Tuberculosis Control in Australia in Tuberculosis Control in Australia in the 21the 21stst Century Century

Dr F T S ChiuDr F T S ChiuOAM,OAM, MBBS, FRACP, FCCP, JPMBBS, FRACP, FCCP, JP

Department of Thoracic MedicineDepartment of Thoracic MedicineRoyal Adelaide Hospital, South Australia, Royal Adelaide Hospital, South Australia, SA 5000 AustraliaSA 5000 Australia

M.Tuberculosis- Active Disease Rate in M.Tuberculosis- Active Disease Rate in SA, 1905-1998SA, 1905-1998

2.8%

10%

7%

*Pre 1980 includes atypicals

Introduction of Anti-TB Drugs

Rate of Decline

0

20

40

60

80

100

120

140

160

1905 1919 1932 1945 1958 1971 1984 1998

Rat

e/10

0,00

0

Current International SituationCurrent International Situation

> 10025 to 100 – 25 å 100< 25No report – Pas de notification

Rates (per 100,000)Taux (pour 100,000)

EastEastMediterraneanMediterranean

55.255.2

EuropeEurope33.333.3

AfricaAfrica96.896.8

AmericaAmerica34.934.9

South East AsiaSouth East Asia94.494.4

Western PacificWestern Pacific55.555.5

Global Emergency WHOGlobal Emergency WHO1/3 infected (1900 million)1/3 infected (1900 million)8 million new cases/year8 million new cases/year3 million death/year3 million death/yearTB leading cause of deathTB leading cause of deathGlobal 60% (1994) Global 60% (1994)

AustraliaAustralia5.475.47

Global TB SituationGlobal TB SituationMost significant public health threat Most significant public health threat • TB infects 2 billion peopleTB infects 2 billion people• ““A global Health Emergency”- WHO 1993 A global Health Emergency”- WHO 1993 • Complicated byComplicated by

– HIV/AIDSHIV/AIDS

– MDRTBMDRTB• 2001 WHO Global Surveillance Program2001 WHO Global Surveillance Program

– 183 countries notified 3.8 million TB cases, 42% sputum smear + ve183 countries notified 3.8 million TB cases, 42% sputum smear + ve

– UnderestimatedUnderestimated

– Global TB incidence increased 0.4% p.a Global TB incidence increased 0.4% p.a

– esp.esp. .Sub-Saharan Africa.Sub-Saharan Africa.Countries of former Soviet Union.Countries of former Soviet Union

– Western Pacific Region (WPR)Western Pacific Region (WPR)

• 24% of notified cases 24% of notified cases

• 4/22 countries high TB burden4/22 countries high TB burden

Global TB Situation (continue)Global TB Situation (continue)AustraliaAustralia• One of the lowest incidence rates of TBOne of the lowest incidence rates of TB

• Two sub-populations have high incidence rates of TB:Two sub-populations have high incidence rates of TB:

- Indigenous Australians- Indigenous Australians

- People born overseas- People born overseas

• National TB Advisory Committee (NTAC)National TB Advisory Committee (NTAC)

- Implemented a National Strategic Plan for TB control in Australia beyond 2000 (Endorsed by - Implemented a National Strategic Plan for TB control in Australia beyond 2000 (Endorsed by Communicable Diseases Net Work Australia. CDNA 2002). Communicable Diseases Net Work Australia. CDNA 2002).

• TB NotificationTB Notification

- National Mycobacteria Surveillance System (past)- National Mycobacteria Surveillance System (past)

- Enhanced surveillance for TB Notification : Commenced 2001 - Enhanced surveillance for TB Notification : Commenced 2001 as part of National Notifiable Diseases Surveillance Systemas part of National Notifiable Diseases Surveillance System

Incidence Rates per 100,000 population for Incidence Rates per 100,000 population for tuberculosis notifications, Australia 1948 to 2002tuberculosis notifications, Australia 1948 to 2002

Rat

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Year1952 1957 1962 1967 1972 1977 1982 1987 1992 1997 2002

1996 1997 1998 1999 2000 2001 2002

Year

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Notifications of new and relapsed cases of tuberculosis and rates Notifications of new and relapsed cases of tuberculosis and rates per 100,000 population, Australia, 2002, by State and Territory*per 100,000 population, Australia, 2002, by State and Territory*

StateState New New New casesNew cases Relapse Relapse Relapse caseRelapse case TotalTotal TotalTotal casescases raterate cases cases raterate raterate

AustralianAustralian 1414 4.34.3 00 00 1414 4.34.3CapitalCapital TerritoryTerritory

