Post on 09-Jul-2020
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 1
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
Disclosures…
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 2
Updated as of March 12, 2019
Reported TB Cases Hawaii, 1930–2018
1060
717
339
293270
167196
136 115 117 136 119 116 120
0
200
400
600
800
1000
1200
1930 1940 1950 1960 1970 1980 1990 2000 2010 2012 2014 2016 2017 2018
No
. o
f ca
ses
Year
15.5
11.2
12.311.9
9.2 9.28.8 8.9
9.5 9.69.1
8.48.9
8.4 8.2
9.6 8.9
8.3 8.1
6.35.8 5.6
5.2 5.1 4.9 4.8 4.6 4.4 4.23.8 3.6 3.4 3.2 3.0 2.9 3.0
2.7 2.8
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Cas
es
pe
r 1
00
,00
0
Hawaii Rate U.S. Rate
TB Case RatesHawaii vs. United States, 1999–2017
U.S. in 2017Hawaii had the Highest
TB Case Rate
Updated as of April 2, 2018
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 3
County
No. of Cases Case Rates(per 100,000 population)
Population Estimates
2017 2018 2017 2018 2017
Hawaii 9 9 4.5 4.5200,381
Honolulu 90 94 9.1 9.5 988,650
Kauai 4 3 5.5 4.2 72,159
Maui 13 14 7.8 8.4 166,260
TOTAL 116 120 8.1 8.4 1,427,538
TB Cases and Case Rates by CountyHawaii, 2017-2018
Updated as of March 12, 2019
Note: Population estimates used to compute case rates were obtained from U.S. Census Bureau: State and County QuickFacts. Data derived from Population Estimates, American Community Survey, Census of Population and Housing, State and County Housing Unit Estimates, County Business Patterns, Nonemployer Statistics, Economic Census, Survey of Business Owners, Building Permits, Consolidated Federal Funds Report (https://www.census.gov/quickfacts (accessed April 2, 2018).
13% (12)13% (12)
1% (1)
9% (7)
24% (21)
12% (11)
5% (5)
1% (1)
3% (3)
0% (0)
1% (1)
0% (0) 1% (1)
0%
5%
10%
15%
20%
25%
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
% R
esi
stan
t
Isoniazid MDR TB
6% (5)4% (4)
0% (0)1% (1)
11% (10)
3% (3)
14% (13)
Updated as of March 12, 2019
Primary Anti-TB Drug Resistance*
Hawaii, 2009–2018
U.S. in 2017INH-R = 9.2%
MDR TB = 1.4%
*Cases are culture positive with initial drug susceptibility testing done. INH-R = at least resistant to INH; MDR = at least resistant to INH and RIF; isolates may be resistant to other drugs. Excludes cases with susceptibility testing not done or unknown for isoniazid and rifampin.
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 4
<15 15-24 25-44 45-64 ≥65
0%
5%
10%
15%
20%
25%
30%
35%
40%
Age Group
Pe
rce
nta
ge o
f C
ases
Hawaii, 2018
Percent of TB Cases by Age Group and GenderHawaii vs. United States, 2018
<15 15-24 25-44 45-64 ≥65
0%
5%
10%
15%
20%
25%
30%
35%
Age Group
Pe
rce
nta
ge o
f C
ases
United States, 2017
Female MaleUpdated as of March 12, 2019
117 115123 117 115
136127
119 116 120
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
20
40
60
80
100
120
140
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
No. of Hawaii Cases Foreign-born (Hawaii Definition) Foreign-born (CDC Definition)
Trends in TB Cases and Percentage ofForeign-born Persons (Hawaii vs. CDC Definition*)
Hawaii, 2009–2018No. of Cases Percentage
*In 2016, the CDC changed the definition of foreign-born to include persons born in the freely associated statesUpdated as of March 12, 2019
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 5
United States12% (14)
FSM8% (10)
China 2% (2)
Other Countries* 8% (9)
Vietnam4% (5)
Korea, Democratic
Republic2% (2)RMI
8% (9)
Philippines58% (69)
Countries of Birth of All PersonsReported with TB, Hawaii, 2018
N=120
*Other countries include: Republic of Korea (1), Germany (1), Hong Kong (1), Guam (1), Mexico (1), Malaysia (1), Russian Federation (1), Tokelau (1), Tonga (1)
FSM = Federated States of Micronesia; RMI = Republic of the Marshall Islands
Updated as of March 12, 2019
FSM9% (10)
RMI 8% (9)
Other countries*8% (9)
Vietnam5% (5)
China 2% (2)
