Controlling Tuberculosis in California: the Influence of Migration and the Global TB Epidemic : Controlling Tuberculosis in California: the Influence of Migration and the Global TB Epidemic Jennifer Flood, M.D., M.P.H.
Chief, Surveillance and Epidemiology, Department of Health Services
Tuberculosis Control Branch
May 12, 2006
Current Events in TB Control 2005-2006: Current Events in TB Control 2005-2006 New diagnostics and new drugs
2006 Global Plan
New International Standards for TB Control
Revised CDC Technical Instructions for panel physicians
Gates funds for TB
World TB Day - XDR
Stop TB legislation – international efforts
Questions:: Questions:
Trends in global TB and migration?
Status of TB control in CA?
How does migration from endemic areas influence our epidemic?
What interventions are needed?
Slide4: 4 x increase in volume as compared to 1960 - 75 Source: Population Action International 1994 Migrating Populations in the 1990s Compared to 1960-75, four-fold increase in migration
The 22 countries shown on the map account for 80% of the TB cases in the world : The 22 countries shown on the map account for 80% of the TB cases in the world http://www.stoptb.org/countries/
Migration into California: Migration into California ~10 million Californians are foreign-born
~400 million crossing US Mexico border each year
~3.5 million visitors to CA
~2 million undocumented enter CA
~250,000 new entrants with perm residence visa
~100,000 new entrants with student visa
Entry airports for 2.79 million directly-arriving Passengers from East Asia1, Jan - Mar 2005: Entry airports for 2.79 million directly-arriving Passengers from East Asia1, Jan - Mar 2005 Los Angeles 22% San Francisco 15% Guam 11% Honolulu 15% New York: 8% Chicago 6% Detroit 5% 1 Includes Brunei, Cambodia, China/Hong Kong,
Indonesia, Japan, Laos, Malaysia, Myanmar,
Philippines, Singapore, South Korea, Taiwan,
Thailand, Vietnam, Japan
Tuberculosis Cases In California, 1995-2005: Tuberculosis Cases In California, 1995-2005 Tuberculosis Cases In California. 1930-1980
Tuberculosis Cases Among the Foreign-born and U.S-born, California, 1995-2005: Tuberculosis Cases Among the Foreign-born and U.S-born, California, 1995-2005 77%
Disparities in TB Case Burden and Case Rate: US-born vs. Foreign-born, CA, 2004: Disparities in TB Case Burden and Case Rate: US-born vs. Foreign-born, CA, 2004 TB cases Case rate
US-born 710 2.8
Foreign-born 2266 24.1
Tuberculosis Cases by Country of Origin: California, 2005: Tuberculosis Cases by Country of Origin: California, 2005 Country Mexico
Philippines
Vietnam
China
India
Korea, South
Guatemala
El Salvador
Cambodia
Laos
Thailand
Peru
F. Soviet (Ukraine, Armenia, Soviet U) No. 721439248
16012567
53
39
38
38
28
25
21 % 32.3
19.7
11.1
7.1
5.6
3.0
2.3
1.8
1.7
1.7
1.3
1.1
0.9
Length of U.S. Residence Prior to TB Diagnosis, California, 2005: Length of U.S. Residence Prior to TB Diagnosis, California, 2005
Characteristics of Foreign-born Cases with TB Diagnosis Within 90 days of U.S. Arrival : Characteristics of Foreign-born Cases with TB Diagnosis Within 90 days of U.S. Arrival Less likely to:
be smear positive/cavitary
More likely to:
experience delays in treatment initiation
move prior to treatment completion
Have AIDS at time of diagnosis
Have INH resistance and MDR TB
Foreign-born Tuberculosis Cases with A/B-notification, California, 2004: Foreign-born Tuberculosis Cases with A/B-notification, California, 2004 Characteristic B-notification No B-not
Smear positive 19 (15%) 836 (39%)
Culture positive 88 (68%) 1318 (62%)
Drug resistance:
INH 17 (20%) 161 (12%)
RIF 8 (9%) 25 ( 2%)
MDR 7 (8%) 22 (1.7%)
h/o TB 22 (17%) 119 (6%)
Case-finding in Foreign-born: B-notification: Case-finding in Foreign-born: B-notification 3,489 B-notifications to California in 2004
( > 1/3 of US total)
3.5% have active TB on US evaluation
Among foreign-born cases diagnosed within a year of arrival, B-notification cases found earlier (3 months vs 5 months without B-notification)
Evaluation and treatment can reduce new TB cases by 6-23 / year.