New South Wales New South Wales 441441 6.66.6 66 0.10.1 447447 6.76.7

Northern TerritoryNorthern Territory 3737 18.718.7 11 0.50.5 3838 19.219.2

Queensland Queensland 124124 3.33.3 99 0.20.2 133133 3.63.6

South AustraliaSouth Australia 4343 2.82.8 33 0.20.2 4646 33

TasmaniaTasmania 99 1.91.9 00 00 99 1.91.9

VictoriaVictoria 272272 5.65.6 77 0.10.1 279279 5.75.7

Western AustraliaWestern Australia 5757 33 44 0.20.2 6161 3.23.2

AustraliaAustralia 997997 5.15.1 3030 0.20.2 10271027 5.25.2

* * There was one case where relapse status was unknownThere was one case where relapse status was unknown

Notification Rates for tuberculosis, Australia, Notification Rates for tuberculosis, Australia, 2000 to 2002, by State and Territory2000 to 2002, by State and Territory

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30

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State/Territory

ACT NSW NT QLD SA VICTAS WA AUS

200020002001200120022002

TB Notification Rates, 2002TB Notification Rates, 2002

33

3.23.2

19.219.2

3.63.6

6.76.7

5.75.7

Indian Ocean

Tasman Sea

Timor Sea

Coral Sea

4.34.3

1.91.9

Australia - 5.2Australia - 5.2Red indicates aboveRed indicates aboveNational averageNational average

Notifications of tuberculosis and incidence Rates in Indigenous and Notifications of tuberculosis and incidence Rates in Indigenous and non- Indigenous people born in Australia, 2002, by State and Territorynon- Indigenous people born in Australia, 2002, by State and Territory

Site/TerritorySite/Territory IndigenousIndigenous RateRate Non-Indigenous Non-Indigenous RateRate Total Total RateRate Australia bornAustralia born Australia born Australia born Australia bornAustralia born

AustralianAustralian 00 0.00.0 11 0.40.4 11 0.40.4CapitalCapital TerritoryTerritory

New South Wales New South Wales 22 1.61.6 6060 1.21.2 6262 1.21.2

Northern TerritoryNorthern Territory 2424 41.941.9 22 1.81.8 2626 14.014.0

Queensland Queensland 99 7.47.4 3434 1.11.1 4343 1.41.4

South AustraliaSouth Australia 11 4.04.0 1010 0.80.8 1111 0.90.9

TasmaniaTasmania 00 0.00.0 55 1.21.2 55 1.21.2

VictoriaVictoria 11 4.04.0 4747 1.21.2 4848 1.31.3

Western AustraliaWestern Australia 00 0.00.0 88 0.60.6 88 0.60.6

AustraliaAustralia 3737 8.58.5 167167 1.11.1 204204 1.31.3

Trends of tuberculosis incidence rates, Australia, Trends of tuberculosis incidence rates, Australia, 1991 to 2002, by Indigenous status and country of birth1991 to 2002, by Indigenous status and country of birth

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Year

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 20022001

Overseas-born personOverseas-born person

Indigenous AustraliansIndigenous Australians

Non-indigenous AustraliansNon-indigenous Australians

Notification of Tuberculosis and Notification of Tuberculosis and estimated rate per 100,000 population for estimated rate per 100,000 population for selected countries of birth, Australia, 2002selected countries of birth, Australia, 2002CountryCountry NewNew Relapsed Relapsed TotalTotal Estimated AustraliaEstimated Australia Rate per 100,000Rate per 100,000 WHO incidenceWHO incidenceof Birthof Birth Cases Cases CasesCases CasesCases Resident PopulationResident Population population inpopulation in rate (per 100,000 rate (per 100,000

by country of Birth,by country of Birth, Australia by Country Australia by Country population forpopulation for20012001 of Birth, 2002*of Birth, 2002* country, 2001#country, 2001#

IndiaIndia 106106 00 106106 9545595455 111.0111.0 4343

VietnamVietnam 9898 44 102102 154833154833 65.965.9 115115

PhilippinesPhilippines 9191 11 9292 103942103942 88.588.5 139139

China**China** 5454 11 5555 142778142778 38.538.5 3838

Indonesia Indonesia 4848 00 4848 4715647156 101.8101.8 134134

Papua Papua 2121 33 2424 2361823618 101.6101.6 323323New GuineaNew Guinea

Somalia Somalia 2222 11 2323 37133713 619.4619.4 7575

ThailanThailan 2222 00 2222 2359923599 93.293.2 7878

HongKong HongKong 1919 11 2020 6712167121 29.829.8 109109

Notification of Tuberculosis and Notification of Tuberculosis and estimated rate per 100,000 population for estimated rate per 100,000 population for selected countries of birth, Australia, 2002selected countries of birth, Australia, 2002

