1. TB Elimination in California Can We Get There? Navigating the Landmines CTCA April 28, 2011 Jennifer Flood MD MPH Chief, Tuberculosis Control Branch California Department of Public Health Jennifer.Flood@cdph.ca.gov

2. 2 Outline Is TB controlled? Who is involved in TB control? Where are the landmines? Way forward?

3. TB Case Trends 3

4. 4 California Population and Tuberculosis Cases, 2001-2010 Tuberculosis Cases Population 3,332 2,329 34 Million 39 Million

5. 5 Change in TB cases by race/ethnicity, 2001-2010 Race/ethnicity 2001-2010 % Change White 365  187 -49 Black 292  151 -48 Hispanic1252  874 -30 Asian 1399  1109 -20

6. 6 TB Cases by Place of Birth Place of Birth 2001-2010 % Change U.S.- born 824  498 -40 Foreign-born 2482  1802 -27

7. Tuberculosis Cases in Foreign-born and U.S.-born Persons by Race/Ethnicity: California, 2010 Note: Excludes 29 cases with unknown race or birthplace 95% 5% 25% 75% 36% 64% 29% 71% 7

8. 8 TB cases by age group Age group 2001-2010 % Change 0-4 133  55 -59 5-14 92  45 -51 15-24318  215 -32 25-441109  680 -39 45-64 953  736 -23 65+ 727  593 -18

9. Foreign-born with active TB within one year of U.S. arrival, 2001-2010 % Foreign-born cases Year 9

10. Is TB controlled? Lowest case count in California history Success in –interrupting TB transmission and –TB disease importation suggested by decline in: pediatric cases US born cases new arrivers 10

11. TB Case Characteristics 11

12. 2010 Foreign-born TB Cases: Immigration status Immigrant 40% Refugee/asylee 5% Tourist 2% Student 2% Worker 2% Other* 16% Unknown** 31% * without above visa but not unknown ** patient does not know status on entry, refused response, or local policy restricts response 12 45%

13. 13

14. 2010 TB Cases: Comorbid conditions 480 (21%) Diabetes 145 (6%)Immunosuppressed 83 (4%) End-stage renal disease 17 (.73%) TNF Antagonist 14 (.60%)Post-organ transplant *Nearly 1/3 with co-morbidities; does not include HIV 14

15. TB Diagnosis and Treatment 15

16. Passive case-finding TB symptoms 1455 (63%) Abnormal CXR* 396 (17%) Incidental lab* 211 (9%) Active case-finding Contact investigation 84 (3.6%) Immigration screening 78 (3.4%) Targeted Testing 44 (1.9%) Employee Screening 28 (1.2%) *purpose of CXR or lab was for something other than TB 2010 TB Cases: Reason for Presentation 16 89%

17. Provider: TB diagnosis and treatment, TB cases, California, 2008* 17 *Randomly selected TB patients; N=280. Source: TBCB 2008 HIV status field study

18. What interventions are high impact? Diagnosis Rapid MTB and drug resistance tests HIV test of TB patients Treatment Effective TB treatment HAART 18

19. Use of new diagnostics 2010 TB cases (n=2314) NAAT892 (39%) IGRA475 (22%) 19

20. HIV Status Determination is not Universal in CA CDC standard is universal testing of all TB cases 20

21. Timing of HIV diagnosis (Dx) in HIV- positive TB patients, 2008 131 HIV co-infected TB patients 129 Alive at Diagnosis 64 (50%)65 (50%) Previously known HIV +Newly diagnosed HIV + 44 (68%) 2 weeks prior – 2 weeks after TB Dx 21

22. Where was HIV test done for HIV/TB co-infected patients? 67%Hospital 16%Outpatient 17%Unknown 22

23. Stage of immunosupporession: HIV-positive TB patients, 2008* CD4 count 83% with count <250 (most below 150) Viral load 88% with VL ≥10,000 *New HIV status at time of TB diagnosis 23

