California Update : TB Epidemiology and Indicators CTCA October 22, 2010 Jennifer Flood MD MPH Chief, Surveillance and Epidemiology Tuberculosis Control Branch California Department of Public Health

2 Objectives Epidemiology Are we on our way… towards TB elimination… finally? How has the TB case population changed? TB Control Indicators Has California successfully deployed available TB control strategies? Compared to the nation?

3 Longview: 80 Years of TB Control in California YEAR TB Cases Case rate , /100, /100,000

4 Hierarchy of TB Case Rate Disparities, California, 2009 Case rate Nativity and race/ethnicity 1.2 U.S.-born White 2.7 U.S.-born Hispanic 3.8 National case rate 4.1 Foreign-born White 4.2 U.S.-born Asian 6.7 U.S.-born Black 12.9Foreign-born Hispanic 35.2Foreign-born Asian 99.0Foreign-born Black

5 U.S.-born Homeless TB Cases in California, Then and Now 1994 vs Total homeless 390 (8%) 103 (4%) U.S.-born TB cases Homeless 274 (17%) 55 (9.5%)

6 U.S. and Foreign-born TB Cases in California, 2009

7 Changes in arrivals by overseas TB classification, TB Class 2009 Jan-Jun2010 B1 (TI 07) 2557(40%) 1790 (54%) B1/B2 (TI 91) 1530 (24%) 170 (5%) ___________________________________ B2 LTBI (TI 07) 2366 (37%) 1353 (41%) Over 6,000 B-notification arrivers in 2009! 60% of arrivers from Philippines

8 TB cases among recent B-notification arrivers from Mexico, the Philippines, or Vietnam Is the revised overseas screening preventing TB importation into California?

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10 Who are California’s HIV co-infected TB cases? 1993 (501) 2008 (126) Median age36 40 Female6% 17% Hispanic 37% 57% Black 33% 22% White 25% 12% Asian4% 8% Foreign birth 34% 60% PZA mono-resistance 1.8% to 14%

11 How many with AIDS/TB die? 1994  (31%)  18 (14%) Source: California AIDS/TB registry match

12 Has the pathogen changed? Anti-TB Drug Resistance, California 2009 Pansusceptible 85% INH 8% Mono-PZA3.6% Increasing! Polydrug2.9% MDR 1.7%

13 Summary: TB Epidemiology in California is Changing TB now affects much fewer Californians Who has TB Disease in 2009? Prominent race and nativity disparities Homeless TB cases shrinking Foreign-born remote arrivers = largest case group Growth of immigrant group with B-notification; marked decline in disease post-arrival Striking changes in HIV/TB intersection and mortality Is the pathogen more difficult to treat? Drug resistance unchanged except climb in M. bovis

14 TB Control Indicators How successful are we in implementing TB control strategies and driving TB morbidity downward?

15 TB Control Indicators: California SHORT LIST Surveillance TB case rate US-born TB case rate Genotyped cases TB Treatment Inappropriate SAT TB disease outcomes Culture conversion Completion of therapy ever TB deaths Case-finding Contacts evaluated B-notification evaluated

16 Selected TB Control Indicators: California compared to Nation Better Culture conversion within 60 days (2008) 64% Universal genotyping (2009) 78% Same as National Average Contact evaluation (2007) 83% Worse TB case rate (2009) 6.7 US born case rate (2009) 2.2

17 California Cases Recommended for DOT Receiving SAT only, by provider type

18 SAT and risk of acquired drug resistance Of 2,315 TB cases in 2008, 350 (15%) were on SAT throughout therapy 77 (22%) of the 350 patients had 1 or more risk factors for acquired drug resistance: HIV infection drug resistance smear positive cavitary CXR

19 Trends: Cases with no documented conversion ever, (private vs. public)

20 Tuberculosis Cases 1 by Outcome of Therapy, Excluding Deaths: California, 2008 Completed Therapy 2,250 (91.5%) Moved 112 (4.6%) Refused/Lost 48 (1.9%) Missing/Other 49 (2.0%) 1 Patient alive at diagnosis, started treatment and did not die during therapy.

21 Death by Consumption 2009 Died with TB 218 (8.8%) Deaths during therapy 177 (7.2%) Dead at diagnosis 42 (1.7%)

22 TB Deaths during Therapy, by Provider Type,

23 Case-finding and Prevention: Evaluation of TB suspects and contacts How many were evaluated in California? 2767 (73%) persons with abnormal overseas CXR (B1 and old B1/B2) evaluated in ,380 (83%) contacts to smear positive pulmonary TB cases in 2007

24 What is not measured in our indicator sets? Time to TB diagnosis (delays in diagnosis) TB transmission events Acquired drug resistance TB treatment failure and relapse _______________________________ Which interventions are most important and most effective not clearly defined

25 Summary: How successful are TB control efforts in California? California has reaped huge benefit from TB control efforts Use of recommended strategies has improved dramatically Vast majority of patients complete TB therapy Fraction who die has not changed More attention needed for those at highest risk for adverse outcomes Private sector lags behind in best practices Improvements suggest private-public collaboration can work Challenge: treatment, case-finding and prevention needs remain very large California without TB: a wellness and prevention expectation for health care reform!

26 Questions?