Multidrug-resistant Tuberculosis Epidemiology · 2020-03-24 · Multidrug-resistant Tuberculosis Epidemiology Pennan Barry, MD, MPH ... Burma Guatemala Nepal Dominican Republic Laos.

Multidrug-resistant Tuberculosis

Epidemiology

Pennan Barry, MD, MPH

California MDR TB Consult Service

Surveillance and Epidemiology Section

Curry International Tuberculosis Center

December 2019

• Describe the national and global epidemiology of MDR TB

• Recognize who is at higher risk for MDR TB

Objectives

1

Terminology

• Mono-resistant: resistant to only one drug

• Multidrug-resistant (MDR): resistant to at least INH and RIF

• Pre-extensively drug-resistant (Pre-XDR): MDR plus resistance to fluoroquinolone (FQ) or a second-line injectable (Amikacin, Kanamycin, or Capreomycin)

• Extensively drug-resistant (XDR): MDR-TB plus resistance to a FQ and at least one second line injectable

Global MDR Burden

• 2018 Estimate: 484,000 incident cases

– 50% from India, China, and Russia

• Surveillance by country and region

– 2018: Data from 85% (164/194) of countries since 1994

– Continuous surveillance (105) vs epidemiological surveys (59)

3WHO Global Tuberculosis Report, 2019

4WHO, Global Tuberculosis Report, 2019

Percentage of New Cases with MDR TBOverall: 3.4%

5

Percent of Previously Treated Cases with MDR-TBOverall: 18%

WHO, Global Tuberculosis Report, 2019

6

Primary Anti-TB Drug Resistance, United States, 1993–2018*

*As of June 6, 2019 Note: Based on initial isolates from persons with no prior history of TB; multidrug-resistant TB (MDR TB) is defined as resistance to at least isoniazid and rifampin.

0

1

2

3

4

5

6

7

8

9

10

1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017

Isoniazid MDR TB

Re

sist

ant

(%)

Year

7

Cases of MDR TB by History of TB, United States, 1993–2018*

* As of June 6, 2019. Based on initial isolates from persons with no prior history of TB; multidrug-resistant TB (MDR TB) is defined as resistance to at least isoniazid and rifampin

Who is at higher risk for MDR-TB?

• History of previous TB treatment, particularly if recent

• Known exposure to MDR-TB case

• HIV (+)

Higher incidence of Rifampin mono resistance

• Poor response to standard 4-drug treatment

Culture remains (+) after 2 months treatment

Proportion MDR varies by birthplaceCalifornia, 2011-2018

Credit: Julian Boyce

Proportion MDR varies by birthplaceCalifornia, 2011-2018

Credit: Julian Boyce 2%

Number and Proportion MDR TB by

Country/Region of Origin, CA 2014–2018

11

Country/Region No. %PPV

(99% spec)PPV

(98% spec)

Former Soviet Republics 6 14.0 94% 89%

Philippines 32 2.0 66% 50%

Vietnam 16 1.8 64% 47%

United States 13 0.9 46% 30%

Mexico 8 0.4 28% 16%

Credit: Julian Boyce

MDR more common <4 years after US arrivalCalifornia, 2011-2018

MDR

Not MDR

4y

MDR-TB Cases by Country/Region of Origin

and Years in the US, CA 2014–2018

Country/Region

TotalMDR TB

cases

≤ 4 years in US

No. (%)>4 years in US

No. (%)

All Countries (excl U.S.)

106 48 (3.6) 56 (1.1)

13

Who is at higher risk for MDR-TB?

• NonUS-born arrived in U.S. within last 4 years• Immigration from or recent extended travel to country with > 2%

MDR among cases from that country diagnosed in California/U.S.• These countries* are:

• Other state or locally identified risk groups, including:– Hmong refugees– Persons of Tibetan origin

*California data from 2014-2018 and U.S. data from 2013-2017

† Current U.S. data are available from the CDC, Division of TB Elimination (DTBE) (www.cdc.gov/tb) 14

India Peru Ethiopia, Eritrea Former Soviet states

Korea Ecuador Nigeria Mongolia

Burma Guatemala Nepal Dominican Republic

Laos

Order rapid molecular test for resistance

for patients with MDR risk!

Among 42 smear positive MDR cases with MDR risk, 20 did not get Xpert or pyrosequencing on sputum (California, 2012-2016)

15Lowenthal, Clin Inf Dis 2019 DOI: 10.1093/cid/ciy937

Acknowledgments

• Lisa True

• Lisa Chen

• Neha Shah

• Grace Lin

• Gisela Schecter

• Janice Westenhouse

• Marya Husary

• Julian Boyce

• Adam Readhead

16pennan.barry@cdph.ca.gov

Pennan Barry(MD)

Kristen Wendorf

(MD)

MaryaHusary(Project

Specialist)

Lisa True(RN)

Phil Lowenthal

(epi)

Shereen Katrak

(MD)

Neha Shah

(MD, ret.)

Leslie Henry

(RN)

Not pictured: Chris Keh, MD