Tuberculosis Control in California: What is the Forecast

1. 1 Tuberculosis Control in California: What is the Forecast? Jennifer Flood, MD, MPH Chief, Surveillance and Epidemiology Tuberculosis Control Branch Center for Infectious Diseases California Department of Public Health April 30, 2009 Ken has described novel approaches that provide hope to the challenges we face in TB control. In California TB has been tenacious and were not close to doing away with it all together. Today I would like to look at our epidemic in CA with the following questions: Ken has described novel approaches that provide hope to the challenges we face in TB control. In California TB has been tenacious and were not close to doing away with it all together. Today I would like to look at our epidemic in CA with the following questions:

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3. 3 Data Sources California Health Information Survey Department of Finance statistics State TB case registry (RVCT) 1993-2008 B Notification 2000-2008 State AIDS/TB match 1997-2007

4. 4 California Tuberculosis Trends

5. 5 Span of TB Control Activities

6. 6 Tuberculosis Cases in California, 1980-2008

7. 7 Slowing Rate of TB Case Decline California, 1992-2008 The intersection also manifests as effect on the epidemic we see here The slowing in the decline of TB. Although we have successfully reduced the number of TB cases each year since 1992 (except 2 years 2001 and 2003 where we saw increased numbers), The pace of decline has slowed substantially. After the 1992 peak in cases, we experienced cases dropping nearly 6% per year. Since 200 we have had two years with case increase and our recent case count of 2726 was only a 1.8% drop in cases. In addition, the degree by which cases dropped has not accelerated evenly. The intersection also manifests as effect on the epidemic we see here The slowing in the decline of TB. Although we have successfully reduced the number of TB cases each year since 1992 (except 2 years 2001 and 2003 where we saw increased numbers), The pace of decline has slowed substantially. After the 1992 peak in cases, we experienced cases dropping nearly 6% per year. Since 200 we have had two years with case increase and our recent case count of 2726 was only a 1.8% drop in cases. In addition, the degree by which cases dropped has not accelerated evenly.

8. 8 At the current rate of case rate decline (-2.4% annually), California will achieve TB elimination (or, <1 case in 1 miliion), in the year 2132. The Healthy People 2010 goal of 1 case per 100,000 population would be reached in the year 2064. Population data source: California Department of Finance (DOF projections through 2050, then I projected past that at the DOF 2050 rate of population growth of 0.93% per year).At the current rate of case rate decline (-2.4% annually), California will achieve TB elimination (or, <1 case in 1 miliion), in the year 2132. The Healthy People 2010 goal of 1 case per 100,000 population would be reached in the year 2064. Population data source: California Department of Finance (DOF projections through 2050, then I projected past that at the DOF 2050 rate of population growth of 0.93% per year).

9. 9 This graph shows the current rate of decline (-2.4% per year, as in previous graph) on the dark blue line, projected out until 2132. The aqua line projects out our current case rate of 7.0, neither declining nor increasing. The pink line projects an annual case rate increase of 0.1% The brown line projects an annual case rate increase of 1%This graph shows the current rate of decline (-2.4% per year, as in previous graph) on the dark blue line, projected out until 2132. The aqua line projects out our current case rate of 7.0, neither declining nor increasing. The pink line projects an annual case rate increase of 0.1% The brown line projects an annual case rate increase of 1%

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11. 11 What will influence TB control? Population Migration TB infection reservoir Groups with high risk of progression to TB disease Risk intersection: infection and progression Pathogen Drug resistance Environment - Healthcare access TB diagnostics and treatment What are the pressure points that might influence the pace of decline or reverse the decline?What are the pressure points that might influence the pace of decline or reverse the decline?

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13. 13 Population and medical risks

14. 14 Populations at risk for TB, California Notes and sources: Foreign-born- US Census, American Community Survey 2007; *Recent defined as five in past five years of available data; Immigrants- CA Dept Finance, 2002-2006; Refugees- CA Refugee Health Section, 2003-2007; Undocumented- Public Policy Institute of California, 2006; Homeless- US Dept Housing & Urban Development July 2008 report (2007 data); Incarcerated- total prison inmate population as of 6/30/2007, US Dept of Justice. Notes and sources: Foreign-born- US Census, American Community Survey 2007; *Recent defined as five in past five years of available data; Immigrants- CA Dept Finance, 2002-2006; Refugees- CA Refugee Health Section, 2003-2007; Undocumented- Public Policy Institute of California, 2006; Homeless- US Dept Housing & Urban Development July 2008 report (2007 data); Incarcerated- total prison inmate population as of 6/30/2007, US Dept of Justice.

