+ Tuberculosis In the United States and China Samantha Phillips Northern Arizona University.

+

TuberculosisIn the United States and China

Samantha PhillipsNorthern Arizona University

+Overview

Tuberculosis is a major global health problem. In 2013, 9 million people fell ill with TB and 1.5 million died from the disease (CDC, 2014).

Tuberculosis (TB) is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent (CDC, 2014).

Over 95% of TB deaths occur in low- and middle-income countries, and it is among the top 5 causes of death for women aged 15 to 44 (CDC, 2014).

+About TB

Tuberculosis, also known as TB, is a bacterial infection caused by Mycobacterium tuberculosis.

Tuberculosis usually affects the lungs and is known as pulmonary Tuberculosis, but may also spread to the musculoskeletal, lymphatic, cardiovascular, neurological, gastrointestinal, or genitourinary systems and is known as extra pulmonary Tuberculosis.

Tuberculosis is also increasing drug resistance, and increased rate of infection in populations with decreased immune functions, for example, infected HIV individuals.

Figure 1. Tuberculosis bacteria (WebMD, 2014)

+Disease Condition SpecificsStage of Susceptibility

Tuberculosis is most commonly transmitted from a person with infectious pulmonary TB to others by droplet nuclei, which are transmitted through the air by coughing, sneezing, or speaking (Dye & Floyd, 2006).

Increases Risk of TB

Poor nutrition

crowded living conditions,

individuals with weakened immune systems

being homeless

Stage of Presymptomatic

In primary TB, the disease shows no outwards signs of the disease, but the damage is occurring in the body, and can only be detected through testing.

After primary infection, 90% of individuals with intact immunity control further replication of bacilli, which may then enter a latent phase (Gardam & Hota, 2012).

Tuberculosis occurs in humans with the inhaling droplets of bacteria that reach the alveoli. In the alveoli macrophages phagocytize the bacilli, if the bacilli are successful in arresting phagosome maturation. Then replication begins and the macrophage eventually ruptures and releases its bacillary contents (Gardam & Hota, 2012).

+Disease Condition Specifics Con’tStage of Clinical Disease

The symptoms of active TB are often vague and nonspecific.

Symptoms typically reported for weeks to months prior to being diagnosed.

Constitutional symptoms such as weight loss, fatigue, fever, night sweats, and rigors tend to be more common with pulmonary and pleural disease, together with a worsening productive cough, eventually cough is present in up to 90% of cases (Gardam & Hota, 2012).

Stage of recovery, disability, or death.

Prognosis is good if known effective treatment is started quickly.

About one-third of patients died within one year of diagnosis, and more than 50% died within five years (Raviglione and O'Brien, 2012).

With effective, timely, and proper chemotherapy, patients have a very high chance of being cured.

Improper use of anti-TB drugs, while reducing mortality rates, may also result in a large number of chronic infection and drug-resistant bacilli (Raviglione and O'Brien, 2012).

+Data & Measures

Incident Rate Worldwide past Ten Years

Since 2001, the incidence rates of TB have started to decline

8.8 million new TB cases in 2003 (Dye & Floyd, 2006)

In 2012, there was an estimated 8.6 million incident cases of TB globally, equivalent to 122 cases per 100,00 population (World Health Organization, 2013).

Prevalence Rate Worldwide

Despite downward trends in TB prevalence rates since 2000, the number of people living with TB worldwide increased from around 8.5 million in 1990 to about 12 million in 2013 (Murray et al., 2014).

There were an estimated 12 million prevalent cases of TB in 2012, which is equal to 169 cases per 100,00 population (World Health Organization, 2013).

By 2012, the prevalence rate had fallen 37% globally since 1990 (World Health Organization, 2013).

Figure 2. Worldwide TB Incidence (WHO,2013) Figure 3. Worldwide Prevalence (WHO, 2013)

+Data & Measures Con’t

Mortality Rate Worldwide

Globally, mortality rates have fallen 45% since 1990 (World Health Organization, 2013).

