Tuberculosis Surveillance and Disease Intersections

in California

Jennifer Flood, M.D., M.P.H.Chief, Surveillance and Epidemiology Section

Tuberculosis Control BranchDivision of Communicable Disease Control

Center for Infectious DiseasesCalifornia Department of Public Health

October 15, 2008

Outline

• TB surveillance

• Disease intersections (HIV/TB)

• Opportunities for collaboration

Global– Every second, a new person becomes

infected with TB – TB is curable but kills 5000 people every

day– TB is the number 1 killer of AIDS patients– 2 billion people , 1/3 of world’s population,

infected with TB– MDR/XDR TB growing

Why is TB important?

Span of TB Control Activities

2727 Californians with Tuberculosis

Over 10,000 Suspect Cases

20,000 – 30,000 Contacts

3 million Californians infected

35 million Californians who breathe

Purpose of surveillance

• Quantifies disease magnitude and changes in disease over time

• Identifies disease characteristics

• Provides roadmap for TB control efforts

Data Sources

• TB Case Report (RVCT)• Contact evaluation reports• B-notification Registry• MDR/XDR surveillance• Outbreak reports• Universal genotyping database• TB Death Investigations

How are TB cases reported?

• Providers and laboratories submit confidential morbidity reports (CMR) to local health dept

• Health department conducts patient interview– provides direct TB case management – or private provider oversight – through 6-24 month treatment

TB Reporting from LHD to TBCB

•at initial diagnosis •at time of susceptibility results •at treatment completion

***********•report form with >200 fields• extensive instructions and instructions

Features of TB Case ReportDemographic Country of origin; date of US entry, visa

status

Risk factors Homeless, incarceration, IVDU HCW, HIV, other co-morbidities

Clinical Disease site, infectious, CXR

Laboratory Drug resistance, genotype

Provider type Public, private

Treatment Regimen, doses, DOT, duration

Outcome Death, death related to TB, moved-destination, lost, rx completed, relapse

Slowing Rate of TB Case Decline California, 1992-2007

Nu

mb

er o

f T

ub

ercu

losi

s C

ases

Year

-5.9% per year (1992-2000) -2.8% per year

(2000-2006)

2,500

3,000

3,500

4,000

4,500

5,000

5,500

6,000

-1.9% per year(2006-2007)

0

500

1,000

1,500

2,000

2,500

3,000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

40

50

60

70

80

U.S.-born Foreign-born Percent Foreign-born

Tuberculosis Cases in Foreign-born and U.S.-born Persons: California, 1998-2007

Nu

mb

er o

f C

ases

Per

cen

t o

f C

ases

TB Disparities: US-born vs. Foreign-born, California, 2007

TB cases Case rate

US-born 588 2.2

Foreign-born 2109 21.1*

*Annual case rate decline has been slower for foreign-born than US-born

Adverse Events

• Pediatric cases

• Drug resistance

• Outbreaks

Deaths in Persons with Tuberculosis: California, 1996-2005

0

100

200

300

400

500

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

0

2

4

6

8

10

12

Per

cen

t o

f C

ases

Nu

mb

er o

f D

eath

s

Dead at Diagnosis

Died During Treatment Died Before Starting Treatment

Percent Dying with Tuberculosis

Data for Public Health Action(Examples)

Surveillance Data:

• Increased importation of infectious MDRTB-> CDC revised overseas TB screening

• Multi-jurisdictional case increase and genotype cluster among homeless outbreak detection and containment

Data Use: Public Health Action

Cost-effectiveness analyses:

• 6% of persons arriving with TB B-notification have active TB on CA arrival domestic evaluation is cost effective (vs other control activities)

• Universal school children TB testing is not cost-effective

• Testing and treatment of HIV infected is highly cost-effective

Intersection of TB, HIV and STDs

TB

AIDSSTD

Disease Intersections: TB/STD Cutaneous Tuberculosis of the Penis and

Sexual Transmission of Tuberculosis Confirmed by Molecular Typing

Angus, Yates, Conlon and Byren

CID 2001;33e132-4

TB ulcer

HIV/TB Interactions:Transmission, Diagnosis, Pathogenesis,

Treatment

• 100 fold greater risk of progression from latent to active TB in HIV co-infected patients

• Rapid TB progression and spread in HIV populations

• TB accelerates HIV progression to AIDS (increases viral load)

• Mortality much higher before HAART (20-35%)• Increased acquired drug resistance

Benefit to patient if HIV status is known

• Diagnosis– TB testing can identify LTBI; Rx prevents TB– HIV positive patients frequently have atypical TB

presentation• Treatment

– Drug selection and dosing differs for HIV positive patients

– Complex drug interactions and IRIS anticipated and acquired drug resistance avoided

