Elizabeth MacNeill, MD, MPH Chief, Tuberculosis Control Branchnid]/tb...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 1



Disclosures…






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






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


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)


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.






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






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


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







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






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


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






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






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


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






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.

Elizabeth MacNeill, MD, MPH Chief, Tuberculosis Control Branchnid]/tb...Updated as of March 12, 2019...

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