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TB in the United States, with a focus on the foreign-born population : 

TB in the United States, with a focus on the foreign-born population Andrew Vernon, MD, MHS Chief, Clinical & Health Systems Research Branch Division of TB Elimination/NCHSTP April 2005

Contents of Presentation: 

Contents of Presentation Overview of TB surveillance data Foreign born population in the U.S. TB in the foreign-born Examples relevant to U.S. efforts to control and eliminate TB in the foreign-born

Overview of National TB Surveillance System: 

Overview of National TB Surveillance System Data reported from 59 reporting areas 50 states D.C. and New York City Puerto Rico 6 jurisdictions in Pacific and Caribbean

Overview of National TB Surveillance System: 

Overview of National TB Surveillance System Data reported on 3-part RVCT form Patient demographics and lab results Drug susceptibility results Treatment outcome Transferred electronically to CDC via TIMS

U.S. TB Case Definition: 

U.S. TB Case Definition Incident cases, active disease Three alternatives: 1. Bacteriological confirmation (~81%) ~80% culture confirmed 2. Clinical evidence (~12%) 3. “provider diagnosis” ( ~7%)

TB Morbidity United States, 2000-2004: 

TB Morbidity United States, 2000-2004 Year Cases Rate* 2000 16,377 5.8 2001 15,989 5.6 2002 15,075 5.2 2003 14,874 5.1 2004† 14,511 4.9 *Cases per 100,000 † provisionall

Reported TB Cases United States, 1982-2003: 

Reported TB Cases United States, 1982-2003 Year 1983 1987 1991 1995 1999 2003 No. of Cases 12,000 16,000 20,000 24,000 28,000

TB Case Rates,* United States, 2003: 

TB Case Rates,* United States, 2003 < 3.5 (year 2000 target) 3.6 - 5.1 > 5.1 (national average) D.C. *Cases per 100,000

Reported TB Cases by Age Group United States, 2003: 

Reported TB Cases by Age Group United States, 2003 25 - 44 yrs (34%) <15 yrs (6%) 15 - 24 yrs (11%) 45 - 64 yrs (29%) 65+ yrs (20%)

TB Case Rates* by Age Group and Sex, United States, 2003: 

TB Case Rates* by Age Group and Sex, United States, 2003 Cases per 100,000 *Cases per 100,000.

Reported TB Cases by Race/Ethnicity* United States, 2003: 

Reported TB Cases by Race/Ethnicity* United States, 2003 Hispanic or Latino (28%) Black or African American (28%) Asian (23%) White (19%) American Indian or Alaska Native (1%) Native Hawaiian or Other Pacific Islander (1%) *All races are non-Hispanic. Persons reporting two or more races comprised less than 1% of all cases.

TB Case Rates* by Race/Ethnicity** United States, 1993-2003: 

TB Case Rates* by Race/Ethnicity** United States, 1993-2003 Cases per 100,000 *Cases per 100,000. **All races are non-Hispanic. In 2003, Asian/Pacific Islander category includes persons who reported race as Asian only and/or Native Hawaiian or Other Pacific Islander only.

Estimated HIV Coinfection in Persons Reported with TB, United States, 1993-2002: 

Estimated HIV Coinfection in Persons Reported with TB, United States, 1993-2002 % Coinfection Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group.

Primary MDR TB United States, 1993-2003: 

Primary MDR TB United States, 1993-2003

Mode of Treatment Administration in Persons Reported with TB United States, 1993-2001: 

Mode of Treatment Administration in Persons Reported with TB United States, 1993-2001 Directly observed therapy (DOT); Self-administered therapy (SA)

Completion of TB Therapy United States, 1993-2001: 

Completion of TB Therapy United States, 1993-2001 *Healthy People 2010 target: 90% completed in 1 yr or less. Note: EXCLUDES persons with initial isolate resistant to rifampin, children < 15 years old, and meningeal, bone or joint, or miliary TB. Percentage *

Concepts and Terminology: 

Concepts and Terminology Foreign Born and Immigrant Foreign Born – Anyone who is not a U.S. citizen at birth, including immigrants, legal nonimmigrants (temporary migrants), humanitarian migrants, and people illegally present in the United States. Immigrant – Aliens admitted to the U.S. for lawful permanent residence, as defined in the Immigration & Nationality Act.