A/B -notification Adverse Events Reported to CDHS, 7/04-4/06, n=61: A/B -notification Adverse Events Reported to CDHS, 7/04-4/06, n=61 Case adverse events:
AFB smear positive 25 (41%)
MDR TB 9 (15%)
Sub-optimal treatment 8 (13%)
Countries of origin:
Thailand (46%)
Vietnam (20%)
Philippines (15%)
India (8%)
Ethiopia (3%)
TB Cases Among Hmong Refugees in CA (n=28) June 2004- Dec 2005: TB Cases Among Hmong Refugees in CA (n=28) June 2004- Dec 2005
TB Status on US Entry: TB Status on US Entry Active TB*
TB infection
No TB infection
or disease
Indeterminate June 2004 - April 2006 25
3
1
1 (83%)
(10%)
(3%)
(3%) (n=30) * Active TB= TB diagnosis <60 days from U.S. entry
Factors Influencing Case Occurrence: Factors Influencing Case Occurrence Arrival 2/05
Screening limitation:
Children < 15 : no CXR + -
No culture for case detection + -
No TB condition assignment + -
Treatment gaps:
No culture at treatment start + +
Inadequate regimen, duration + +
Case management issues:
Lab delays + +
? DOT quality ? ?
? Case monitoring ? ?
No isolation + +
TB progression: + +
100% of MDR TB cases reported in 2005 in California occurred in individuals who were born outside the U.S.: 100% of MDR TB cases reported in 2005 in California occurred in individuals who were born outside the U.S.
Extensively Drug-resistant (XDR) TB: MDR TB Resistant to 3 Classes of Second Line Drugs : Extensively Drug-resistant (XDR) TB: MDR TB Resistant to 3 Classes of Second Line Drugs 13 of 74 in US reported in CA 1994-2003
4% of California’s MDR cases
30% diagnosed within 90 days of arrival
S. Korea (3), Philippines (3),Mexico (2), China (1) Mongolia (1)Nicaragua (1)
64% more likely to die than other MDR cases
Slide24: Tuberculosis, AIDS, and TB/AIDS Cases, California 1985-2004
Proportion of TB Cases with AIDS by Place of Birth, CA 1993-2004: Proportion of TB Cases with AIDS by Place of Birth, CA 1993-2004
Foreign-born HIV/TB Cases by Country of Origin, California, 1994-2004 (n=1440): Foreign-born HIV/TB Cases by Country of Origin, California, 1994-2004 (n=1440) Nation N % HIV/TB cases
Mexico 910 (63%)
Guatemala 76 (5%)
Philippines 76 (5%)
El Salvador 75 (5%)
Honduras 36 (2.5%)
Vietnam 25 (1.7%)
Ethiopia 19 (1.3%)
Cuba 16 (1.1%)
Other (nations with < 1% of total)
Is HIV testing of TB Patients Taking Place? Study of 4 Local TB Programs: Is HIV testing of TB Patients Taking Place? Study of 4 Local TB Programs 252 Charts reviewed
213 (85%) Patients Counseled
130 (52%) Testing Performed
65% of those tested returned for test results
Reasons for not testing*
HIV Status Known (24) Patient Refused (15)
No Risk Factors (4) No Reason Given (36)
Previous Negative Test (6)
Not offered testing or not counseled (107)
3/3 newly diagnosed HIV positive in Mexican-born
*Note: these are not mutually exclusive. All reasons for not testing were recorded.
TB Among the Mexican-born: TB Among the Mexican-born Among those diagnosed within 1 year of arrival, only 36% in diagnosed in first 3 months vs 56% other foreign-born
1% diagnosed within first year had B-notifications vs 55% in Asian Pacific Islanders
More likely to be smear positive and cavitary than other foreign-born cases
Task Order #3: Zero Tolerance for Pediatric Tuberculosis: Task Order #3: Zero Tolerance for Pediatric Tuberculosis Alameda and San Diego Counties
n= 61, 2002-2004
77% Hispanic; 7% foreign-born
72% with foreign-born parents
26% parents with history of TB
48% travel outside country
23% ingested raw milk
In San Diego, 69% had M.bovis
Slide30: Simulation of Case Count Resulting
From Increasing Imported TB and LTBI
Slide31: Interventions to reduce
global TB burden
Global TB Plan: Global TB Plan Stop TB partnership : 400 partners
TB/HIV
DOTS-plus for MDRTB;
research and development
Requires $56 billion; shortfall $31 billion
Global TB Plan: Global TB Plan 2010:
First new TB drug in 40 years will be introduced along with new diagnostic tests
2015
New short regimen 1-2 months by 2015.
