Tuberculosis epidemiology: Using data to inform TB control ... · Tuberculosis epidemiology: using data to inform tuberculosis control approaches and priorities 8 U.S. TB Cases by

Tuberculosis epidemiology: using data to inform tuberculosis control approaches and priorities 1

Tuberculosis epidemiology: Using data to inform TB control approaches and priorities

Lisa Pascopella, PhD, MPHSenior EpidemiologistTuberculosis Control BranchCalifornia Department of Public HealthNovember 18, 2019

Objectives

• Describe the epidemiology of tuberculosis in the U.S. • Describe how epidemiologic and population data can

be used to inform TB prevention and control activities


Topics• Epidemiology of TB in the United States• Death with TB• Epidemiology of TB in California• TB prevention cascades in

Contacts to infectious TB cases

New arrivers with abnormal chest radiographs

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Tuberculosis in the United States1993–2018*

National Tuberculosis Surveillance System

Division of Tuberculosis Elimination

*Updated as of June 6, 2019


Reported Tuberculosis (TB) Cases and Rates United States, 1993–2018

Percentage of TB Cases by State, United States, 2018

DC, District of Columbia

DC

12.56.5

23.2

8.3


Tuberculosis Case Rates by Reporting Area United States, 2018

3.9

5.3

8.5

TB Incidence Rate (per 100,000 persons)8.4

5.3

8.5

3.9

NYC (6.7)

D.C. (5.1)

TB Incidence Rate (per 100,000 persons)

8.5

5.3

TB Cases and Rates Among U.S.-Born versus Non-U.S.–Born Persons, United States, 1993–2018

Cas

es

pe

r 1

00

,00

0 P

op

ula

tio

n


Countries of Birth Among Non-U.S.–Born Persons Reported with TB, United States, 2018*

*Percentages are rounded.

Percentage of Non-U.S.–Born TB Casesby Time in the United States at Diagnosis, 2018

Pe

rce

nta

ge o

f TB

Cas

es

Time in the United States


TB Case Rates by Race/Ethnicity,* United States, 2010–2018

* All races are non-Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† Asian race category reporting includes Pacific Islander from 1993–2002; Native Hawaiian/Other Pacific Islander race first reported separately in 2003.§ Multiple race rates first reported in 2003..

Cas

es

pe

r 1

00

,00

0 p

op

ula

tio

n

Reported TB Cases by Origin and Race/Ethnicity*, United States, 2018†

Non-U.S.–born persons § U.S.-born persons

* All races are non-Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† Percentages are rounded.§ American Indian/Alaska Native accounted for


TB Case Rates by Age Group, United States, 1993–2018

Cas

es

pe

r 1

00

,00

0 p

op

ula

tio

n

Year

Distribution of Sex by Age Group, United States, 2018

Males Females


U.S. TB Cases by Site of Disease, 2018

*Any pulmonary involvement which includes cases that are pulmonary only and both pulmonary and extrapulmonary.Patients may have more than one disease site but are counted in mutually exclusive categories for surveillance purposes.

Note: Percentages are rounded.

National guidance: Assess pulmonary involvement for any form of TB

For diagnostic purposes, all persons suspected of having TB disease at any site should have sputum specimens collected for an AFB smear and culture, even those without respiratory symptomsfrom CDC’s Core Curriculum on TB Chapter 4


Isoniazid Resistance Among U.S.-Born versus Non-U.S.–Born Persons, United States, 1993–2018

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

* 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.


HIV Coinfection by Age Among Persons Reported with TB, United States, 2011–2018

Reported TB Cases by Risk Factor, United States, 2018

Non-HIV immunosuppression

Contact to Infectious TB

Diabetes Mellitus

Contact to Infectious TB Diabetes Mellitus

Comparison of Selected Risk Factors by Origin of BirthMost Common Risk Factors Reported Among TB Patients


*Correctional facilities include federal prisons, state prisons, local jails, juvenile correctional facilities, other correctional facilities, or unknown type of

correctional facility.

TB Cases among Residents of Correctional Facilities Ages ≥15, 1993–2018*

TB Cases Ages ≥15 with Other Selected Risk Factors, 2018

Risk Factor


Substance Misuse Among TB Patients ≥15 years, United States, 2018

Risk factors for TB

Born in a non-US country where TB is endemicLiving with HIV, diabetes, other immunosuppressionExperiencing homelessnessUsing substances (e.g. injection drugs)Living in certain institutional settings


TB treatment outcomes

The majority of TB patients complete their treatment within 12 monthsFew TB patients are lost to followupTB patients who move may be provided with continuity of careAlmost 10% of TB patients die while on treatment

TB Cases by Reason Therapy Stopped, 2016*

*Data available through 2016 only.