15. 15 Populations with medical risk factors, California Each of these groups is growing. Diabetes- 85-90% is Type II (NIDDM), 10-15% is type I (IDDM). The diabetes prevalence is estimated to grow to 4 million in California by 2020 (California Diabetes Program). 35% of cases are foreign born. Of foreign-born diabetics, 21% originated in Central/Latin America (majority Mexico), 10% in Asia. How are each of these populations distributed throughout CA? Note those that are distributed in usual ways (e.g. in large urban areas) Note interesting deviations that may point to interventions in locations where healthcare is accessed- e.g. if there are 3 dialysis centers in Fresno that represent 50% of ESRD patients Sources: Diabetes- type 1 and type 2, California Health Interview Survey 2005; Rheumatoid arthritis- estimate based on CDPH/CA Arthritis Partnership and CDC MMWR 2007; HIV- CA Office of AIDS cumulative HIV/AIDS cases, Sep 2008; Renal dialysis- Western Pacific Renal Network, and Southern California Renal Disease Council, Annual Report 2007; Crohn’s Disease- estimate based on Herrinton et al 2008 study of CD in Northern California (2002 data); Organ transplant recipients- Organ Procurement and Transplantation Network, 2007. Notes on estimates of N(%) foreign-born: Diabetes: I queried the CHIS 2005 data, selecting those who reported diabetes, and querying country of birth. Rheumatoid arthritis: CHIS 2005 data estimates that 17% of all persons with arthritis are foreign-born. I multiplied the estimate of 185,000 persons with RA by 0.17 to derive the estimated number and percent who are foreign-born (assuming that the foreign-born ration is the same in RA as it is for arthritis overall) HIV/AIDS: according to US Census Bureau, American Community Survey (2006), I calculated that 63.73% of Californians of Asian/Pacific Islanders, and 41.16% of Hispanics/Latinos are foreign-born. Assuming that these proportions apply to those with HIV/AIDS, and assuming that all Whites, Blacks, and Native Americans are US born, the estimates are: 28,122 x 0.4116= 11,575 Hispanic and 3,100 x 0.6373=1,976 Asian/PIs who are foreign-born with HIV/AIDS, for a total of 13,551 Renal dialysis: I applied the same proportions as in HIV/AIDS above to estimate the number of foreign-born hispanic and Asian/PI persons receiving renal dialysis. In the Herrinton paper Crohn’s Disease group, 5% were Asian and 3% Hispanic (n=948). I used the ACS 2006 foreign born proportions to arrive at the n=1,507 value. The OPTN data query for race/eth showed that of the n=3,297 organ transplant recipients, 31.5% where hispanic, and 14.4% were Asian/PI. I used the ACS FB proportions to arrive at the n=730 foreign born organ transplant recipients estimate. Each of these groups is growing. Diabetes- 85-90% is Type II (NIDDM), 10-15% is type I (IDDM). The diabetes prevalence is estimated to grow to 4 million in California by 2020 (California Diabetes Program). 35% of cases are foreign born. Of foreign-born diabetics, 21% originated in Central/Latin America (majority Mexico), 10% in Asia. How are each of these populations distributed throughout CA? Note those that are distributed in usual ways (e.g. in large urban areas) Note interesting deviations that may point to interventions in locations where healthcare is accessed- e.g. if there are 3 dialysis centers in Fresno that represent 50% of ESRD patients Sources: Diabetes- type 1 and type 2, California Health Interview Survey 2005; Rheumatoid arthritis- estimate based on CDPH/CA Arthritis Partnership and CDC MMWR 2007; HIV- CA Office of AIDS cumulative HIV/AIDS cases, Sep 2008; Renal dialysis- Western Pacific Renal Network, and Southern California Renal Disease Council, Annual Report 2007; Crohn’s Disease- estimate based on Herrinton et al 2008 study of CD in Northern California (2002 data); Organ transplant recipients- Organ Procurement and Transplantation Network, 2007. Notes on estimates of N(%) foreign-born: Diabetes: I queried the CHIS 2005 data, selecting those who reported diabetes, and querying country of birth. Rheumatoid arthritis: CHIS 2005 data estimates that 17% of all persons with arthritis are foreign-born. I multiplied the estimate of 185,000 persons with RA by 0.17 to derive the estimated number and percent who are foreign-born (assuming that the foreign-born ration is the same in RA as it is for arthritis overall) HIV/AIDS: according to US Census Bureau, American Community Survey (2006), I calculated that 63.73% of Californians of Asian/Pacific Islanders, and 41.16% of Hispanics/Latinos are foreign-born. Assuming that these proportions apply to those with HIV/AIDS, and assuming that all Whites, Blacks, and Native Americans are US born, the estimates are: 28,122 x 0.4116= 11,575 Hispanic and 3,100 x 0.6373=1,976 Asian/PIs who are foreign-born with HIV/AIDS, for a total of 13,551 Renal dialysis: I applied the same proportions as in HIV/AIDS above to estimate the number of foreign-born hispanic and Asian/PI persons receiving renal dialysis. In the Herrinton paper Crohn’s Disease group, 5% were Asian and 3% Hispanic (n=948). I used the ACS 2006 foreign born proportions to arrive at the n=1,507 value. The OPTN data query for race/eth showed that of the n=3,297 organ transplant recipients, 31.5% where hispanic, and 14.4% were Asian/PI. I used the ACS FB proportions to arrive at the n=730 foreign born organ transplant recipients estimate.

