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Tuberculosis Surveillance and Disease Intersections in California

Tuberculosis Surveillance and Disease Intersections in California. Jennifer Flood, M.D., M.P.H. Chief, Surveillance and Epidemiology Section Tuberculosis Control Branch Division of Communicable Disease Control Center for Infectious Diseases California Department of Public Health

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Tuberculosis Surveillance and Disease Intersections in California

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  1. Tuberculosis Surveillance and Disease Intersections in California Jennifer Flood, M.D., M.P.H. Chief, Surveillance and Epidemiology Section Tuberculosis Control Branch Division of Communicable Disease Control Center for Infectious Diseases California Department of Public Health October 15, 2008

  2. Outline • TB surveillance • Disease intersections (HIV/TB) • Opportunities for collaboration

  3. Why is TB important? 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

  4. 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

  5. Purpose of surveillance • Quantifies disease magnitude and changes in disease over time • Identifies disease characteristics • Provides roadmap for TB control efforts

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

  7. 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

  8. 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

  9. Features of TB Case Report

  10. 6,000 5,500 5,000 4,500 4,000 3,500 3,000 2,500 Slowing Rate of TB Case Decline California, 1992-2007 -5.9% per year (1992-2000) -2.8% per year (2000-2006) Number of Tuberculosis Cases -1.9% per year (2006-2007)

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

  12. 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

  13. Adverse Events • Pediatric cases • Drug resistance • Outbreaks

  14. Died During Treatment Died Before Starting Treatment Dead at Diagnosis Percent Dying with Tuberculosis Deaths in Persons with Tuberculosis: California, 1996-2005 Percent of Cases Number of Deaths

  15. 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

  16. 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

  17. Intersection of TB, HIV and STDs

  18. 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

  19. 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

  20. 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)

  21. RVCT – HIV Status: CDC required Field

  22. Current CA RVCT fields – HIV Status

  23. No. TB Cases with AIDS % TB Cases with AIDS IncidentTuberculosis Cases by AIDS Diagnosis*: California, 1997-2006 Number of Cases with AIDS Percent of Cases with AIDS * AIDS Case Registry, California Office of AIDS

  24. ≥ 100 Cases 50-99 Cases 25-49 Cases 10-24 Cases 1-9 Cases None AIDS-associated Tuberculosis Cases* California, 2000-2004 AIDS-associated Tuberculosis Cases Berkeley San Francisco Pasadena Long Beach *Match found in AIDS Cases Registry, Office of AIDS

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

  26. Reporting Counties: Rank Order by Case Count

  27. AIDS/TB Cases Contributed by Selected Local Health Departments

  28. AIDS/TB Case Trends: Socio-demographic Characteristics

  29. Risk Factors / SettingsAIDS/TB Cases California, 1995 - 2004 TBTB/AIDS Homelessness 253 (17%) 166 (22%) Drugs/alcohol 556 (38%) 281(37%) Corrections 133 (9%) 30 (4%)

  30. 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%

  31. AIDS/TB Case Trends: Care and Outcome Characteristics

  32. 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

  33. Opportunities Diagnosis TB infection HIV infection LTBI Treatment HAART TB Disease / AIDS Expert Co-management Death X X

  34. 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

  35. Surveillance opportunities in CA Number of ? HIV co-infected TB patients HIV-infected patients with LTBI Preventable AIDS/TB cases Preventable AIDS/TB deaths

  36. 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

  37. CDPH TB Control Surveillance Team TB Control Registry Janice Westenhouse- Lead Jen Allen Bill Elms Linda Johnson Phil Lowenthal Kelly Waldow

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