National Quick Facts: 2000: 

National Quick Facts: 2000 Source: 1990 Census and Census 2000

Percent Foreign Born by World Region of Birth: 2002: 

Percent Foreign Born by World Region of Birth: 2002 Source: American Community Survey 2002

Percent Foreign Born Within Each State: 2000: 

Percent Foreign Born Within Each State: 2000 Source: Census 2000 Prepared with American FactFinder

Top Five States with the Highest Foreign-Born Population and Highest Rate of Change: 2000: 

Top Five States with the Highest Foreign-Born Population and Highest Rate of Change: 2000 Highest Number of Foreign Born 2000 Number Highest Percent Change 1990-2000 Percent Source: U.S. Census Bureau, Census 2000

Age Distribution by Sex for the Native and Foreign-Born Populations: 2002 : 

Age Distribution by Sex for the Native and Foreign-Born Populations: 2002 Source: Current Population Survey, (2002) Annual Social and Economic Supplement Native Foreign Born Age Male Female Male Female

Percent of Foreign Born Naturalized by Year of Entry: 2002 (In Percent): 

Percent of Foreign Born Naturalized by Year of Entry: 2002 (In Percent) Source: Current Population Survey, (2002) Annual Social and Economic Supplement

Percent of Population with Less Than 9th Grade Completed by Place of Birth: 2002 (Population 25 years and over): 

Percent of Population with Less Than 9th Grade Completed by Place of Birth: 2002 (Population 25 years and over) Source: Current Population Survey, (2002) Annual Social and Economic Supplement Foreign Born

Language Spoken at Home for the Foreign Born: 2002 (Population 5 years and over): 

Language Spoken at Home for the Foreign Born: 2002 (Population 5 years and over) Source: American Community Survey 2002

Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, 1993-2003: 

Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, 1993-2003 No. of Cases

Percentage of TB Cases Among Foreign-born Persons, United States: 

Percentage of TB Cases Among Foreign-born Persons, United States >50% 25% - 49% <25% 1993 2003 DC DC

The gap in TB rates between foreign- born and U.S.- born persons is widening: 

The gap in TB rates between foreign- born and U.S.- born persons is widening Rates Rate ratios 1992 2002 1992 2002 Foreign-born 34.5 23.6 U.S.-born 8.2 2.8 4.2 8.4

Percent Foreign-born TB Cases, United States, 2004*: 

Percent Foreign-born TB Cases, United States, 2004* D.C. *Percent foreign-born cases over total cases 57% – 66% ≥ 67% 41% - 56% (%foreign-born for U.S.= 53.7%) 26% - 40% ≤ 25%

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Percent Foreign-born TB Cases, United States, 2004* D.C. *Percent foreign-born cases over total cases 57% – 66% ≥ 67% 41% - 56% (%foreign-born for U.S.= 53.7%) 26% - 40% ≤ 25% Percent Foreign Born Within Each State: 2000 Source: Census 2000 Prepared with American FactFinder

Countries of Birth for Foreign-born Persons Reported with TB United States, 2003: 

Countries of Birth for Foreign-born Persons Reported with TB United States, 2003 Mexico [33] (26%) Philippines [320] (12%) Viet Nam [189] (8%) India [168] (8%) China [113] (5%) Haiti [319] (3%) S. Korea [91] (2%) Other Countries (36%) Incidence per 100,000 shown in brackets

Length of U.S. Residence Prior to TB Diagnosis, United States, 2003: 

Length of U.S. Residence Prior to TB Diagnosis, United States, 2003

Primary MDR TB in U.S.-born vs. Foreign-born Persons, United States, 1993-2003: 

Primary MDR TB in U.S.-born vs. Foreign-born Persons, United States, 1993-2003 % Resistant Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.

