Tuberculosis Update for Indiana – 2018

1. Tuberculosis Update for Indiana – 2018 Bradley Allen, MD, PhD, FACP, FIDSA Indiana University School of Medicine Division of Infectious Diseases Roudebush VAMC Indianapolis March 23, 2018

2. Disclosures • Medical Consultant, TB Control Program Indiana State Department of Health • Have personally endured over 37 Tuberculin skin tests (either negative or misinterpreted…) Major thanks to Kelly White, ISDH TB Program Mgr and Sang Thao, TB Epidemiologist, for Indiana data updates!

3. Outline/Objectives Learn the current Tuberculosis Incidence - World, U.S. and Indiana TB Radiology Dr. John Christenson Upcoming TB Items Dr. Maunank Shah Case Presentations Brandon White Deciphering TB Lab Reports Jessica Gentry Purdue Pharmacy Dr. Nicole Noel Review available County and State Support Systems Thanks to Dr. Kristina Box for her support and intro! 1) 2) 3) 4) 5) 6) 7)

4. Global/U.S. TB Burden, 2017 • An estimated 10.4 million new TB disease cases • 1.3 million deaths due to TB disease (1.4, ‘16) – Additional 0.4 million deaths from TB among HIV- positive people • The rate of decline remains low at 2% per year (1.5%, ‘16) – Must accelerate to 4-5% annual decline by 2020 to reach first milestone of End TB Strategy • Estimated 10-15 million persons in U.S. TB infected Source: WHO Global Tuberculosis Report 2017

5. TB Epidemiology, worldwide • Africa has the highest incidence rate (254 per 100,000 population, v. ~ 2.9 U.S.) (275 & 3.0 ‘16) – Some regions of Africa have rates up to 500! • Largest number of cases from Asian Countries: – India, Indonesia, China, Nigeria, Pakistan and South Africa account for 60% of global cases in 2015 • Three countries (China, India, and Russian Federation) account for 47% of MDR-TB

7. Reported Tuberculosis (TB) Cases United States, 1982–2016* 30,000 25,000 20,000 No. of cases 15,000 10,000 5,000 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Year *As of June 21, 2017.

8. Reported Tuberculosis (TB) Cases United States, 1982–2016* 30,000 25,000 20,000 No. of cases 15,000 10,000 5,000 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Year *As of June 21, 2017.

9. Reported Tuberculosis (TB) Cases United States, 1982–2016* 30,000 25,000 20,000 No. of cases 15,000 10,000 5,000 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Year *As of June 21, 2017.

10. Factors Contributing to the Increase in TB Morbidity: 1985-1992 Deterioration of the TB public health infrastructure • HIV/AIDS epidemic • Immigration from countries where TB is common • Transmission of TB in congregate settings • •homeless shelters, prisons, etc.

11. Estimated HIV Coinfection Among Persons Reported with TB, United States, 1993–2016* 70 All ages Ages 25–44 yrs 60 Coinfection (%) 50 40 30 20 8.6% 5.6% 10 0 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Year * As of June 21, 2017. Note: Minimum estimates are based on reported HIV-positive status among all TB patients in the age group.

12. Estimated HIV Coinfection Among Persons Reported with TB, United States, 1993–2016* 70 All ages Ages 25–44 yrs 60 Coinfection (%) Remember to check HIV status on EVERY new diagnosis of TB infection 50 40 30 20 10 0 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Year * As of June 21, 2017. Note: Minimum estimates are based on reported HIV-positive status among all TB patients in the age group.

13. TB Case Rates Among U.S.-Born versus Non-U.S.–Born Persons, United States, 1993–2016* 40 U.S. overall U.S.-born Non-U.S.–born Cases per 100,000 population 35 30 25 20 14.7 15 10 5 2.9 1.1 0 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Year *As of June 21, 2017.

14. Impact of culture v. smear screening of immigrants to the U.S. Classification: Class A : Pos. smear and abnl CXR Class B1: Neg. smears with abnl CXR Class B2: Neg. smears with CXR suggesting latent disease Ann Intern Med. 2015;162(6):420-428. doi:10.7326/M14-2082

15. Tuberculosis Cases & Case Rates Indiana, 2013 - 2017 2017 Cases = 100 Incidence Rate = 1.5/100,000 140 2 1.8 1.8 120 1.5 Contrast rate to: U.S. – 2.9 (3.0) Global – 140 (160) 1.6 1.4 100 Case Rate oer 100,000 Population 1.4 100 1.2 Number of Cases 80 1 60 0.8 0.6 40 0.4 20 0.2 0 0 2013 2014 2015 2016 2017 Year

16. Decrease in heaviest burden county, Marion from 44 to 37 cases

18. Tuberculosis Cases by Race Indiana, 2017 1.0% White 11.0% Asian 45.0% Black or African American Native Hawaiin or Other Pacific Islander Tuberculosis Cases by U.S./Foreign Birth Indiana, 2017 43.0% N = 100 27.0% U.S.-Born 73.0% N = 100

19. Percentage of Foreign-Born Tuberculosis Cases by Country of Birth, Indiana, 2017 23.3% Burma 39.7% Mexico India Philippines 16.4% Other 8.2% 12.3%

20. State of Indiana Tuberculosis - 2017 Race and Ethnicity-specific Incidence Rates*# White, not Hispanic or Latino = 0.43 Black or African-American = 1.8 Hispanic or Latino, all races = 4.9 Asian = 30.9 Males = 1.9 Female = 1.1 *Per 100,000 population #All rates decreased from 2016

21. Percentage of TB Cases by HIV Testing Status & Age Group Indiana, 2016 ≥ 15 Years 25-44 Years HIV Testing Status Percentage of TB Cases by HIV Testing Status & Age Group Indiana, 2017 Test Results Known 94.1% 98.0% Testing Not Offered 3.9% 2.0% ≥ 15 Years 25-44 Years Refused Testing 2.0% 0.0% HIV Testing Status Test Results Known 90.40% 94.40% Testing Not Offered 3.20% 0.00% Refused Testing 6.40% 5.60% Thank you for all your hard work in improving our HIV screening rates!