New TB vaccine
Halving TB prevalence and deaths from 1990
50 million will be treated for TB: (800,000 with MDR and 3 million with TB/HIV)
2006-2015: 14 million lives will be saved!
International Standards: International Standards “Intended to facilitate effective engagement of all care providers in delivering high-quality care for patients of all ages and all forms of TB including drug-resistant TB and TB combined with HIV infection”.
17 standards for diagnosis, treatment and public health responsibilities
CSTE Recommendations 1/05: CSTE Recommendations 1/05 Expand overseas TB diagnosis and treatment programs
Evaluate for MDR and treat prior to US entry
Quality assessment of IOM providers
Fully fund EDN
Establish multi-agency group
2006 – CDC Immigration Requirements: Revised Technical Instructions for TB Screening and Treatment: 2006 – CDC Immigration Requirements: Revised Technical Instructions for TB Screening and Treatment Instructions for Panel Physicians
Applies to all “applicants” or immigrants applying for US immigration status and non-immigrants required to have an overseas medical examination
Lead Agency : Division of Global Migration and Quarantine, CDC
Adds culture and susceptibility testing to screening and full treatment for travel clearance
Enhancing TB Control in Thailand for U.S.- bound Individuals : Enhancing TB Control in Thailand for U.S.- bound Individuals CDC Thailand/IOM TB program evaluation: all MDR TB patients in WAT and current TB patients to assess practices and outcomes
CDC laboratory quality assessment
Global detection funds allocated to DGMQ to enhance Thailand case detection and laboratory services
Statewide Strategies to Address TB Control Among the Foreign-born: Statewide Strategies to Address TB Control Among the Foreign-born B-notification enhancements
EDN
Adverse events reporting
Understanding barriers to create targeted strategies:
TB Epi Studies Consortium
Collaboration with Refugee health:
Surveillance and evaluation
Health education and translation funds
HIV/TB:
Improving HIV C and T in collaboration with Office of AIDS
Statewide Strategies Cont’d: Statewide Strategies Cont’d Movement and treatment completion:
CURE –TB
ICE procedure: for continuity of care/deportation stay
Patient locating service
Outbreak assistance:
Emergency funds
Assistance with extended CIs, clusters, outbreaks
MDR TB
CDHS / Curry service
MDR TB Epi study (TBESC Task #8)
CDHS assessment of acquired drug resistance
Summary: TB Control Status: Summary: TB Control Status Large disparity in foreign-born and U.S. born TB case rates in CA
TB among new arrivals represents key case-finding opportunity
MDR TB and AIDS/TB dominated by foreign-born cases
Pediatric TB manifestation of foreign-born TB in CA
Summary: How Does Migration from Endemic Areas and Global TB California Influence TB Control?: Summary: How Does Migration from Endemic Areas and Global TB California Influence TB Control? CA thrives on migration especially from areas with endemic TB (East Asia and Mexico)
CA’s TB cases generated by importation of active TB, infection and transmission and reactivation in CA
Case count amplified by increases in imported TB, infection and MDR TB
Dependent on global solutions
Summary: How Can We Intervene?: Summary: How Can We Intervene? Identifying and preventing disease in newcomers is critical to success
Shorten time to diagnosis especially for those without overseas screening
Strengthen B-notification
Global partnership more critical than ever
Acknowledgements : Acknowledgements California Local TB Control Programs
California Department of Health Services,
TB Control Branch Jen Allen
Martin Cilnis
Melissa Ehman
Bill Elms
Rachel Jervis
Linda Johnson
Phil Lowenthal Elizabeth Lawton
Peter Oh
Sarah Royce
Gisela Schecter
Katya Salcedo
Sumi Sun
Special thanks to Travis Porco and Janice Westenhouse