1. Mortality Among a Tuberculosis Outbreak Los Angeles County, 2007–2013 Brian Baker, MD Amit Chitnis, MD MPH Leslie Henry, BSN RN PHN 48th CTCA Educational Conference April 24, 2014

2. Mortality Among Patients with Tuberculosis Most cases of tuberculosis (TB) are curable with appropriate treatment for 6 to 9 months However, an estimated 7–10% of patients with TB die prior to diagnosis or during treatment Better understanding of deaths is needed to guide future strategies to reduce mortality

3. Objectives Describe deaths among outbreak cases, including frequency and timing Assess demographic and clinical factors among outbreak deaths Identify possible opportunities for intervention

4. Methods Reviewed reported cases of tuberculosis in Los Angeles County during 2007–2013 Defined outbreak cases based upon: –Genotype results from a Mycobacterium tuberculosis isolate OR –Epidemiologic link to a confirmed outbreak case For outbreak patients who died, medical records were reviewed

5. Methods Timing of death was measured from TB treatment start date (for those alive at diagnosis) Severity of TB disease was assessed using standardized tool

6. Outbreak Cases Los Angeles County, 2007–2013

8. Timing of Outbreak Deaths (n=21)

9. Demographic and Clinical Characteristics Among Outbreak Deaths (n=21) No.(%) Age<250(0.0) 25–449(42.8) 45–648(38.1) >654(19.1) SexMale21(100.0) Female0(0.0)

10. Demographic and Clinical Characteristics Among Outbreak Deaths (n=21) No.(%) OriginU.S.-born9(42.9) Foreign-born10(47.6) Unknown2(9.5) Race/EthnicityHispanic15(71.4) Black5(23.8) White1(4.8) Asian / Other0(0.0)

11. Demographic and Clinical Characteristics Among Outbreak Deaths (n=21) No.(%) HomelessYes15(71.4) No4(19.1) Unknown2(9.5) Substance abuseYes9(42.9) No3(14.3) Unknown9(42.9) Incarceration at diagnosis Yes1(4.8) No20(95.2)

12. Demographic and Clinical Characteristics Among Outbreak Deaths (n=21) No.(%) HIVPositive8(38.1) Negative8(38.1) Unknown5(23.8) Sputum smearPositive12(57.1) Negative8(38.1) Not done1(4.8) Chest radiographCavitary3(14.3) Non-cavitary17(81.0) Normal0(0.0) Not done1(4.8)

13. Demographic and Clinical Characteristics Among Outbreak Deaths (n=21) No.(%) Site of diseasePulmonary17(81.0) Extrapulmonary1(4.8) Both3(14.3) TB severity indexMild1(4.8) Moderate1(4.8) Severe19(90.5) Co-morbid conditionsCirrhosis3(14.3) Diabetes3(14.3) Cancer2(9.5)

14. Adherence Among Outbreak Deaths No.(%) Type of non-adherence Left against medical advice3(14.3) Eloped2(9.5) Refused treatment1(4.8) Any of above6(28.6)

15. Deaths Among Patients with TB and HIV n=8No.(%) CD4 count, median (range)54(2–154) New HIV diagnosis3(37.5) Already receiving ART at TB diagnosis0(0.0) Received ART during TB treatment2(25.0) Poor adherence5(62.5) ART = antiretroviral therapy

16. Time from hospital admission to first specimen collection Days MedianMeanRange Hospitalized patients with suspected TB (n=20) 120–12

17. Time from first specimen collection to initiation of treatment, by AFB smear status Initial smear results Days MedianMeanRange AFB smear positive (n=11) 141–26 AFB smear negative (n=7) 17244–80

18. Treatment among patients with initially smear negative specimens (n=9) Precipitating factorNo.(%) Subsequent positive smear4(44.4) Positive culture3(33.3) Never initiated treatment2(22.2) NAAT performed0(0.0) Received empiric treatment0(0.0) NAAT = nucleic acid amplification test

19. Limitations Some data missing, particularly among patients dead at diagnosis or during initial hospitalization Deaths were not necessarily related to TB

20. Summary Most deaths occurred early among patients with severe disease at the time of diagnosis Large number of patients with other contributing medical conditions (e.g., HIV) Patients were evaluated for TB, but treatment only started after positive smear or culture Adherence to TB treatment is a substantial challenge

21. Areas of Opportunity Implementing policies and practices to diagnose homeless patients earlier Connecting HIV-infected homeless persons to HIV- related care and treatment before TB diagnosis Improving availability of rapid diagnostics for active TB disease (i.e., NAATs) Continuing use of public health resources to support patients during treatment

22. Acknowledgments Los Angeles County Department of Public Health –Tuberculosis Control Program –Community Health Services California Tuberculosis Control Branch Partners in shelters, clinics, and hospitals

23. Questions?