Worldwide around 1.6 million people died from TB in 2000 compared with 1.4 million all TB (1.3 million non-HIV TB) in 2013 (Murray et al, 2014).

Figure 4. Global Trends in TB Mortality (WHO, 2013)

+Patterns of Tuberculosis in the US In 1989, CDC published A Strategic Plan for the Elimination of

Tuberculosis in the United States, which was a plan for the elimination by 2010. This implementation of this plan was set back by the resurgence of TB in relation to the onset of HIV epidemic, increases in TB cases among foreign-born persons, outbreaks in congregate settings, and the transmission of deadly multidrug resistant TB strains (Centers for Disease Control & Prevention, 2012).

Overall current & 2010 prevalence rate for the United States. In 2013, there were 9,582 cases, the rate of 3.0, of tuberculosis compared to 11,164 cases, a rate of 3.4, in 2010.

+Prevalence

Gender

In 2010, there were 6,835 male, 4,296 female, and 51 unknown cases of tuberculosis in U.S. born persons (Centers for Disease Control & Prevention, 2010).

In 2013, there were 2,183 male, 1,188 females, and four unknown tuberculosis cases in U.S. born persons (Centers for Disease Control & Prevention, 2014).

+Prevalence Con’t

Note. Adapted from Centers for Disease Control & Prevention. (2014). Reported Tuberculosis in the United States 2013. Retrieved from http://www.cdc.gov/tb/statistics/reports/2013/pdf/report2013.pdf

Hispanic African American

Asian White

3,246 cases (6.5)

2,660 cases (7.0)

3,149 cases (22.5)

1,776 cases (0.9)

Table 1. Ethnicity

In 2010

Hispanics African American

Asian White

658 cases 1,257 cases

152 cases 1,099 cases

In 2013

+Prevalence Con’t

<5 5 to 14

15 to 24

25 to 44

45 to 64

>65

524 cases

246 cases

648 cases

1,386 cases

2,466 cases

1,478 cases

In 2013

0 to 14

15 to 24

25 to 44

45 to 65

>65

637 cases

1,200 cases

3,672 cases

3,439 cases

2,230 cases

In 2010

Table 2. Age

Note. Adapted from Centers for Disease Control & Prevention. (2014). Reported Tuberculosis in the United States 2013. Retrieved from http://www.cdc.gov/tb/statistics/reports/2013/pdf/report2013.pdf

+Prevalence Con’t

Geographic Location

In 2010, California, Nevada, Arizona, Alaska, Hawaii, Texas, Louisiana, Mississippi, Georgia, Florida, New Jersey, Delaware, Washington D.C and Maryland had greater than or equal to 3.60 above the national rate of the population. All other states were less than 3.60 per 100,000 population (Adams et al, 2010).

Thirty-three states had lower rates in 2013 than in 2012. Nine states and the District of Columbia had incidence rates higher than the national rate. In 2013, as in 2012, four states (California, Texas, New York, and Florida) reported more than 500 cases each (Alami, Yuen, Miramontes, Pratt, Price, & Navin, 2014).

TB Rates, United States, 2010

Figure 7. TB Rates US 2013 (CDC, 2011)Fi

gure

6.

TB

Rate

s U

S,

20

10

(C

DC

, 2

01

1)

+

Insight into US

Based on the information gather from articles, the World Health Organization, and the Centers of Disease Control and Prevention would indicate the overall pattern of decrease of tuberculosis in the United States. It would seem to indicate that measure put into place by A Strategic Plan for the Elimination of Tuberculosis in the United States and the National Action plan to Combat Multidrug-Resistant Tuberculosis is progressing towards the goal of eliminating tuberculosis in the United States.

+Patterns of Disease Outside the United States- China

China has an estimated one million new cases of tuberculosis every year, more than any country other than India (WHO, n.d).