CountryCountry NewNew RelapsedRelapsed TotalTotal Estimated AustraliaEstimated Australia Rate per 100,000Rate per 100,000 WHO incidenceWHO incidenceof Birthof Birth Cases Cases CasesCases CasesCases Resident PopulationResident Population population inpopulation in rate (per 100,000 rate (per 100,000

by country of Birth,by country of Birth, Australia by Country Australia by Country population forpopulation for20012001 of Birth, 2002*of Birth, 2002* country, 2001#country, 2001#

Korea***Korea*** 1616 11 1717 3895838958 43.643.6 79~79~

MalaysiaMalaysia 1515 00 1515 7885878858 19.019.0 6666

United United 1414 00 1414 10833181083318 1.31.3 1010KingdomKingdom

CambodiaCambodia 1313 00 1313 2297922979 56.656.6 143143

Sri Lanka Sri Lanka 1212 00 1212 5346053460 22.422.4 3939

Other Other 247247 99 259259 21481402148140

Overseas 798 21 819 4087928 19.9

AustraliaAustralia 197197 77 204204 1561927215619272 1.31.3

Not StatedNot Stated 22 22 44

TotalTotal 997997 3030 10271027 1970720019707200 5.25.2

Notifications and Estimated Incidence Rate Notifications and Estimated Incidence Rate of Tuberculosis per 100,000 Population, Australia, 2002, by Age Group, of Tuberculosis per 100,000 Population, Australia, 2002, by Age Group, Indigenous Status and Country of BirthIndigenous Status and Country of Birth

AgeAge IndigenousIndigenous IndigenousIndigenous Non-Indigenous Non-Indigenous Non-Indigenous Non-Indigenous OverseasOverseas OverseasOverseasGroupGroup Australia born Australia born Australia born Australia born Australia born Australia born Australia bornAustralia born -born-born -born-born

NUMBERNUMBER RATERATE NUMBERNUMBER RATERATE NUMBERNUMBER RATERATE

0 - 40 - 4 33 5.75.7 1212 11 44 15.915.9

5 - 145 - 14 44 3.73.7 77 0.30.3 1010 5.65.6

Sub total 7 4.3 19 0.5 14 6.9for<15 years

15 - 2415 - 24 22 2.72.7 1515 0.70.7 109109 27.727.7

25 - 34 25 - 34 66 9.49.4 1515 0.70.7 191191 31.631.6

35 - 44 35 - 44 99 17.817.8 1717 0.80.8 148148 17.117.1

45 - 54 45 - 54 33 9.39.3 1616 0.90.9 120120 13.713.7

55 - 6455 - 64 77 43.443.4 1818 1.51.5 6969 9.99.9

6565++ 33 26.226.2 6767 4.14.1 159159 18.18.

AUTRALIAAUTRALIA 3737 99 167167 1.11.1 810810 18.118.1

Incidence rate of Tuberculosis in Australian-born and Incidence rate of Tuberculosis in Australian-born and Overseas-born people, 2002, by Age Group and SexOverseas-born people, 2002, by Age Group and Sex

40

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Age Group (Years)

Male Australia-bornMale Australia-born

Male Overseas-bornMale Overseas-born Female Overseas-bornFemale Overseas-born Female Australian-bornFemale Australian-born

TB and Selected Risk FactorsTB and Selected Risk Factors20022002

• 220/1028 (21.4%) cases reported220/1028 (21.4%) cases reported

• 139 household members or close contacts139 household members or close contacts

• 9 Correctional Services9 Correctional Services

• 17 Aged Care Facilities17 Aged Care Facilities

• Individuals Working in High Risk SettingsIndividuals Working in High Risk Settings

– 3 Correctional Facilities or Aged Care Facilities 3 Correctional Facilities or Aged Care Facilities

– 10 Health Industries10 Health Industries

• 140 resided >3 months in High Risk Countries140 resided >3 months in High Risk Countries

TB & HIV StatusTB & HIV Status

20022002

• 281/1028 (27.3%) TB case notified reported HIV Status281/1028 (27.3%) TB case notified reported HIV Status

• 11 HIV positive11 HIV positive

– 2 born in Australia2 born in Australia

– 9 born overseas9 born overseas

20012001

• 4.2% TB case notified reported HIV status4.2% TB case notified reported HIV status

New and relapsed cases in Australia, 2002, New and relapsed cases in Australia, 2002, by site of diseaseby site of disease

SiteSite New casesNew cases Relapse casesRelapse cases Total casesTotal cases % of cases% of cases

