TB Elimination in California Can We Get There? Navigating the Landmines CTCA April 28, 2011 Jennifer Flood MD MPH Chief, Tuberculosis Control Branch California.

TB Elimination in California

Can We Get There?Navigating the Landmines

CTCAApril 28, 2011

Jennifer Flood MD MPHChief, Tuberculosis Control Branch

California Department of Public [email protected]

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Outline

• Is TB controlled?

• Who is involved in TB control?

• Where are the landmines?

• Way forward?

TB Case Trends

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California Population andTuberculosis Cases, 2001-2010

Tu

ber

culo

sis

Cas

es

30

32

34

36

38

40

2001 2010

Po

pu

lati

on

3,332

2,329

34 Million

39 Million

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Change in TB cases by race/ethnicity,2001-2010

Race/ethnicity 2001-2010 % ChangeWhite 365 187 -49Black 292 151 -48Hispanic 1252 874 -30Asian 1399 1109 -20

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TB Cases by Place of Birth

Place of Birth 2001-2010 % Change

U.S.- born 824 498 -40

Foreign-born 2482 1802 -27

Tuberculosis Cases in Foreign-born and U.S.-born Persons by Race/Ethnicity:

California, 2010

Note: Excludes 29 cases with unknown race or birthplace

95%

5%

25%

75%

36%

64%

29%

71%

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TB cases by age group

Age group 2001-2010 % Change

•0-4 133 55 -59

•5-14 92 45 -51

•15-24 318 215 -32

•25-44 1109 680 -39

•45-64 953 736 -23

•65+ 727 593 -18

Foreign-born with active TB within one year of U.S. arrival, 2001-2010

Year9

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

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TB Case Characteristics

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2010 Foreign-born TB Cases: Immigration status

• Immigrant 40%• Refugee/asylee 5%• Tourist 2%• Student 2%• Worker 2%• Other* 16%• Unknown** 31%• * without above visa but not unknown

• ** patient does not know status on entry, refused response, or local policy restricts response

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45%

1313

2010 TB Cases:Comorbid conditions

480 (21%) Diabetes

145 (6%) Immunosuppressed

83 (4%) End-stage renal disease

17 (.73%) TNF Antagonist

14 (.60%) Post-organ transplant

*Nearly 1/3 with co-morbidities;

does not include HIV 14

TB Diagnosis and Treatment

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Passive case-finding•TB symptoms 1455 (63%)•Abnormal CXR* 396 (17%)•Incidental lab* 211 (9%)

Active case-finding•Contact investigation 84 (3.6%)•Immigration screening 78 (3.4%)•Targeted Testing 44 (1.9%)•Employee Screening 28 (1.2%)

*purpose of CXR or lab was for something other than TB

2010 TB Cases: Reason for Presentation

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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

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Use of new diagnostics

2010 TB cases (n=2314)

•NAAT 892 (39%)

•IGRA 475 (22%)

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HIV Status Determination is not Universal in CA

CDC standard is universal testing of all TB cases20

Timing of HIV diagnosis (Dx) in HIV-positive TB patients, 2008

131 HIV co-infected TB patients

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Alive at Diagnosis

64 (50%) 65 (50%)

Previously known HIV + Newly diagnosed HIV +

44 (68%)

2 weeks prior – 2 weeks after TB Dx

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Where was HIV test done for HIV/TB co-infected patients?

• 67% Hospital

• 16% Outpatient

• 17% Unknown

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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

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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

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Time to Death for Patients Starting Therapy, California 2008

Median time to death = 48 days25

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TB Deaths during Therapy, by Provider Type, 1994-2009

0

2

4

6

8

10

12

14

16

18

20

Year

Per

cen

t

Private Provider

Health Department

Why are TB deaths occurring?

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Is TB a contributor to Death?

Preliminary Results: Mortality Study TBESC

•In 75%, TB contributed to death !

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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

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Who are our cases?

• 40% of foreign-born underwent pre-departure screening

• A sizeable fraction with comorbid conditions

• Opportunity to prevent TB and

detect disease earlier

• TB deaths = compelling reason to intervene

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Navigating Landmines

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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

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Too busy killing alligators to drain the swamp?

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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 well-accepted 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

Force34

Prevention:

Can we afford it?Can we afford not to do it?

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Horsburgh CR Jr, Rubin EJ. Clinical Practice: Latent Tuberculosis Infection in the United States. NEJM 2011;364 (15):1441-8.

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;17937

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%)

Source: Sterling et al. International Union Meeting, presented November 201138

What is the Evidence?

Evaluation of individuals with B-notification (abnormal CXR)

Percent of

active cases

COST-SAVING 3% and above

COST-EFFECTIVE 4% - 1.5%

Source: Porco et al. BMC Public Health 2006;639

Case Prevention

Should we prioritize LTBI treatment for arrivers with B-notification of TB2 and TB4?

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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

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What Strategic Direction is Under Consideration?

• Adopt cost-effective diagnostic and treatment approaches

• Abandon ineffective unproven approaches

• Tackle case prevention as cases decline

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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

Hot Off the Press

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