24. Death by Consumption Nearly 1 in 10 die with TB in California In the last decade in California: Total TB deaths……………………………2,715 Dead before diagnosis or treatment………657 Death during treatment…………………...2,058 24

25. Time to Death for Patients Starting Therapy, California 2008 Median time to death = 48 days 25

26. 26 TB Deaths during Therapy, by Provider Type, 1994-2009

27. Why are TB deaths occurring? 27

28. Is TB a contributor to Death? Preliminary Results: Mortality Study TBESC In 75%, TB contributed to death ! 28

29. Who is diagnosing and treating TB in California? Private providers are most likely to diagnose TB and start TB treatment TB diagnosis often occurs in a hospital or emergency room Public providers provide the majority of care during treatment 29

30. Who are our cases? 40% of foreign-born underwent pre- departure screening A sizeable fraction with comorbid conditions Opportunity to prevent TB and detect disease earlier TB deaths = compelling reason to intervene 30

31. Navigating Landmines 31

32. Waning TB Control Capacity Less TB control funds and positions Increase # cases per case-manager Decreased oversight of private providers Jeopardized safety net activities Upstream activities (eg surveillance, evaluation) Overshadowed daily pressures 32

33. Too busy killing alligators to drain the swamp? 33

34. Treating TB is an excellent investment of public health dollars Every $614 invested in treating TB cases and contacts saves a year of life Far more cost-effective than other well- accepted public health interventions* –Cervical or colorectal cancer screening cost $12,000 per year of life saved –Cholesterol screening costs $19,000 per year of life saved *Recommended by the U.S. Preventive Services Task Force 34

35. Prevention: Can we afford it? Can we afford not to do it? 35

36. 36 Horsburgh CR Jr, Rubin EJ. Clinical Practice: Latent Tuberculosis Infection in the United States. NEJM 2011;364 (15):1441-8.

37. Case Prevention: Which Regimen for Whom? Problem INH x 9 months: limited by poor completion Purpose Evaluated cost and cost-effectiveness of 4 LTBI regimens Regimens Rifampin x 4 months (SAT) Rifapentine and INH x 12 doses weekly (DOT) INH daily (SAT) x 9 months INH twice-weekly (DOT) x 9 months Findings Rifampin is less costly, increased benefits, cost-saving INH and Rifapentine is cost-saving for extremely high risk patients and cost-effective for lower risk patients Source: Holland et al. Am J Respir Crit Care Med 2009;179 37

38. PREVENT TB Study: TB Trials Consortium Study 26 Study design Daily INH x 9 months –Vs. Once weekly Rifapentine + INH x 12 weeks (DOT) Randomized open-label 33 months follow-up Study population Contacts and TST converters Small group of HIV+, children, TB4s Findings 3RPT/INH is noninferior to 9INH Completion rate of 3RPT/INH (81.9%) is significantly higher thank 9INH (69.5%) Source: Sterling et al. International Union Meeting, presented November 2011 38

39. What is the Evidence? Evaluation of individuals with B-notification (abnormal CXR) Percent of active cases COST-SAVING3% and above COST-EFFECTIVE4% - 1.5% Source: Porco et al. BMC Public Health 2006;6 39

40. Case Prevention Should we prioritize LTBI treatment for arrivers with B-notification of TB2 and TB4? 40

41. The Way Forward? Prioritize the most effective activities Engage partners BOTH upstream and more direct TB control activities needed TB funds are a required ingredient Examining outcomes is paramount 41

42. What Strategic Direction is Under Consideration? Adopt cost-effective diagnostic and treatment approaches Abandon ineffective unproven approaches Tackle case prevention as cases decline 42

43. Source: Bindman AB, Schneider AG. Catching a Wave – Implementing Health Care Reform in California. N Engl J Med April 21, 2011; 364(16):1487-89 Hot Off the Press 43