5, 2.1) Poor outcome = death, lost, stopped due to adverse event, refused Good = completed Tx 48

49 TB Elimination 49

50 Year of TB elimination in California Extrapolation based on current rate of decline* Rate per 1 Million Actual Current decline (-4%) 2040 Elimination (-14%) Elimination Year * Average annual decline in case rate

51 What does elimination mean? Tuberculosis Rate (case per million) 2015 (Current) Elimination by 2040 Averted 2040 (cumulative) 55 <1 - Cases ,000 Deaths ,500 Direct costs (2015 dollars) $72 Million $1.3 Million >$850 million 2040 cases based on 2014 US Census Estimate of California Population: 38.8 million Elimination definition: WHO. Framework towards TB Elimination in Low-Incidence Countries Deaths estimated as 10% of active cases Direct costs estimated using average cost per case in 2015 ($33,692). Includes only direct medical costs for case. 51

52 LTBI Care Cascade Alsdurf et al Lancet Infect Dis 2016; 16:

53 35000 B notification LTBI Care Cascade California, ,241 Total Arrivers 100% TB4 TB2 TB0 Evaluated 71% TB3 N=172 (<1%) MDR N=6 (3.5%) 53

54 B notification LTBI Care Cascade California, TB TB2 0 Evaluated 71% No prior Rx (eligible) Rx Started 47% RxComplete 15% of eligible 54

55 B notification LTBI Care Cascade California, TB TB2 Missing Missing 0 Evaluated 71% No prior Rx (eligible) Rx Started 47% RxComplete 15% of eligible 55

56 Contacts Care Cascade: Evaluation ARPE Data California, TB2/4 12,353 TB3 335(0.6%) ,162 Number contacts TB1 41,761 Evaluated 56

57 Contacts Care Cascade: Treatment ARPE Data California, % % ,353 7,498 4,831 Latent TB infection Started Treatment Completed treatment 57

58 Contacts Completing LTBI Treatment (of those who start treatment) 80% 70% 60% 50% 40% 30% 20% ARPE Data California, % 0% 65% 63% 62% 62% 73%

59 Reason Contacts did not complete LTBI treatment ARPE Data California, Contact chose to stop 972 Contact is lost to follow-up 505 Contact moved Provider decision Med adverse effect Active TB developed Death 0% 20% 40% 60% 80% 100% 59

60 2016: A Good Year for TB Elimination USPSTF issued LTBI recommendations California TB Elimination Plan Many activities already underway ATS/CDC/IDSA Guidelines updated TB Treatment Guideline TB Diagnostic Guideline But no LTBI Guideline yet WHO recommends short course MDR treatment 60

61 Power of Public Health to Address Health Equity and Influence the Epidemic Few cases in children under 5 Low MDR death rate No impact of rural residence on outcome Low rate of TB in prisons Turn around of 1990s peak 61

62 California tuberculosis cases and interventions ,000 5,500 5,000 5,382 Tuberculosis Cases 4,500 4,000 3,500 3,000 2,500 2,000 1,500 3,244 Gotch Legislation Medi-Cal TB Program Curry National TB Center CTCA/CDHS Joint Guidelines Cure TB $2.9 Million Housing and Detention Tuberculosis Indicator Project (TIP) 1, $17.4 Million Local Assistance