16. 16 LTBI and medical risk in California

17. 17 What is fraction of TB is attributed to specific exposures/conditions?

18. 18 Medical risk among foreign-born TB cases in CA, TBESC (n= 264) Medical conditions associated with higher risk of TB diseaseMedical conditions associated with higher risk of TB disease

19. 19 Complex N. (kom’pleks) Containing intricately combined parts; many components interface or intersect Not easy to understand or analyze; perplexing Solvable or comprehensible only with painstaking effort; Executed with painstaking attention to numerous parts or details

20. 20 TB Case Complexity Very young < 5 Older > 65 Drug use Foreign-born, new arriver Comorbidity (eg HIV) Smear positive, cavitary, infectious, extrapulmonary, drug resistant Prior TB HCW, LTC facility, corrections, homeless Movement, migrant worker Private provider

21. 21 Median Age Trend of California Cases, 1993-2008 This graph is on a logarithmic scale, and represents a statistically significant trend of 1.0% annual percent increase in the median age of California TB cases from 1993 to 2008.This graph is on a logarithmic scale, and represents a statistically significant trend of 1.0% annual percent increase in the median age of California TB cases from 1993 to 2008.

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23. 23 Number of nations contributing TB cases resistant to > 5 drugs, CA, 1993-2007

24. 24 TB Case Infectivity

25. 25 TB Case Infectivity Culture-positive Smear-positive ? Cavitary disease The case features here show the burden of cases that are our most infectious cases; 2000 cases,( 2/3 of cases have TB in site that allows transmission). Over 1000 cases each year have a high enough bacillary load to be visualized under the microscope as smear positive. We know these cases are much more likely to transmit to others. Finallly, the special condition in TB of cavitary disease occurs in over 500 patients yearlyThe case features here show the burden of cases that are our most infectious cases; 2000 cases,( 2/3 of cases have TB in site that allows transmission). Over 1000 cases each year have a high enough bacillary load to be visualized under the microscope as smear positive. We know these cases are much more likely to transmit to others. Finallly, the special condition in TB of cavitary disease occurs in over 500 patients yearly

26. 26 Congregate Settings

27. 27 Healthcare Workers with Tuberculosis California, 2000-2008 2-4% of cases are healthcare workers (HCW) Foreign-born > US-born Fraction of HCW among US-born increasing

28. 28 Who is infectious? Symptomatic (cough) Smear-positive, cavitary, culture-positive Mexican-born > other foreign-born Undocumented > other visa type Delayed culture conversion XDR > MDR > non-MDR Acquired drug-resistance HIV, baseline INH or rifampin resistance, cavitary without DOT

29. 29 Health Care Access

30. 30 6.7 million uninsured in California For every 1% rise in unemployment, 1.1 million more people go without health insurance

