Tuberculosis (TB) Update National IMAC workshop Sept 2018 · 2018-11-22 · Tuberculosis (TB) Update National IMAC workshop Sept 2018 ... • Burden of MDR TB • Burden of HIV co

Auckland Regional Public Health Service Rātonga Hauora ā Iwi o Tamaki Makaurau

Working with the people of Auckland, Waitemata and Counties Manukau

Tuberculosis (TB) Update National IMAC workshop

Sept 2018

Dr Lavinia PerumalPublic Health Medicine Specialist

Medical Officer of Health- TB Portfolio Lead

www.arphs.govt.nz @aklpublichealthTB Update : National IMAC Workshop September 2018Dr Lavinia Perumal, PHMS, MOH, ARPHS

Take Home messages

• A brief history of TB• TB / LTBI• ARPHS role in TB control• Epidemiology on TB Disease

– global/national• NZ trends

– Population profiles– Risk profiles– Emerging trends

The TB Story – the people, the communities

• Patient A– Frail 93 year old Cantonese

speaking lady. 38 kg.– 1/12 hx back pain– CXR - Right pleural effusion.– Sputum 4+ AFB, PCR Mtb +ve– Anti TB meds and isolation– ARF. Hypothermic,

bradycardic, hypotensive– Died 14 days post admission

• Patient B– 20 year old Somali male.

Student. Born in NZ.100kg– HH contact of a pulmn TB– CXR - mediastinal widening. – CT Chest - necrotic nodes– Developed cough - sputum

AFB –ve, Culture positive– On treatment- well tolerated-

managed in the community

IS TB still relevant today?

Global movement

End TB Strategy 2014: 3 Pillars

• Pillar 1: integrated patient-centred care and prevention

• Pillar 2: bold policies and supportive systems

• Pillar 3: intensified research and innovation.

End TB Strategy :Pillars 2 and 3

History of tuberculosis• 460 BC: ‘Phthisis’;

– Hippocrates (hereditary) vs. Aristotle (contagion)

• Middle Ages: ‘scrofula’– lymph node disease – England and France - ‘king’s evil’

• 18th C: ‘consumption– 25% of all deaths in Europe. Urban

centres. High fatality• 1882: ‘infectious disease’

– M.tb bacillus isolated (R Koch). Won the 1905 Nobel Prize in Medicine.

– 1/7 died from TB in USA and Europe

• 19th C: Sanatoria – Isolation + improv hygiene, rates

decreasing

• 1921: BCG vaccine • 1946: Streptomycin- First effective

antibiotic: became resistant due to monotherapy

• 1952: Isoniazid - originally an antidepressant

• 1980s: Increase in rates- HIV/AIDS• 1990s to now: MDR TB and global

movement/migration

The Bug: Mycobacterium tuberculosis

• Rod shaped, slow growing• Cell wall is very acidic,

absorbs a dye used in staining slides for microscopy and the red colour cannot be removed -acid fast baccilli (AFB)

The disease: Tuberculosis

Symptoms Signs

• Cough, Shortness of Breath• Night sweats• Chills/Fevers• Loss of appetite• Lethargy• Weight loss• Confusion/delirium

• Pneumonia:– Consolidation on CXR– Crackles on auscultation

• Enlarged lymph nodes• Swollen joints• Blood in sputum

TBD vs. LTBI• Active vs. sleeping• Symptoms vs.

asymptomatic• Infectious vs. non

infectious• Testing- blood

tests/cultures/imaging/skin tests

• Both treatable• 1 in 10 LTBI→TBD (lifetime)

• RF: Immunosupressed, elderly, HIV, Diabetes, alcoholism, hepatitis

Why does TB matter

• Leading cause of death and disability– TB leading cause of death from single

infectious agent– Global data, 2016:

• 10.4 million cases (1 million children)• 253,000 children died (i.e. 1 in 4)

• Can affect anyone, any body part• Infectious: Aerosolised transmission• LTBI - 1 in 10 lifetime risk of

developing active disease– Immunosuppression: HIV, DM, elderly

• TB incidence and estimated case numbers

• Burden of MDR TB

• Burden of HIV co infection

Global Tuberculosis epidemiology

MDR TB- A global challenge

• 1 in 5 new TB case in European region had MDR TB, 2016.