US-Born: 

US-Born Disproportionately affects minorities Elderly Homeless Substance abuse HIV co-infection Access to care

Foreign-Born: 

Foreign-Born Culture Language Western medical approach Stigma Access to care Fear of deportation

“Ending Neglect” Challenges: 

“Ending Neglect” Challenges Maintain TB control – focus on Foreign-born Overseas screening and stateside notification Speed TB decline – Identify and treat latent infection (LTBI) Develop new tools Tests (LTBI), drugs, vaccine Increase U.S. role in global elimination Mobilize support and measure progress

Estimated Migrants “Entering” U.S. : 

Source: U.S. Department of Homeland Security, 2003 (2002 data) Status adjusters in U.S.: 679,305 Immigrants and refugees 411,266 Undocumented migrants ~ 275,000 ???? Non-immigrant visas 27,907,139 N= ~ 59,000,00000 Visitors without visas ~ 30,000,000 Estimated Migrants “Entering” U.S.

Foreign-born (FB) Persons Screened for TB Before U.S. “Entry”: 

Foreign-born (FB) Persons Screened for TB Before U.S. “Entry” * CXR, chest radiograph; TST, tuberculin skin testing **2001: 68,925 Source: U.S. Department of Homeland Security, 2003 (2002 data)

Foreign-born Persons not Screened for TB before U.S. "Entry”: 

Foreign-born Persons not Screened for TB before U.S. "Entry” Visitors not requiring visas: ~30, 000,000 Non-Immigrant Visas: 27,907,139 Temporary Visitors 24,344,216 Temporary Workers/family 722,424 Students/family 687,506 Transit Aliens 614,934 Treaty traders 171,368 Foreign government officials 140,898 Other 1,225,793 Undocumented visitors: ??? Source: U.S. Department of Homeland Security, 2003 (2002 data)

Opportunities for TB Prevention in Foreign-born Persons in U.S.: 

Opportunities for TB Prevention in Foreign-born Persons in U.S.

Slide43: 

Bureau of Customs and Border Protection BCBP is one of three components in the Border and Transportation Security Directorate….(it is) responsible for enforcing customs and immigration laws at and between the 307 ports of entry. Approximately 30,000 inspectors from the Customs Service, INS and the Plant Protection and Quarantine (PPQ) Bureau of Agriculture work together under the new bureau.  The Border Patrol, from INS is also part of BCBP.

Objectives of Overseas TB Screening: 

Objectives of Overseas TB Screening Restrict travel/entry of persons with infectious TB Class A TB (AFB-smear positive) Identify persons with suspect TB requiring follow-up stateside evaluation, and notify receiving jurisdictions of US arrival

Process Overview: 

Process Overview Overseas Medical Exam Classification US Admissions Visa Domestic notification Follow-up by Local TB Program

Overseas TB Screening Process: 

Overseas TB Screening Process Chest radiograph > 15 years old Active TB AFB sputum smears (3) Inactive TB No TB Infectious TB Class A Noninfectious active TB Class B1 All (-) (at least one +) Class B2

TB Notification in the US: 

TB Notification in the US Generated by the CDC Quarantine Stations Mailed to health departments Follow-up evaluation Submit follow-up to CDC

TB Classifications for Refugees and Immigrants, IMP, FY 2003 : 

TB Classifications for Refugees and Immigrants, IMP, FY 2003 * Class B1 TB: 3 - 14% active TB in US; Class B2 TB: 0.4 - 3.8% active TB in US (Binkin, et al. CID 1996)

Overseas TB Class, Notifications, and Outcome, IMP, CY 2003 : 

Overseas TB Class, Notifications, and Outcome, IMP, CY 2003 B1 rate of smear+ TB = 62/1637 = 3,787/100,000 B2 rate of smear+ TB = 24/ 847 = 2,834/100,000