Pulmonary Pulmonary 585585 1717 602602 58.758.7

LymphaticLymphatic 160160 55 165165 16.116.1

PleuralPleural 9393 44 9797 9.59.5

Bone/JointBone/Joint 5151 11 5252 5.15.1

MeningealMeningeal 2121 00 2121 2.02.0

GenitourinaryGenitourinary 1919 11 2020 2.02.0

MiliaryMiliary 1111 00 1111 1.11.1

PeritonealPeritoneal 77 00 77 0.70.7

OtherOther 2323 00 2323 2.22.2

Antimicrobial TherapyAntimicrobial Therapy20022002

• Antimicrobial drug regime reported for 930 (90.5%) TB casesAntimicrobial drug regime reported for 930 (90.5%) TB cases

– 23 cases 23 cases 2D2D

– 101 cases 101 cases 3D3D

– 804 cases 804 cases 4D (99.69%, INH, RIF, PYZ, ETM)4D (99.69%, INH, RIF, PYZ, ETM)

– 2 cases 2 cases >5D>5D

• Under 8 yearsUnder 8 years

13 cases 13 cases 3D (INH, RIF, PYZ)3D (INH, RIF, PYZ)

Outcome of Treatment for Tuberculosis amongst cases evaluated, Outcome of Treatment for Tuberculosis amongst cases evaluated, Australia, 2002, by Australian-born Australia, 2002, by Australian-born (Indigenous and Non-indigenous) and Overseas-born individuals(Indigenous and Non-indigenous) and Overseas-born individuals

Treatment Treatment IndigenousIndigenous Non-Indigenous Non-Indigenous OverseasOverseas UnknownUnknown Total Total PercentPercent OutcomeOutcome Australia Australia Australia Australia bornborn of Casesof Cases

bornborn bornborn

Cured (BacteriologicalCured (Bacteriological 1919 1111 4343 11 7474 9.2%9.2%confirmed)confirmed)

Completed Treatment Completed Treatment 99 8787 482482 00 578578 72.1%72.1%

Interrupted TreatmentInterrupted Treatment 00 11 22 00 33 0.4%0.4%

Died of TB Died of TB 22 55 1010 11 1818 2.2%2.2%

Died of Other CauseDied of Other Cause 22 2020 4040 22 6464 8.0%8.0%

Defaulted*Defaulted* 00 22 44 00 66 0.7%0.7%

Failed**Failed** 0 0 00 11 00 11 0.1% 0.1%

Transferred out ofTransferred out of 11 22 5353 22 5858 7.2%7.2%AustraliaAustralia

TotalTotal 3333 128128 635635 66 802802

National Tuberculosis performance indicators, performance criteria National Tuberculosis performance indicators, performance criteria and the current status of Tuberculosis in Australia, 2002and the current status of Tuberculosis in Australia, 2002

National TB Performance Indicator National TB Performance Indicator PerformancePerformance 20012001 20022002CriteriaCriteria

Annual Incidence of TB (per 100,000 population)Annual Incidence of TB (per 100,000 population) %% %%Crude IncidenceCrude IncidenceIndigenous AustraliansIndigenous Australians <1<1 9.89.8 8.58.5Non-indigenous Australian-bornNon-indigenous Australian-born <1<1 11 1.11.1Overseas-born persons*Overseas-born persons* **** 10.210.2 11.511.5

<2% of total <2% of total NANA NANA

Relapse cases initially treated in AustraliaRelapse cases initially treated in Australia treated casestreated cases

Incidence in children <15 years, by risk group Incidence in children <15 years, by risk group Indigenous Australian Children Indigenous Australian Children <0.1<0.1 2.42.4 4.34.3Non-indigenous Australian-born Children Non-indigenous Australian-born Children <0.1<0.1 0.50.5 0.50.5Overseas-born Children*Overseas-born Children* **** 11 0.10.1Collection of HIV status in TB caseCollection of HIV status in TB case 100% over100% over(% of cases with data collected)(% of cases with data collected) next 3 yearsnext 3 years 4.24.2 27.327.3Treatment outcome measures(%)Treatment outcome measures(%)Cases evaluated for outcome#Cases evaluated for outcome# 100100 76.976.9 78***78***Cases that have treatment completed and are curedCases that have treatment completed and are cured >90>90 83.683.6 8080Cases recorded as treatment failures#Cases recorded as treatment failures# <2<2 0.90.9 0.1 0.1