• Every 5th MDR TB in the world is in Europe

TB/HIV Co Epidemic (Double Trouble)• 2014: 1.2 million (12%) TB

cases were also HIV positive• 25% of all TB deaths are HIV-

associated• TB accounts for 33% of all

HIV/AIDS deaths• Need better coverage of ART,

CPT, IPT• In Europe, 1 in 8 new TB cases

notified were HIV positive (2016)- unprecedented rise-260% increase in 10 years

Global TB pressures

• Funding gap

• MDR-TB detection and treatment gap

• TB and HIV co-epidemics

• Diabetes, other diseases, smoking

• Lack of laboratory capacity

Tuberculosis epidemiology in New Zealand

• TB incidence in New Zealand

• Epidemiology of TB cases notified in past 10 years born in NZ

• Epidemiology of TB cases notified in past 10 years born outside of NZ

TB in NZ• + 250-300 TB cases annually

• Auckland – 1/3rd of population, 1/2 of TB cases

• 80% born overseas

• NZ born , overseas born –migration

• TB notification rate fairly static since 2007

• Transmission within NZ: declining trend

TB disease notification rates, 1980-2017

TB screening introduced for international students staying over 6 months at the end of 2004

Graph courtesy of Liza Lopez, ESR, Sept 2018

TB disease cases, born in NZ or overseas 2008-2017

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

ificat

Born out of NZ Born in NZ % born out of NZ

TB cases born in NZ by ethnicity and DHB, 2008-2017

Māori Pacific Peoples Asian MELAA European or Other

TB cases born in NZ by age group and ethnicity

<1 1-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70+

Age group

2008-2012

<1 1-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70+

Age group

2013-2017

TB cases by birth region, 2008-2017

Australia PacificIslands

NAfrica SSAfrica NEAsia SEAsia SCAsia Europe Americas

Birth RegionGraph courtesy of Liza Lopez, ESR, Sept 2018

TB notification rate by birth region, 2008-2017

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Pacific Islands SSAfrica NEAsia SEAsia SCAsia

South & Central Asia by age group and years since arrival 2008-2017

<1 yr 1-5 yrs 6-10 yrs >11+ yrs

Years since arrival 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70+

Tuberculosis – Auckland Region

• ARPHS Role in TB Control

• Regional Surveilance data on TB

Auckland Regional Public Health: TB Prevention and Control

• Case management – Health Act , Multidisciplinary

team– Surveillance – Direct Lab Notifications– Liaison– Successful treatment: DOT/

education, support and care – Advocacy

• Contact tracing and investigation – Identification and screening– targeted LTBI treatment

• BCG vaccination– targeted for at risk children

Pillar one of End TB Strategy

TB in Auckland

• Auckland has a third of NZ’s population, but has half of NZ’s TB cases annually

• Reflects Auckland’s diverse demography and migration trends/countries of origin of migrants

• Up to 90-95% of TB cases in Auckland are overseas-born

• Most MDR-TB cases that occur are in Auckland

ARPHS Weekly TB Surveillance

ARPHS Surveillance Team12 September, 2018

Auckland Region: TB Disease summary of cases

Current / Future Developments

• Reintroduction of Auckland BCG Programme after national absence for two years – restarted July 2018

• Updated NZ Guidelines on TB Case and Contact Management 2018- Draft for external consultation Aug 2018…..

• Australasian TB Conference in Wellington August 2018

• Whole Genome Sequencing (LabPlus)- quicker outbreak recognition, drug sensitivity testing, resistance identification

• TeleDOT access- already in Auckland

• Latent TB Infection Screening and Treatment-NZ guidance and leadership

Acknowledgments

• ESR – Liza Lopez, Helen Heffernan, Jill Sherwood• ARPHS- Surveillance team• WHO TB Reports

Tuberculosis (TB) Update National IMAC workshop Sept 2018 · 2018-11-22 · Tuberculosis (TB) Update National IMAC workshop Sept 2018 ... • Burden of MDR TB • Burden of HIV co

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