Median Time Intervals for Migrants with Suspect TB and Subsequent AFB Positive Smears, IMP, CY 2003 : 

Median Time Intervals for Migrants with Suspect TB and Subsequent AFB Positive Smears, IMP, CY 2003

Current Challenges and Opportunities : 

Current Challenges and Opportunities Quality assurance of overseas TB screening Limitations of screening algorithm Sensitivity and specificity Diagnostic tools Local resources Timely state-side notification, follow-up, and interventions Expansion of scope and underlying objectives

Two examples: Foreign-born TB and the national effort to eliminate TB : 

Two examples: Foreign-born TB and the national effort to eliminate TB

1. US-Mexico Binational Tuberculosis Referral and Case Management Project: 

1. US-Mexico Binational Tuberculosis Referral and Case Management Project

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Baja California Norte Chihuahua Sonora Nuevo Leon Tamaulipas Coahuila de Zaragoza California (CA) Arizona (AZ) Texas (TX) New Mexico (NM) * 2000 Data

Goals of the US-Mexico Binational TB Referral and Case Management Project: 

Goals of the US-Mexico Binational TB Referral and Case Management Project Ensure continuity of care and completion of therapy Reduce TB incidence and prevent drug resistance Coordinate referral of patients between health systems Provide model for other diseases

Slide56: 

Unique identification number Location where card was issued Treatment initiation date Date of last dose TB treatment Treatment regimen DOT (yes/no) Bilingual Toll-free telephone numbers in the US and Mexico Binational Health Card – Data Elements

TB Patients - Eligibility : 

TB Patients - Eligibility US Active TB Mexico-born, and/or Mexico-bound, such as: Recently arrived to the US from MX Migrant worker Close or immediate family lives in MX Works in the US and lives in MX Lives in the US and receives medical care in MX Suspect TB ICE Detention Centers Mexico Active TB

Pilot Sites: 

Pilot Sites US-Mexico border sister cities/states San Diego, CA – Tijuana, BC El Paso, TX/Las Cruces, NM - Ciudad Juarez, CHIH Webb/Cameron Counties, TX – Matamoros, TAMAU Arizona – Sonora INS / ICE Detention Centers Texas, California, Arizona Mexican states Coahuila, Nuevo Leon US States Tennessee, Washington, Illinois

Data Flow/Management: 

Data Flow/Management ACTION Registers patient Educates/issues card Notifies Referral System when patient MOVES Registers patient Notifies TB provider in destination location Reports final outcome to both US/MX Notifies Referral System on other side of border Provides information US-MEXICO BORDER

Card Distribution: 

Card Distribution As of December 31, 2004: US Pilot Sites (n=488) Mexico Pilot Sites (n=793)

Project Partners: 

Project Partners National TB Program of Mexico Mexican Ministry of Health Mexican National Center for Epidemiological Surveillance National Institute of Diagnostic and Epidemiological Laboratory Centers for Disease Control and Prevention US-Mexico Border Health Commission California Department of Health Services San Diego County Health and Human Services Agency and its CureTB program Texas Department of Health, TB Elimination Division El Paso City-County Health Department Migrant Clinicians Network and its TBNet program The Binational TB Prevention and Control Project, “JUNTOS” La Fe Community Health Center Institute of Health Services of Baja California State of New Mexico Department of Health Secretary of Health of Chihuahua, Tamaulipas, Sonora, Coahuila. Nuevo Leon Secretary of Health of Jalisco, Michoacan, Vera Cruz, Oaxaca Ciudad Juarez Secretary of Health US Agency for International Development (USAID) US Department of Health and Human Services (HHS) US Department of Homeland Security US Department of Health Resources and Services Administration (HRSA) US Department of Immigration and Naturalization Services (INS)/ICE Ten Against TB American Lung Association American Lung Association of Texas (ALAT) Pan American Health Organization (PAHO)

Project Summary: 

Project Summary Responds to identified TB needs in the region Has become an integral part of TB management in ICE detention centers Strong political commitment exists at the national, state, and local levels Represents a model for consensus for binational collaboration Should lead to improved treatment outcomes Should provide model for other similar settings or for other diseases in this setting