Outcomes for patients that did not complete treatment


Death with TB

Reported Tuberculosis (TB) Deaths* and Rates United States, 1993–2017

*National Vital Statistics System Multiple Causes of Death (accessed from CDC Wonder)


TB Surveillance data is more accurate than Vital Statistics data for TB patients who die

We have reviewed the characteristics of the population who has TBNow let’s review what we know about persons who die with TB

Although TB is a preventable and curable disease, approximately 10% of persons with TB die with TBWhy?Can we prevent death with TB?


Published in Annals ATS, Vol 15 June 2018

TB Epidemiologic Studies Consortium Mortality Study Objectives

Assess the frequency of TB-related deathsIdentify risk factors for TB-related death


Methods

• Reviewed deaths of TB cases reported 2005-2006

• Inpatient and outpatient medical records

• Laboratory records

• Used standardized and piloted algorithm to determine TB-relatedness

• Trained data abstractors

• 2 reviewers per case (at least 1 TB clinician)

• 3rd reviewer to resolve disagreements

• Classification

• Definitely or probably TB-related

• Definitely not or unlikely TB-related

• Unclassifiable

TB relatedness and timing of deaths

1,304 adults who died

942 (72%)TB-related deaths

272 (21%) TB-unrelated

deaths

90 (7%) could not be classified

705 (75%) TB-related deaths during

treatment

237 (25%) TB-related deaths before

treatment

329 (47%) TB-related deaths

within 30 days of diagnosis

371 (53%) TB-related deaths >31

days after diagnosis


Time to deathTB related vs TB-unrelated

TB unrelated

TB related

Days to death

Study algorithm/Death cert TB was not an immediate,

underlying, or contributing

cause of death

TB was an immediate,

underlying, or

contributing cause of

death

Totala

Not TB-related death 185 (75) 61 (25) 246 (23)

TB-related death 378 (45) 469 (55) 847 (77)

Totala 563 (52) 540 (48) 1093 (100)

Study algorithm vs. Death certificate

aDeath certificates were not available for 10% of decedents

Kappa = 0.21 (0.16, 0.26)

Sensitivity of death certificate=55.4% (51.9,58.7)Specificity of death certificate=75.2% (69.3, 80.5)


Risk factors for TB-related death

Delayed diagnosis

Extensive TB disease

Immune suppression

Comorbidities

Started anti-TB treatment as inpatient

TBESC study conclusions

• 72% TB deaths were TB-related• Death certificates were not reliable

• and underestimate TB-related death• Need information from medical/hospitalization charts• Increased death risk when TB was diagnosed in hospital


What do we know about TB deaths in CA?

Reviewed recent surveillance data for 2 types

• Dead at diagnosis

• Died during treatment

Report of Verified Case of TuberculosisWas TB a cause of death?

1. Dead at diagnosis


CA TB surveillance data 2010-2016Dead at diagnosis

2% (n=304) TB cases dead at diagnosis

• 30% TB-related

• 40% not TB-related

• 30% unknown relatedness

Report of Verified Case of Tuberculosis Was death related to TB disease or TB therapy?

2. Died during treatment


CA TB surveillance data 2010-2016Died during treatment

8.4% (n= 1267) TB cases died on treatment

• 36% related to TB disease

• 1.6% related to TB therapy

• 41% not TB-related

• 21% unknown

Deaths on treatment for select local TB programsCA TB surveillance data 2010-2016

LHJ Unrelated to TB disease

Related to TB disease

Related to TB therapy

Unknown

a 40% 21% 0.5% 39%

b 43% 47% 2.8% 7%

c 24% 56% 1.9% 19%

d 55% 16% 0 29%

e 19% 70% 0 12%

Large range of responses across CA


Why the difference in TB-related deathTBESC study (72%) vs.CA surveillance (38%)?

• Diversity of responses to RVCT questions in CA• Variability in methods to ascertain TB-relatedness?• Role for independent review?

TB programs should review every death using a standardized approach that includes medical and hospital records

• To identify potential missed prevention opportunities• To monitor trends• To identify areas for working with partners


Consider using algorithm developed in CA for review of deaths

https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/TBCB-RVCT-Death-Algorithm-v1.0.pdf


TB epidemiology in California

How do TB Cases Occur in California?