31. 31 TB in New Arrivers

32. 32 TB among Foreign-born persons in the United States: Achieving Tuberculosis Elimination TB rates among FB Time in US before TB diagnosis 121/100,000 < 1 year 30/100,000 1-5 years 11.9/100,000 >5 years Cains et al. Am J Resp Crit Care Med. 2007;175:75-79 Rates highest for those in US <1 year Lowest for those >5 years Less than 1 yr rates higher than actual country of origin but decreased below country of origin >1 yr These data and the recommendations that follow deserve further discussion. How would we interpret these findings and what recommendatios should we disseminate in CA? Are CA data different? What about the feasibility. Under program conditions is testing of all 10 million FB in Ca feasible, even if some degree of testing done in pvt setting? 30 million FB , 10 in CA. We have a not short rx and imperfecct tests Our largest group has risk that starts to approx pop; alternative not mentioned is not rates and at leats search for those with cofactors where risk clear. Expand targeted testing when thefedearl TT funds eliminated and cuts 5% /yr. Our case count decline is stalled but is it due to people recactivating from remote infection > 5 years?has proportion increased in this group because we address the remainder?Rates highest for those in US <1 year Lowest for those >5 years Less than 1 yr rates higher than actual country of origin but decreased below country of origin >1 yr These data and the recommendations that follow deserve further discussion. How would we interpret these findings and what recommendatios should we disseminate in CA? Are CA data different? What about the feasibility. Under program conditions is testing of all 10 million FB in Ca feasible, even if some degree of testing done in pvt setting? 30 million FB , 10 in CA. We have a not short rx and imperfecct tests Our largest group has risk that starts to approx pop; alternative not mentioned is not rates and at leats search for those with cofactors where risk clear. Expand targeted testing when thefedearl TT funds eliminated and cuts 5% /yr. Our case count decline is stalled but is it due to people recactivating from remote infection > 5 years?has proportion increased in this group because we address the remainder?

33. 33 Total Foreign-born TB cases diagnosed within 1 year of US arrival With B Notification 44% Without B Notification 56%

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35. 35 California B-notification arrivers by B class 2000-2008 33% of all B-note arrivers to the US resettle in California 43% increase in the overall number of B-note arrives (2000-2008) Large volume of B2 LTBI arrivers (start date 10/1/2007) Percent of total 2006 US-bound B-notification arrivers who resettled in California: 3,600/10,502 = 34% 33% of all B-note arrivers to the US resettle in California 43% increase in the overall number of B-note arrives (2000-2008) Large volume of B2 LTBI arrivers (start date 10/1/2007) Percent of total 2006 US-bound B-notification arrivers who resettled in California: 3,600/10,502 = 34%

36. 36 2000-2007 average (4.0%) (<1 yr following US arrival) Q: Will we see a decrease with the addition of cultures under the 2007 TIs? 2000-2007 average (4.0%) (<1 yr following US arrival) Q: Will we see a decrease with the addition of cultures under the 2007 TIs?

37. 37 2007 Technical Instructions for TB Screening and Treatment

38. 38 Assessing Effectiveness of Overseas TB Screening Enhancement Compared frequency of TB Cases diagnosed within 6 months of U.S. arrival Among of B-notification arrivers from Mexico, Philippines, Vietnam Cohort A = arrivers with B-notification screened under 1999 Technical Instructions Cohort B = arrivers with B-notification screened under 2007 Technical Instructions

39. 39 TB cases with B Notification diagnosed within 6 months of arrival to California Cohort A (1991 TIs) Cohort B (2007 TIs) n=2,115 n=3,621 TB cases 87 (4.1%) 32 (0.9%) TB case rate 4113/100,000 872/100,000 B1 TB cases 75 (5.1%) 26 (1.8%) Culture-positive 82% 48%

40. 40 Culture-positive TB cases: 2007 TI B-notification arrivers to CA (n=15)

41. 41 Culture-positive TB cases reported among 2007 TI B-notification arrivers (n=15)

42. 42 Culture-positive TB cases reported among 2007 TI B-notification arrivers (n=15) Characteristic No. % Prior TB treatment 2 13% Smear-positive 1 7% INH resistant 4 27% MDR 2 13%

43. 43 Progression to disease Relapse of treated TB Reasons for case occurrence?

