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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
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2 Outline Is TB controlled? Who is involved in TB control? Where are the landmines? Way forward?
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TB Case Trends 3
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4 California Population and Tuberculosis Cases, 2001-2010 Tuberculosis Cases Population 3,332 2,329 34 Million 39 Million
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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
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6 TB Cases by Place of Birth Place of Birth 2001-2010 % Change U.S.- born 824 498 -40 Foreign-born 2482 1802 -27
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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
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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
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Foreign-born with active TB within one year of U.S. arrival, 2001-2010 % Foreign-born cases Year 9
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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
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TB Case Characteristics 11
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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%
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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
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TB Diagnosis and Treatment 15
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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%
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Provider: TB diagnosis and treatment, TB cases, California, 2008* 17 *Randomly selected TB patients; N=280. Source: TBCB 2008 HIV status field study
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What interventions are high impact? Diagnosis Rapid MTB and drug resistance tests HIV test of TB patients Treatment Effective TB treatment HAART 18
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Use of new diagnostics 2010 TB cases (n=2314) NAAT892 (39%) IGRA475 (22%) 19
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HIV Status Determination is not Universal in CA CDC standard is universal testing of all TB cases 20
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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
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Where was HIV test done for HIV/TB co-infected patients? 67%Hospital 16%Outpatient 17%Unknown 22
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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
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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
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Time to Death for Patients Starting Therapy, California 2008 Median time to death = 48 days 25
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26 TB Deaths during Therapy, by Provider Type, 1994-2009
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Why are TB deaths occurring? 27
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Is TB a contributor to Death? Preliminary Results: Mortality Study TBESC In 75%, TB contributed to death ! 28
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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
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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
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Navigating Landmines 31
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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
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Too busy killing alligators to drain the swamp? 33
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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
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Prevention: Can we afford it? Can we afford not to do it? 35
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36 Horsburgh CR Jr, Rubin EJ. Clinical Practice: Latent Tuberculosis Infection in the United States. NEJM 2011;364 (15):1441-8.
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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
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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
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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
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Case Prevention Should we prioritize LTBI treatment for arrivers with B-notification of TB2 and TB4? 40
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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
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What Strategic Direction is Under Consideration? Adopt cost-effective diagnostic and treatment approaches Abandon ineffective unproven approaches Tackle case prevention as cases decline 42
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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
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