+China

The country began to address the tuberculosis problem on a large scale in the 1990s in half of the country’s population, using the DOTS program (Wang et al., 2014).

The 2010 rate of 108 per 100,00 population for Tuberculosis.

In 2013, the overall prevalence of tuberculosis in China was a rate of 94 per100, 000 population (WHO, 2014a).

Due to this rate, in 2010, China achieved one of the key global tuberculosis targets set by the Stop TB Partnership: to reduce the prevalence of smear-positive tuberculosis by 50% (Wang et al., 2014).

+Prevalence

In 2010, the female prevalence per 100,000 population was 64. In 2010, the male prevalence per 100,00 population was 183.

In 2010 and 2012 the ratio of men to women was 2:5 (WHO, 2013).

Tuberculosis epidemiology is characterized by significant differences in prevalence between men and women worldwide, with men greater than women by a ratio of 2:1 (Rhines, 2013).

There are many different views for why women are affected more. Views range from biology to cultural.

Gender

+Prevalence Con’tTable 3. Age

0 to 14

15 to 24

25 to 34

35 to 44

45 to 54

55 to 65

>65

1,685 cases

69,915 cases

31,556 cases

70,668 cases

69,000 cases

74,195 cases

84,534 cases

In 2010

0 to 14

15 to 24

25 to 34

35 to 44

45 to 54

55 to 65

>65

1,091 cases

46,804 cases

43,873 cases

47,990 cases

52,409 cases

58,205 cases

65, 968 cases

In 2012

Note. Adopted from World Health Organization. (2013). Global Tuberculosis Report 2013. Retrieved from http://www.who.int/tb/publications/global_report/gtbr13_main_text.pdf?ua=1

+Prevalence Con’tGeographical Area

Figure 8. Averaged notification rate of active TB during 2001-2010 in P. R. China. (Xin-Xu Li et al., 2014)

+Prevalence Con’t

Geographical Area 2

There is a greater prevalence rate in rural than urban areas in China (Wang et al., 2014).

In 2010, the Eastern region of China prevalence rate was 66 per 100,000 population (Wang et al., 2014).

The central region of China prevalence rate was 124 per 100,00 population (Wang et al., 2014).

The Western region of China prevalence rate was 212 per 100,00 (Wang et al., 2014).

+

Insights of China

China has a larger population than the United States and greater prevalence of tuberculosis based on the information provided. Also based on data provided, both the United States and China have decreased the occurrence of tuberculosis in 2012 compared to 2010.

China like many other countries still face problems with tuberculosis resistance and increase in populations with decreased immune systems, such as individuals with HIV. Due to the results of the data it would seem that the DOTS program is being effective and progressing towards targeted goals.

One study found that investment for TB control and prevention, service level of TB control and prevention, investment for health work, health level of residents, economic level, air quality, climatic factors and geography impacted on TB prevalence to various extents (Li et al., 2014).

+Conclusion

The United States and China have different needs for prevention and disease management of tuberculosis.

Globalization has had an impact on all infectious disease allowing more rapid routes of transmission for infectious diseases around the world.

In 2014, China’s national TB budget is 347 millions US dollars to control tuberculosis (WHO, 2014a). In 2014, the United States national TB budget is 135 millions US dollars (WHO, 2014b).

It is important to continue financing and using epidemiology data to progress towards tuberculosis elimination.