TB in new arrivers TB within 6 months of arrival in US 2015-2017

Recent TransmissionRT recipient 2014-2016

Reactivation of remote infection. Cases not from importation or recent transmission

2,000 TB cases/yr

12%

82%

6%

50


The Long View: Dramatic ProgressCalifornia Tuberculosis Epidemic 1930–2018

0

20

40

60

80

100

120

140

160

180

200

0

2,000

4,000

6,000

8,000

10,000

12,000

Nu

mb

er

of

TB C

ase

s

TB Cases TB Rate

Cas

e R

ate

pe

r 1

00

,00

0

51

The Medium View: Dramatic ProgressCalifornia Tuberculosis Epidemic 1991–2018

0

2

4

6

8

10

12

14

16

18

20

0

1,000

2,000

3,000

4,000

5,000

6,000

1991 1996 2001 2006 2011 2016

Nu

mb

er

of

TB C

ase

s

TB Cases TB Rate

Cas

e R

ate

pe

r 1

00

,00

0

52


The Medium View: Slowing ProgressCalifornia Tuberculosis Epidemic 1991–2018

0

2

4

6

8

10

12

14

16

18

20

0

1,000

2,000

3,000

4,000

5,000

6,000

1991 1996 2001 2006 2011 2016

Nu

mb

er

of

TB C

ase

s

TB Cases TB Rate

Cas

e R

ate

pe

r 1

00

,00

0

-4.3%

53

-6.2%

-1.2%

Progress StalledCalifornia Tuberculosis Epidemic 2014–2018

0

1

2

3

4

5

6

7

8

9

10

0

500

1,000

1,500

2,000

2,500

2014 2015 2016 2017 2018

Nu

mb

er

of

TB C

ase

s

TB Cases TB Rate

Cas

e R

ate

pe

r 1

00

,00

0

54



2091

5.3

0

1

2

3

4

5

6

7

8

9

10

0

500

1,000

1,500

2,000

2,500

2014 2015 2016 2017 2018

Nu

mb

er

of

TB C

ase

s

TB Cases TB Rate

Cas

e R

ate

pe

r 1

00

,00

0

55


2133 2131 2058 2059 2091

5.3

0

1

2

3

4

5

6

7

8

9

10

0

500

1,000

1,500

2,000

2,500

2014 2015 2016 2017 2018

Nu

mb

er

of

TB C

ase

s

TB Cases TB Rate

Cas

e R

ate

pe

r 1

00

,00

0

56


Photograph by Jodie JoOx http://yourshot.nationalgeographic.com/photos/6232126/ 57

Match the TB program strategy to the TB mechanism

58

TB in recent arrivers

Recent transmission

Reactivation of LTBI

• Overseas screening and treatment• Domestic evaluation and treatment

• Outbreak investigation• Contact investigation

• Risk assessment• LTBI testing• LTBI treatment


83% of cases in people born outside U.S.TB Cases by country of birth California, 2018

0% 20% 40% 60% 80% 100%

60

Other Countries

Mexico PhilippinesVietnam

China

India

83%

CentralAmerica

17%

U.S.


Cases from >120 countriesCountry of origin of TB cases 2014-2018, California

61

62

60

40

20

0

TB Incidence by Country of Birth,California, 2001−2016

Cas

es p

er

10

0,0

00

Philippines

Vietnam

IndiaChina

Mexico

U.S.

2004 2008 2012 2016


Large disparity by place of birthTB case rate by nativity California 2009–2018

2.21.2

18.9

16.1

0

2

4

6

8

10

12

14

16

18

20

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

63

Non-U.S.-born

U.S.-born

Disparity by place of birth increasingTB case rate by nativity California 2009–2018

2.21.2

18.9

16.1

9

13

0

2

4

6

8

10

12

14

16

18

20

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

FB:USB Ratio

64

U.S.-born

Non-U.S.-born


20x-60x higher rates among non-U.S.-born

minorities compared with U.S.-born whitesTB rate by race/ethnicity and nativity, 2018

0.5

1.7

2.7

2

4

11

19

29

0 10 20 30 40

White

Hispanic

Black

Asian

Rate per 100,000

Non-U.S.-born

U.S.-born

65

Most People with TB have been U.S. residents for many yearsYears in U.S. at TB diagnosis California, 2014-2018

0

200

400

600

800

1000

1200

0-1

2-3

4-5

6-7

8-9

10

-11

12

-13

14

-15

16

-17

18

-19

20

-21

22

-23

24

-24

26

-27

28

-29

30

-31

32

-33

34

-35

36

-37

38

-39

40

-41

42

-43

44

-45

46

-47

48

-48

50

-51

52

-53

54

-55

56

-57

58

-59

60

-61

62

+

TB C

ase

s

Years in U.S.