Korea, Democratic
Republic2% (2)
Philippines 65% (69)
Countries of Birth of Foreign-born PersonsReported with TB, Hawaii, 2018
N=106
*Other countries include: Republic of Korea (1), Germany (1), Hong Kong (1), Guam (1), Mexico (1), Malaysia (1), Russian Federation (1), Tokelau (1), Tonga (1)FSM = Federated States of Micronesia; RMI = Republic of the Marshall Islands
Updated as of March 12, 2019
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 6
United States56%
Philippines11%
FSM16%
Marshall Islands
13%
Burundi 2%
Guam2%
Hawaii Pediatric TB Cases by Birth Country, 2007-2018
Age ≤14n=45
Parent/Guardian Country of Birth Among US-Born Pediatric Cases, 2007-2018
Philippines7%
Marshall Islands22%
United States18%
Tonga2%
American Samoa
FSM45%
Vietnam4%
88% of US-Born Pediatric Cases have at Least One non-US Born
Parent/Guardian
n=45 Guardians among 25 US-Born Cases
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 7
Country of Birth 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Total
FSM* 10 10 8 9 5 11 14 7 8 10 92
Marshall Islands 8 7 8 6 5 5 8 3 14 9 73
American Samoa 2 1 1 1 1 6
Guam 2 1 1 1 5
CNMI† 1 1 2
Palau 1 1
TOTAL: 18 19 18 16 12 17 25 11 23 20 179Percent of Cases: 15% 17% 15% 14% 10% 13% 20% 9% 20% 17%
TB Cases Born in the U.S.-Affiliated Pacific IslandsHawaii, 2009–2018
*FSM = Federated States of Micronesia which includes Chuuk, Kosrae, Pohnpei, and Yap†CNMI = Commonwealth of the Northern Mariana Islands
Updated as of March 12, 2019
Risk Factors for TB ExposureAll Hawaii TB Cases, 2012-2016
6%
13%
0.3%
2%
0.3%
5%
7%
0.3%
4%
87%
0% 20% 40% 60% 80% 100%
No Known Risk Factor for…
Other Exposure or Progession…
Lived Outside the US > 2 Months
Resident of Long-Term Care…
Resident of Correctional Facility
Homeless within the Past Year
Known Contact to Infectious TB…
Known Contact to MDR-TB Case
Occupational Risk*
Foreign-Born
Percent with Risk Factor
n=614
*Occupational Risk: Health Care Worker, Migrant/Seasonal Worker, Correctional Facility Employee
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 8
Risk Factors for TB ProgressionAll Hawaii TB Cases, 2012-2016
26%
13%
3%
0.2%
4%
0.3%
2.0%
10%
5%
0.5%
57%
0% 20% 40% 60% 80% 100%
No Known Risk Factor for…
Other Exposure or Progression…
End Stage Renal Failure
Post-Organ Transplant
Immunosuppression
HIV Positive
Any Drug Use
Excess Alcohol Use
Incomplete LTBI Treatment
TNF-Alpha Use
Diabetes History or Positive…
Percent with Risk Factor
n=614
Risk Factors Among Pediatric TB Cases, 2007-2018
36%44%
84%
20%2% 2% 4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Known Contactto Infectious TB
Case
Foreign-Born At Least 1Foreign-Born
Guardian
Lived Outsidethe US > 2
Months
History ofDiabetes
Homeless in thePast Year
No Known RiskFactor
Perc
ent
wit
h R
isk
Fact
or
Age ≤14n=45
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 9
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Philippines FederatedStates of
Micronesia
Marshall Islands Vietnam Other All Foreign-born
Unknown* <1 1-4 ≥5
Percent of Foreign-born TB Cases by Years of Residence in U.S. Prior to Diagnosis
Hawaii, 2018
*Foreign-born TB cases for whom information on length of residence in the U.S. prior to diagnosis is missing or unknown
Updated as of March 12, 2019
Targeted TB ScreeningRisk of Exposure
▪ Time spent in high risk country▪ Household member from high risk country
▪ Exposure to active case
▪ Congregate Settings
▪ Homeless/Shelter
▪ Occupational
Elizabeth MacNeill, MD, MPH
Chief, Tuberculosis Control Branch
State of Hawaii Department of Health
Supporting Patients with Latent TB Infection:
What Nurses Need to Know
Hilo, HI
June 20, 2019 10
Targeted TB ScreeningRisk for Progression
▪ Diabetes▪ Excess Alcohol Use
▪ Severe Immunosuppression
▪ End Stage Renal Disease
▪ And for immigrants, progression can occur many years later.