• HIV Care– Early referral to HIV and treatment

• TB Contact Investigation (TB Exposure)– HIV positive patients are prioritized (given progression

risk)

RVCT – HIV Status: CDC required Field

Current CA RVCT fields – HIV Status

Incident Tuberculosis Cases by AIDS Diagnosis*: California, 1997-2006

0

100

200

300

400

500

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2004

2005

2006

Year

0

2

4

6

8

Nu

mb

er o

f C

ases

wit

h A

IDS

Per

c en

t o

f C

ases

wit

h A

IDS

* AIDS Case Registry, California Office of AIDS

No. TB Cases with AIDS

% TB Cases with AIDS

AIDS-associated Tuberculosis Cases* California, 2000-2004

*Match found in AIDS Cases Registry, Office of AIDS

Long BeachPasadena

BerkeleySan Francisco

AIDS-associatedTuberculosis Cases

≥ 100 Cases

50-99 Cases

25-49 Cases

10-24 Cases

1-9 Cases

None

Proportion of TB Cases with AIDS by Place of Birth, CA 1994-2006

0%

20%

40%

60%

80%

100%

Per

cent

of

case

s

1994 1996 1998 2000 2002 2004 2006

U.S.-bornMexico/Ctrl AmOther Foreign-born

Reporting Counties: Rank Order by Case Count

As of 2/2008 Cumulative

2007 2006 2006

Rank AIDS TB Gonorrhea Syphilis

1 Los Angeles Los Angeles Los Angeles Los Angeles

2 San Francisco San Diego San Diego San Francisco

3 San Diego Santa Clara San Francisco San Diego

4 Alameda Orange Alameda Orange

AIDS/TB Cases Contributed by Selected Local Health Departments

County 1995 – 1999 2000 – 2004

San Diego 147 (11%) 132 (17.2%)

San Francisco 156 (10.7%) 79 (10.3%)

Los Angeles 642 (44.3%) 296 (38.6%)

AIDS/TB Case Trends: Socio-demographic Characteristics

Characteristics 1995-1999 2000 – 2004

n (%) n (%)

Age

25 – 44 1030 (71) 491 (64)

45 – 64 345 ( 24) 229 (30)

65+ 27 (1.8) 18 (2.3)

Race

White 306 (21) 112 (15)

Black 419 (30) 160 (19)

Hispanic 660 (45) 422 (55)

Asian 57 (3.9) 62 (8)

Country of origin

US-born 815 (56) 310 (40)

Foreign-born 630 (43) 452 (59)

Risk Factors / SettingsAIDS/TB Cases

California, 1995 - 2004

TB TB/AIDS

Homelessness 253 (17%) 166 (22%)

Drugs/alcohol 556 (38%) 281(37%)

Corrections 133 (9%) 30 (4%)

Clinical characteristics, AIDS/TB Cases, California, 1995-2004

TB AIDS/TB

Smear positive 43% 47%

Cavitary 20% 7%

Extrapulmonary 10% 29%

rifampin resistance 0.1% 1%

PZA resistance 2% 6%

AIDS/TB Case Trends: Care and Outcome Characteristics

Characteristics 1995 – 1999 2000 – 2004

n (%) n (%)

Provider Type

Health Dept. only 685 (47%) 382 (50%)

Private Provider only 390 (27%) 226 (30%)

Both 371 (26%) 151 (20%)

Therapy Supervision

Directly Observed 723 (52%) 537 (72%)

Completed Therapy 972 (70%) 608 (82%)

Deaths among AIDS/TB Cases in CA, 1995-2006

• 9% TB vs 18% AIDS/TB cases died

• TB/AIDS deaths has declined from 22% in 1995-1999 to 11% 2000-2004

Opportunities

Diagnosis

TB infection HIV infection

LTBI Treatment HAART

TB Disease / AIDS

Expert Co-management

Death

X

X

Points of Intersection

• Populations at risk

• Overlapping high incidence areas

• Transmission settings

• Social networks

• Service/points of care intersections

• DOT/case management

• Housing and drug rehab access

Surveillance opportunities in CA

Number of ?HIV co-infected TB patients

HIV-infected patients with LTBI

Preventable AIDS/TB cases

Preventable AIDS/TB deaths

Areas for collaboration

• Early identification: HIV testing of TB cases TB testing of HIV-infected

• Timely TB treatment and HAART initiation• Understanding/ preventing TB/HIV deaths• Private provider oversight /guidance • Expert case management of co-morbidities:

TB/ HIV/ hep B/ hep C• Rapid diffusion of science/ innovations

use of quantiFERON and rapid HIV test

CDPH TB Control Surveillance Team

TB Control Registry

Janice Westenhouse- Lead

Jen Allen

Bill Elms

Linda Johnson

Phil Lowenthal

Kelly Waldow