Communities at Risk for TuberculosisCommunities at Risk for Tuberculosis

TuberculosisTuberculosisTuberculosisTuberculosis

UnemployedUnemployedNo access to careNo access to care

MalnutritionMalnutrition

PovertyPoverty

MinoritiesMinorities

Indigenous AustralianIndigenous Australian(Aboriginal & Torres Strait Island People)(Aboriginal & Torres Strait Island People)

ImmigrantsImmigrantsUneducatedUneducated

Health Care WorkersHealth Care Workers

ElderlyElderly

HIV/AIDSHIV/AIDS

Drug AbusersDrug Abusers

IncarceratedIncarcerated

HomelessHomeless

01990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Pulmonary Extra-Pulmonary Linear (Pulmonary) Linear (Extra-Pulmonary)

Year

Num

ber

of c

ases

TB Notifications in South Australia 1990-2000TB Notifications in South Australia 1990-2000

10

20

30

40

50

60

70

80

Extra-Pulmonary Tuberculosis 1990-2000Extra-Pulmonary Tuberculosis 1990-2000S

ite o

f D

isea

se

Number of Cases

0 10 20 30 40 50 60 70 80

GIT

Peritoneal

Skin

Meningeal

Miliary

Other

Bone/Joint

Genito/urinary

Pleura

Lymph Node 43%

18%

11%

10%

6%

5%

3%

2%

1%

1%

Abnormal TST

Active Disease

M.tuberculosis Notification Rates M.tuberculosis Notification Rates Compared with Abnormal TST RatesCompared with Abnormal TST Rates

0

10

20

30

40

50

6019

45

1960

1975

1990

Year

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SA 2.3/100,000SA 2.3/100,000Aust 5.47/100,000Aust 5.47/100,000

Current SituationCurrent Situation• Australia has one of the lowest incidences of TB in the Australia has one of the lowest incidences of TB in the

Western Pacific RegionWestern Pacific Region

20022002• 5.2/100,000 (5 to 6/100,000 since mid -1980)5.2/100,000 (5 to 6/100,000 since mid -1980)• Sub-population Sub-population

– Indigenous AustraliansIndigenous Australians• 8.5/100,000 8.5/100,000

(2/3 in Northern Territory, 28% of overall population c/w 2% national wide)(2/3 in Northern Territory, 28% of overall population c/w 2% national wide)

– Those born overseasThose born overseas• 20.2/100,00020.2/100,000

• Highest rates of TB in 15–34 years old Highest rates of TB in 15–34 years old

• 34.5% of all TB notified in people born in India, Vietnam, 34.5% of all TB notified in people born in India, Vietnam, Philippines, Indonesia & China.Philippines, Indonesia & China.

Global PartnershipGlobal Partnership• To foster global partnershipsTo foster global partnerships

• RAH– Bali TB project in partnership with Bali Department of HealthRAH– Bali TB project in partnership with Bali Department of Health

• Australia Red CrossAustralia Red Cross

– $400,000 grant over six years $400,000 grant over six years

– training in treatment and laboratory services based on WHO “DOT” strategytraining in treatment and laboratory services based on WHO “DOT” strategy

• IMVS IMVS

– Indonesian - Australian Specialized Training Project for laboratory Indonesian - Australian Specialized Training Project for laboratory diagnosis of TB, quality assurance and TB community developmentdiagnosis of TB, quality assurance and TB community development

• Train the trainer approachesTrain the trainer approaches

• SA at forefront of regional TB controlSA at forefront of regional TB control

Footnote on Chinese Community Footnote on Chinese Community in Australiain Australia

• Chinese population in Australia relatively small (? Official censors)Chinese population in Australia relatively small (? Official censors)• Chinese have overcome racial prejudice and blended into the Australian CommunityChinese have overcome racial prejudice and blended into the Australian Community• National Centenary Celebration of Federation of AustraliaNational Centenary Celebration of Federation of Australia

– held in Melbourne 2001held in Melbourne 2001– Chinese also held national conference at the same timeChinese also held national conference at the same time

• Chinese widely respected and enjoy proportional previleges Chinese widely respected and enjoy proportional previleges • Many Chinese OrganizationsMany Chinese Organizations

– Medical Medical eg ACMA, ACCMAeg ACMA, ACCMA– Other organizations, culture clubs, Chambes of Commerce, welfare associations etcOther organizations, culture clubs, Chambes of Commerce, welfare associations etc– FederationFederation– In SA, Forum of Chinese organizations in SA 1996In SA, Forum of Chinese organizations in SA 1996

Federation of Chinese organizations in SA (FOCOSA) 2001Federation of Chinese organizations in SA (FOCOSA) 2001• Chinese Community in AustraliaChinese Community in Australia

– A cohesive and fairly united groupA cohesive and fairly united group– Future fairly brightFuture fairly bright