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
Outline
• Is TB controlled?
• Who is involved in TB control?
• Where are the landmines?
• Way forward?
2
TB Case Trends
3
Tuberculosis Cases
California Population and
Tuberculosis Cases, 2001-2010
3,332
2,329
Population
40
39 Million
38
36
34
34 Million
32
30
4
2001
2010
Change in TB cases by race/ethnicity,
2001-2010
Race/ethnicity
White
Black
Hispanic
Asian
5
2001-2010
365  187
292  151
1252  874
1399  1109
% Change
-49
-48
-30
-20
TB Cases by Place of Birth
6
Place of Birth
2001-2010
U.S.- born
Foreign-born
824  498
2482 1802
% Change
-40
-27
Tuberculosis Cases in Foreign-born and
U.S.-born Persons by Race/Ethnicity:
California, 2010
5%
95%
25%
75%
7
64%
71%
36%
29%
Note: Excludes 29 cases with unknown race or birthplace
TB cases by age group
Age group
• 0-4
• 5-14
• 15-24
• 25-44
• 45-64
• 65+
8
2001-2010
133  55
92  45
318 215
1109 680
953 736
727 593
% Change
-59
-51
-32
-39
-23
-18
% Foreign-born
cases
Foreign-born with active TB within one year
of U.S. arrival, 2001-2010
9
Year
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
TB Case Characteristics
11
2010 Foreign-born TB Cases:
Immigration status
•
•
•
•
•
•
•
•
12
Immigrant
Refugee/asylee
Tourist
Student
Worker
Other*
Unknown**
* without above visa but not unknown
40%
5%
2%
2%
2%
16%
31%
45%
• ** patient does not know status on entry, refused response, or local
policy restricts response
TB cases among B notification arrivers with abnormal chest
radiograph on pre-immigration exam from Mexico, the
Philippines, or Vietnam, reported <6 months after U.S. arrival
6.0
4.2%
5.0
3000
4.0
2000
3.0
1.4%
1000
2.0
1.0
0
0.0
2006
2007
2008
B notification arrivals
13
2009
2010
(Jan-Jun)
% cases among arrivals
% arrivers reported as cases
B notification arrivers
4000
2010 TB Cases:
Comorbid conditions
480
145
83
17
14
(21%)
(6%)
(4%)
(.73%)
(.60%)
Diabetes
Immunosuppressed
End-stage renal disease
TNF Antagonist
Post-organ transplant
*Nearly 1/3 with co-morbidities;
does not include HIV
14
TB Diagnosis and Treatment
15
2010 TB Cases:
Reason for Presentation
Passive case-finding
• TB symptoms
1455
• Abnormal CXR*
396
• Incidental lab*
211
Active case-finding
• Contact investigation 84
• Immigration screening 78
• Targeted Testing
44
• Employee Screening 28
16
(63%)
(17%)
(9%)
(3.6%)
(3.4%)
(1.9%)
(1.2%)
*purpose of CXR or lab was for something other than TB
89%
Provider: TB diagnosis and treatment,
TB cases, California, 2008*
17
*Randomly selected TB patients; N=280.
Source: TBCB 2008 HIV status field study
What interventions are high
impact?
Diagnosis
• Rapid MTB and drug resistance tests
• HIV test of TB patients
Treatment
• Effective TB treatment
• HAART
18
Use of new diagnostics
2010 TB cases (n=2314)
• NAAT
892 (39%)
• IGRA
19
475 (22%)
HIV Status Determination is not Universal in CA
CDC standard is universal testing of all TB cases
20
Timing of HIV diagnosis (Dx) in HIVpositive TB patients, 2008
131 HIV co-infected TB patients
129
Alive at Diagnosis
64 (50%)
Previously known HIV +
65 (50%)
Newly diagnosed HIV +
44 (68%)
2 weeks prior – 2 weeks after TB Dx
21
Where was HIV test done for
HIV/TB co-infected patients?
• 67%
• 16%
• 17%
22
Hospital
Outpatient
Unknown
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
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
Time to Death for Patients Starting
Therapy, California 2008
25
Median time to death = 48 days
TB Deaths during Therapy, by
Provider Type, 1994-2009
20
18
Percent
16
14
12
10
Private Provider
Health Department
8
6
4
2
19
9
19 4
95
19
96
19
9
19 7
9
19 8
99
20
0
20 0
0
20 1
02
20
03
20
0
20 4
05
20
06
20
0
20 7
0
20 8
09
0
26
Year
Why are TB deaths occurring?
27
Is TB a contributor to Death?
Preliminary Results: Mortality Study TBESC
• In 75%, TB contributed to death !
28
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
Who are our cases?
• 40% of foreign-born underwent predeparture screening
• A sizeable fraction with comorbid
conditions
• Opportunity to prevent TB and
detect disease earlier
• TB deaths = compelling reason to
intervene
30
Navigating Landmines
31
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
Too busy killing alligators to drain
the swamp?
33
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 wellaccepted 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
Prevention:
Can we afford it?
Can we afford not to do it?
35
Horsburgh CR Jr, Rubin EJ. Clinical Practice: Latent Tuberculosis Infection in the United States.
NEJM 2011;364 (15):1441-8.
36
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
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%)
38
Source: Sterling et al. International Union Meeting, presented
November 2011
What is the Evidence?
Evaluation of individuals with B-notification
(abnormal CXR)
COST-SAVING
COST-EFFECTIVE
Percent of
active cases
3% and above
4% - 1.5%
Source: Porco et al. BMC Public Health 2006;6
39
Case Prevention
Should we prioritize LTBI treatment for
arrivers with B-notification of TB2 and TB4?
40
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
What Strategic Direction is Under
Consideration?
• Adopt cost-effective diagnostic and
treatment approaches
• Abandon ineffective unproven approaches
• Tackle case prevention as cases decline
42
Hot Off the Press
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
43