Challenges: 

Challenges Notification/ referral information flow between and within countries not completely functional Database management challenging Remains difficult to obtain treatment outcome status of patients who have moved Budget needs

2. Drug-sensitive and Multidrug-resistant Tuberculosis Among U.S.-bound Hmong Refugees: 

2. Drug-sensitive and Multidrug-resistant Tuberculosis Among U.S.-bound Hmong Refugees

Hmong Refugees, Thailand , 2004-2005: 

Hmong Refugees, Thailand , 2004-2005 Historically persecuted Fled Laos to Thailand >20 years ago First wave of U.S. resettlement > 10 years ago Wat Tham Krabok, 2004 Urgent U.S. resettlement ~ 15, 000 refugees 52% < 15 years old Anticipated high TB rates Enhanced TB diagnosis and treatment

Timeline of Overseas Screening and U.S. Resettlement, Hmong Refugees, 2004-2005: 

Movement to US, CDC Enhanced TB Screening Rec #1 Standard overseas TB screening started Timeline of Overseas Screening and U.S. Resettlement, Hmong Refugees, 2004-2005 Overseas & U.S.-based investigations CDC Enhanced TB Screening Rec #2 June 2004-January 2005 4 MDR-TB cases overseas; 6 active TB cases in US (2 MDR-TB) Additional overseas data: 17 MDR-TB Movement halted

Hmong Refugees Preliminary Data* (1) Overseas TB Screening : 

Hmong Refugees Preliminary Data* (1) Overseas TB Screening Total Population 15,645 (7,499 > 15 years [48%]) Arrived in U.S. : 9,455 Still in Thailand: 6,190 Majority adults underwent initial overseas screening Thailand ~424 with overseas TB classification ~351 with TB cultures performed 56 positive TB culture results 17 MDR TB (30%) 184 negative TB culture results 111 culture results pending *As of February 5, 2005

Hmong Refugees Preliminary Data* (2) Overseas TB Screening : 

Hmong Refugees Preliminary Data* (2) Overseas TB Screening Thailand 247 active cases 175 on treatment Estimated rates among adults Active: 3,294/100,000 (247/7,499) MDR: 227/100,000 (17/7,499) *As of February 5, 2005

Top Five States of U.S. Arrivals, Hmong Refugees, June-January 2005: 

Top Five States of U.S. Arrivals, Hmong Refugees, June-January 2005 * Resettled to 22 other states

Overseas Classifications, Hmong Refugees, March 2004 – Feb 2005: 

Overseas Classifications, Hmong Refugees, March 2004 – Feb 2005 *One with HIV infection

Hmong Refugees Preliminary Data* U.S. Stateside Reporting : 

Hmong Refugees Preliminary Data* U.S. Stateside Reporting 36 verified TB cases in Hmong refugees 29 from CA, 5 from WI, 1 from MN, 1 from OH At least 4 MDR-TB 21/36 (58%) adults 8/21 (38% ) with overseas TB classification 15/36 (42%) in children < 15 years *As of April 7, 2005

Slide72: 

Relative Risk of TB Each Year After Initial Infection1 1. Sutherland I. KNCV 1968

Slide73: 

National TB Genotyping and Surveillance Network, 1996-2000

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Summary Points Future burden of TB in the U.S. will be increasingly driven by patterns of immigration Other factors that will effect future TB burden: Hard-to-reach/poor/disenfranchised persons

Slide75: 

With assistance of: Thomas Navin, MD Surv. Epid. Outbreak Inv. Br., DTBE Kayla Laserson, PhD Internat. Prog. & Res. Br., DTBE Susan A. Maloney, MD, MHSc Div Global Migration and Quarantine Zachary Taylor, MD Field Svcs. & Eval. Br., DTBE

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I was gratified to be able to answer promptly. I said I didn’t know. Mark Twain -- Questions --

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