22. Tuberculosis Cases by Directly Observed Therapy Utilization Indiana, 2016 15.0% Total DOT Partial DOT 85.0% Kudos to everyone! Over 85% DOT N=107

23. LTBI ~ 30 % of heavily exposed persons will become infected Small, NEJM 2001 Small, NEJM 2001

24. Treatment of TB Disease Increased dosing frequency is better • •7 or 5 days a week dosing more effective •3 times weekly is acceptable •2 times weekly not routine any more Clin Infect Dis, 63 (7):e147–e195, https://doi.org/10.1093/cid/ciw376

25. Treatment of LTBI 3 HP dosing gaining momentum • •12 weekly doses by DOT •INH plus rifapentine Other rifampin based regimens coming •

26. Clever Ideas for 3 HP Tracking DIRECTLY OBSERVED THERAPY LOG 12-Dose Isoniazid-Rifapentine Latent TB Infection Treatment Patient Name: _____________________________ Date of Birth: ___________ Initial Weight _____________kg Date: Dose: __1__ __2__ Loss of Appetite □ □ Nausea or vomiting □ □ Yellow eyes or skin □ □ Diarrhea □ □ Rash or hives □ □ Fever or chills □ □ Sore muscles □ □ Numbness or Tingling □ □ Fatigue □ □ Dizziness/fainting □ □ Abdominal pain □ □ Other _______________ □ □ Rx stop or held (complete adverse reaction log) No adverse reaction □ □ Current Weight kg Blood Pressure / / Provider Initials* * Printed name for initials: ____ _____________________ | ____ _______________________ | ____ ____________________ Initials Printed name Initials Provider Initials* Dose: ______mg INH______mg RPT Date: Dose: Loss of Appetite Nausea or vomiting Yellow eyes or skin Diarrhea Rash or hives Fever or chills Sore muscles Numbness or Tingling Fatigue Dizziness/fainting Abdominal pain Other _______________ Rx stop or held (complete adverse reaction log) No adverse reaction Current Weight Blood Pressure __/__ __1__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __/__ __2__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __/__ __3__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __4__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __5__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __6__ □ □ □ □ □ □ □ □ □ □ □ __/__ __7__ □ □ □ □ □ □ □ □ □ □ □ __/__ __8__ □ □ □ □ □ □ □ □ □ □ □ __/__ __9__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __10__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __11__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __12__ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __3__ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __4__ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __5__ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __6__ □ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __7__ □ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __8__ □ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __9__ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __10__ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __11__ □ □ □ □ □ □ □ □ □ □ □ □ □ __/__ __12__ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ kg □ kg □ □ □ kg □ kg □ □ □ kg kg kg kg kg kg kg / / / / / / / / / / □ □ □ □ □ □ □ □ □ □ □ □ kg kg kg kg kg kg kg kg kg kg kg kg / / / / / / / / Printed name / / / / Printed name Initials (Over) 6/2015

27. http://www.in.gov/isdh/19662.htm

28. Questions?

29. References/Resources • Liu, et al. 2015. Effect of a Culture-Based Screening Algorithm on Tuberculosis Incidence in Immigrants and Refugees Bound for the United States: A Population- Based Cross-sectional Study. Ann Intern Med. 162(6):420-428. https://doi:10.7326/M14-2082 Nahid, et al. 2016. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis, 63 (7):e147–e195, https://doi.org/10.1093/cid/ciw376 Recommendations for Use of an Isoniazid-Rifapentine Regimen with Direct Observation to Treat Latent Mycobacterium tuberculosis Infection. MMWR December 9, 2011 / 60(48);1650-1653 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6048a3.htm?s_cid=mm6048 a3_e%0d%0a Tuberculosis: Professional Resources and Tools. https://www.cdc.gov/tb/education/professionaltools.htm Accessed March 11, 2018 • • •

30. Number & Percentage of TB Cases by Risk Factor Indiana, 2017 Risk Factor Number of Cases Percent of Cases Resident of Correctional Facility 1 1.0% Homelessness 4 4.0% Resident of Long-Term Care Facility 2 2.0% Injecting Drug Use 1 1.0% Non-Injecting Drug Use 5 5.0% Excess Alcohol Use 9 9.0%

31. Dosage for a combination regimen of isoniazid and rifapentine in 12 once-weekly doses under direct observation for treating latent Mycobacterium tuberculosis infection. MMWR December 9, 2011 • MUST BE DONE WITHIN A DOT PROGRAM*** • Isoniazid – 15 mg/kg rounded up to the nearest 50 or 100 ; – 900 mg maximum • Rifapentine – 10.0–14.0 kg 300 mg – 14.1–25.0 kg 450 mg – 25.1–32.0 kg 600 mg – 32.1–49.9 kg 750 mg – ≥50.0 kg 900 mg maximum • INH is formulated as 100 mg and 300 mg tablets. Rifapentine (RPT)is formulated as 150 mg tablets, new formulations and fixed- dose INH-RPT combos are in development.