44. 44 2009 CTCA/CDPH B-notification Guidelines

45. 45 TB/ HIV Co-infection

46. 46 Tuberculosis Cases with AIDS, 1997-2007 HIV co-infection is important sub population of TB cases Describe trends (decreased 1995-2000, then slight uptick from 2001-2003. Bears watching. Impact of HARRT evident. Branch has been doing a lot of work over the past years to ensure that TB patients are tested for HIV and that HIV patients are screened for TB infection or disease and treated accordingly. We don’t know where it’s going on – rise in AIDS among Hispanics may impact TB rates. In general, the Branch needs to better understand the HIV epi in f-b. For example, what’s happening with HIV in Mexico? HIV co-infection is important sub population of TB cases Describe trends (decreased 1995-2000, then slight uptick from 2001-2003. Bears watching. Impact of HARRT evident. Branch has been doing a lot of work over the past years to ensure that TB patients are tested for HIV and that HIV patients are screened for TB infection or disease and treated accordingly. We don’t know where it’s going on – rise in AIDS among Hispanics may impact TB rates. In general, the Branch needs to better understand the HIV epi in f-b. For example, what’s happening with HIV in Mexico?

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48. 48 Race/Ethnicity of TB Cases with AIDS, 1997-2007

49. 49 Trends in California TB Cases with AIDS: U.S. and Foreign-born The fraction of AIDS/TB cases that are FB doubled in the past decadeThe fraction of AIDS/TB cases that are FB doubled in the past decade

50. 50 Top Countries of Origin (?10 cases):TB/AIDS Cases, California, 1997-2007

51. 51 AIDS/TB Cases, California 1997-2007

52. 52 AIDS/TB Cases, California 1997-2007

53. 53 2009 HIV Opportunistic Infections Guidelines

54. 54 Death by Consumption

55. 55 Deaths in Persons with Tuberculosis: California, 1997-2006

56. 56 Time to Death for Patients Starting Therapy, California 2006

57. 57 Independent Predictors of TB Death, California 1993-2006 Age HIV/AIDS Private provider Extrapulmonary disease: disseminated or meningeal

58. 58 Survival among TB patients cared for by private vs. public providers, California, 1993-2007

59. 59 Has the California population at risk changed? >14 million with population risk factor for TB infection from high burden countries in congregate settings > 1 million with medical risk for TB progression Population with medical risks growing at accelerated rate Diabetes, renal dialysis, transplant, immune-biologics Living with HIV/ AIDS Intersection: ~ 20,000-30,000 with medical risk factors also have latent TB infection

60. 60 Is TB case epidemiology changing? TB cases decline is sluggish One in 10 with TB continue to die TB case population older Diverse countries of origin: TB and MDR TB Increased infectivity markers Confluence of multiple factors = increased case complexity

61. 61 What strategies will control TB in California? Risk intersections = opportunities for intervention New arriver/B-notification/prior TB treatment HIV infection/LTBI/foreign-born Diabetes/US born/Black /older Foreign-born/diabetes/older US born/health care worker Older/Asian

62. 62 TB Control Strategies for 2009 and Beyond Early diagnosis Rapid Tests: HIV, TB , MDR Rapid effective treatment HAART, shorter course TB rx Treat LTBI in highest risk LTBI diagnostics, shorter rx

63. 63 TB Control Forecast? Potential examples- Recurrent TB- to address TBCB may want to develop recommendation for LHJs to perform active surveillance, active follow-up of TB cases with independent risk factors- up to 3 years after treatment completion. Would this be cost-effective? Why is COT decreasing? What can TBCB do to improve the trend? Increasing co-management of HD and private providers, potential for poor outcomes in private sector- shall TBCB develop strategies to help LHJs improve outcomes specificallyin private sector? And/or is there more work TBCB can do directly- e.g. Kaiser? Shall TBCB focus on improving DOT statewide?– more encouragement of LHJs during TIP process? Incentives/enablers?Potential examples- Recurrent TB- to address TBCB may want to develop recommendation for LHJs to perform active surveillance, active follow-up of TB cases with independent risk factors- up to 3 years after treatment completion. Would this be cost-effective? Why is COT decreasing? What can TBCB do to improve the trend? Increasing co-management of HD and private providers, potential for poor outcomes in private sector- shall TBCB develop strategies to help LHJs improve outcomes specificallyin private sector? And/or is there more work TBCB can do directly- e.g. Kaiser? Shall TBCB focus on improving DOT statewide?– more encouragement of LHJs during TIP process? Incentives/enablers?

64. 64 Acknowledgements Melissa Ehman Kathy DeRiemer Julia Hill Linda Johnson Phil Lowenthal Peter Oh Lisa Pascopella James Watt Janice Westenhouse