1. TB in North Dakota: Changing Demographics John R. Baird, MD, MPH Fargo Cass Public Health North Dakota Department of Health April 11, 2012

2. Objectives Shift of US TB cases to foreign born Change in ND TB demographics Challenges in TB evaluation and treatment in new ethnic groups

3. Module 1 – Transmission and Pathogenesis of Tuberculosis M. tuberculosis causes most TB cases in U.S. Mycobacteria that cause TB: –M. tuberculosis –M. bovis –M. africanum –M. microti –M. canetti Mycobacteria that do not cause TB –e.g., M. avium complex M. tuberculosis Types of Mycobacteria

4. Module 1 – Transmission and Pathogenesis of Tuberculosis Sites of TB Disease Bacilli may reach any part of the body, but common sites include:

5. Module 2 – Epidemiology of Tuberculosis TB is one of the leading causes of death due to infectious disease in the world Almost 2 billion people are infected with M. tuberculosis Each year about: –9 million people develop TB disease –2 million people die of TB Global Epidemiology of TB

6. Reported TB Cases United States, 1982–2010* *Updated as of July 21, 2011 No. of Cases Year

7. TB Case Rates,* United States, 2010 *Cases per 100,000. < 3.6 (2010 national average) >3.6 D.C.

8. TB cases in ND - Numbers

9. TB cases in ND - Rates

10. TB rates – US vs. ND

11. TB Case Rates* by Age Group United States, 1993–2010 * Updated as of July 21, 2011 Cases per 100,000 Age Group (years)

12. TB cases in ND - Age

13. TB cases in ND - Sex

14. Reported TB Cases by Race/Ethnicity* United States, 2010 *All races are non-Hispanic. Persons reporting two or more races accounted for less than 1% of all cases.

15. TB cases in ND - Race

16. Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, 1993–2010* *Updated as of July 21, 2011 No. of Cases

17. >50% 25%–49% <25% 20002010 DC *Updated as of July 21, 2011 Percentage of TB Cases Among Foreign-born Persons, United States* DC

18. TB cases in ND US vs. Foreign Born

19. Countries of Birth of Foreign-born Persons Reported with TB, United States, 2010

20. TB cases in ND - Origin Foreign Born 2007 - 2011 Africa – Somalia (5), Ethiopia (2), Kenya (2), Sudan, Zambia South Asia – Bhutan (4), Nepal (2), India Asia – China, Mongolia, Korea SE Asia – Vietnam, Philippines

21. Refugee Arrivals North Dakota LSS of ND

22. Resettlement Cities North Dakota

23. Countries of Origin - Refugees to ND Maps adapted from The Perry-Castañeda Library Map Collection, The University of Texas at Austin http://www.lib.utexas.edu/maps

25. Latent TB Infection (LTBI) LTBI is the presence of M. tuberculosis organisms (tubercle bacilli) without symptoms or radiographic evidence of TB disease. 25

26. Latent TB Infection TST* or QFT † positive Negative chest radiograph No symptoms or physical findings suggestive of TB disease Pulmonary TB Disease TST or QFT usually positive Chest radiograph may be abnormal Symptoms may include one or more of the following: fever, cough, night sweats, weight loss, fatigue, hemoptysis, decreased appetite Respiratory specimens may be smear or culture positive *tuberculin skin test † QFT (QuantiFERON-TB and QuantiFERON-Gold) is a blood test to detect M. tuberculosis infection. LTBI vs. Pulmonary TB Disease

27. Cases in ND – LTBI & TB

28. Challenges Language Culture Proper & prompt evaluation Care coordination Complete LTBI treatment Homeless Others?

29. TBNet http://www.migrantclinician.org

30. Case #1 4 month old – adopted from Africa Birth mother HIV+ Baby HIV neg @ 6 mo Staph skin and proctitis on US entry BCG given in Africa – no TST done is US Hospitalized at 11 mo sore ankle, limp, temp 101-103 refused to bear weight 3 days Splinted for possible fracture

31. Case #1 (cont.) TST 16 mm – QuantiFERON neg Dx – abcess left distal tibia, staph, ? TB Rx – IV Rocephen, Vacomycin, Septra DOT – INH, RIF, EMB, PZA Daycare concerns Culture – PZA resistant – Bovine TB

32. http://www.heartlandntbc.org/casestudies/cs9.pdf Case Presentation June 2008 – Adherence Difficulties in a Child with Tuberculosis Case History: A 15 month old child with active pulmonary tuberculosis became a significant management challenge to his public health nursing providers because of his consistent refusal to take medications. Consultation may be requested through your state's TB Control Program or by contacting Heartland National TB Center directly at our toll-free number: 1-800-TEX-LUNG (1-800-839-5864) Consultation line staffed Mon — Fri, from 8:00 AM until 5:00 PM, Central Time http://www.heartlandntbc.org

33. Questions Craig Steffens, MPH csteffens@nd.gov TB Controller, NDDoH 701.328.2377 http://www.ndhealth.gov/disease/tb John R. Baird, MD, MPH jbaird@nd.gov Field Med Officer, NDDoH Health Officer, FCPH 701.241.8118 http://www.heartlandntbc.org http://www.migrantclinician.org http://www.cdc.gov/tb