California Update: TB Epidemiology

and Indicators

CTCAOctober 22, 2010

Jennifer Flood MD MPHChief, Surveillance and Epidemiology

Tuberculosis Control BranchCalifornia Department of Public Health

Jennifer.Flood@cdph.ca.gov

2

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?

3

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

4

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

5

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%)

6

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)

7

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

8

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

9

10

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%

11

How many with AIDS/TB die?

1994 2007

140 (31%) 18 (14%)

Source: California AIDS/TB registry match

12

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%

13

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

14

TB Control Indicators

• How successful are we in implementing TB control strategies and driving TB morbidity downward?

15

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

16

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

17

California Cases Recommended for DOT Receiving SAT only,

by provider type

0

10

20

30

40

50

60

70

80

90

100

1994 1996 1998 2000 2002 2004 2006 2008Year

Per

cen

t

PMD All HD

18

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

19

Trends: Cases with no documented conversion ever, 1994-2008

(private vs. public)

0

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

20

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.

21

Death by Consumption 2009

Died with TB 218 (8.8%)

• Deaths during therapy 177 (7.2%)

• Dead at diagnosis 42 (1.7%)

22

TB Deaths during Therapy, by Provider Type, 1994-2009

0

2

4

6

8

10

12

14

16

18

20

Year

Per

cen

t

Private Provider

Health Department

23

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

24

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

25

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!

26

Questions?