+ReferencesAdams, D., Gallagher, K., Jajosky, R.A., Ward, J., Sharp, P., Anderson, W.J., …Park, M. (2010). Summary of Notifiable Diseases- United States, 2010. Morbidity and Mortality Weekly Report (MMWR), 59(53). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5953a1.htmCenters for Disease Control and Prevention. (2011). Trends in Tuberculosis- United States, 2010. Morbidity and Mortality Weekly Report, 60(11). Retrieved from http://www.cdc.gov/mmwr/pdf/wk/mm6011.pdfCenters for Disease Control & Prevention. (2012). CDC’s Response to Ending Neglect. Retrieved from http://www.cdc.gov/tb/publications/reportsarticles/iom/iomresponse/execsummary.htmCenters for Disease Control & Prevention. (2014). Reported Tuberculosis in the United States 2013. Retrieved from http://www.cdc.gov/tb/statistics/reports/2013/pdf/report2013.pdfDye, C., Lonnroth, K., Jaramillo, E., Williams, BG., & Raviglione, M. (2009). Trends in tuberculosis incidence and their determinants in 134 countries. Bulletin of the World Health Organization, 87(9). Retrieved from http://www.who.int/bulletin/volumes/87/9/08-058453/en/Gardam M, Hota S (2012). Chapter 204. Tuberculosis. In McKean S.C., Ross J.J., Dressler D.D., Brotman D.J., Ginsberg J.S. (Eds), Principles and Practice of Hospital Medicine. Retrieved October 9, 2014 from http://accessmedicine.mhmedical.com/content.aspx?bookid=496&Sectionid=41304191.Li, X., Wang, L. Zhang, J., Liu, Y., Zhang, H. Jiang, S., Chen, J., and Zhou, X. (2014). Exploration of ecological factors related to the spatial heterogeneity of tuberculosis prevalence in P.R. China. Global Health Action. Retrieved from http://www.globalhealthaction.net/index.php/gha/article/viewFile/23620/pdf_1Murray, C., Ortblad, K., Guinovart, C., Lim, S., Wolock, T., Roberts, D.A., … Vos, T. (2014). Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 384. Retrieved from http://ac.els-cdn.com.libproxy.nau.edu/S0140673614608448/1-s2.0-S0140673614608448-main.pdf?_tid=fe41da8c-57c5-11e4-8f38-00000aacb35e&acdnat=1413747041_dbe0246b35c6fcb2e1243bcfefa3cdea

Raviglione M.C., O'Brien R.J. (2012). Chapter 165. Tuberculosis. In Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J (Eds), Harrison's Principles of Internal Medicine, 18e. Retrieved October 8, 2014 from http://accessmedicine.mhmedical.com/content.aspx?bookid=331&Sectionid=40726917.Rhines, A.S. (2013). The role of sex differences in the prevalence and transmission of tuberculosis. Tuberculosis, 93. Retrieved from http://cap-tb.org/sites/default/files/documents/Gender.Role%20of%20sex%20in%20transmission%20and%20prevalence%20of%20TB.Rhines.pdfWang, L., Zhang, H., Yunzhau, R., Chin, D.P., Xia, Y., Cheng, S., Chen, M., … Wang, Y. (2014). Tuberculosis prevalence in China, 1990-2010; a longitudinal analysis of national survey data. The Lancet, 383. Retrieved from http://ac.els-cdn.com.libproxy.nau.edu/S0140673613626392/1-s2.0-S0140673613626392-main.pdf?_tid=5a78a656-6c60-11e4-86b0p-d-00000aacb362&acdnat=1416012361_08a76fbae9fe72caa0ccab9990a9ea5a WebMD. (2001). Tuberculosis. [Image file] Retrieved from http://www.webmd.com/a-to-z-guides/understanding-tuberculosis-basicsWorld Health Organization. (2013). Global Tuberculosis Report 2013. Retrieved from http://www.who.int/tb/publications/global_report/gtbr13_main_text.pdf?ua=1World Health Organization. (2014a). China Tuberculosis Profile. [Data File]. Retrieved from https://extranet.who.int/sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPROD%2FEXT%2FTBCountryProfile&ISO2=CN&LAN=EN&outtype=htmlWorld Health Organization. (2014b). The United States Tuberculosis Profile. [Data File] Retrieved from https://extranet.who.int/sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPROD%2FEXT%2FTBCountryProfile&ISO2=US&LAN=EN&outtype=html

References Continued