66

>50% in US >18 yrs


Half of TB cases are older than 55Age at Report of TB, 2018

0

5

10

15

20

25

30

35

40

45

50

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100

Nu

mb

er

of

case

s

Age

Median

Median age continues to increase: 53 (2014) 55 (2018)2018: Born outside US=57 years US-born=36 years 67

More TB Cases are Older% of TB Cases Aged 65+, 1993-2018

18%

23%

34%

0

5

10

15

20

25

30

35

40

1993 2008 2018

% o

f C

ases

68


More TB Cases are Older% of TB Cases Aged 65+, 1993-2018

5%9%

12%

0

5

10

15

20

25

30

35

40

1993 2009 2018

% o

f C

ases

80+

69

Decreasing TB in youngest kidsPediatric Cases


Correctional cases increased in 2018Cases Diagnosed in a Correctional Facility, 2009-2018

38 (1.8%)

67 (3.2%)

0

0.5

1

1.5

2

2.5

3

3.5

4

0

10

20

30

40

50

60

70

80

90

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Pe

rce

nt

of

case

s

Nu

mb

er

of

Cas

es

Correctional case Percent correctional71

Cases increased most in local jails and others*Type of Correctional Facility, 2017-2018

10

3

11

1412

4

28

22

0

5

10

15

20

25

30

Federal State Local Other*

Nu

mb

er

of

case

s 2017 2018

* Includes ICE detention centers

72


Low education associated with high TB rateTB rate by % of adults in census tract with HS education

United States, 4.5

China, 3.3

India, 1.4

Mexico, 1.5

Philippines, 1.7

Vietnam, 2.7

0

10

20

30

40

50

60

94%

Inci

de

nce

rat

e p

er

10

0,0

00

Percent of adults with HS education

Country, Rate Ratio

73

Lower SES associated with higher TB rate.TB Rate by SES Level and Country of Birth

0

10

20

30

40

50

60

Un

ited

Sta

tes

Me

xico

Ind

ia

Ch

ina

Vie

tnam

Ph

ilip

pin

es

Un

ited

Sta

tes

Me

xico

Ind

ia

Ch

ina

Vie

tnam

Ph

ilip

pin

es

Un

ited

Sta

tes

Me

xico

Ind

ia

Ch

ina

Vie

tnam

Ph

ilip

pin

esIn

cid

ence

rat

e p

er 1

00,0

00

Low SES High SES

74


2018 CA TB Epi Highlights Summary

Stall in decline confirmedSimilar epi patterns continue: disparitiesHigh TB rate in older age groupsFalling number of peds cases reason for optimismCases in local jails and other facilities bears monitoringTB is associated with lower socioeconomic status!(even in California and after accounting for country of birth)

75

Contacts Care Cascade: EvaluationARPE Data California, 2016‒2017

23,589 19,2040

5,000

10,000

15,000

20,000

25,000

Contactsto Smr +

Evaluated

Nu

mb

er

of

con

tact

s

81%

76NTIP data for California based on ARPE reporting for cohorts reported in 2016 and 2017


TB prevention cascade amongContacts to infectious TB, California, 2016-2017

3,117 2,125 1,5100

500

1000

1500

2000

2500

3000

3500

With LTBI Started treatment Completedtreatment

Started treatment Completed treatment

68%

71%

77

NTIP data based on ARPE California data, 2016-2017

Contacts with LTBI

Improving treatment completionContacts Completing LTBI Treatment (of those who start)

62% 62% 73% 69% 72% 70%0%

10%

20%

30%

40%

50%

60%

70%

80%

2012 2013 2014 2015 2016 2017

78ARPE data reported to California 2012-2017


81

Class B1 arriver care cascade2014-2018

32215

1994562%

711936%

310444% 1574

51%

0

5000

10000

15000

20000

25000

30000

35000

ClassB arrivers

Evaluated& reported

LTBI*

Started Tx Completed Tx

*Excludes B1 arrivers who reported a history of treatment for active TB

Potential room for program improvement?

• Only 42% of contacts with LTBI completed treatment

• Only 22% of B1 arrivers with LTBI completed treatment

82


TB programs are responsible for at least 2 populations at risk of TB: Contacts and New arrivers with B-notifications

Improved evaluation and treatment to prevent TB

83

Contacts for California TB programs

• CDPH TB Branch 510-620-3865• Program Liaisons

– Lisa True– Stephanie Spencer– Leslie Henry– Anne Cass– Michael Joseph

• Epi Liaisons– Lisa Pascopella– Melissa Ehman– Adam Readhead– Phil Lowenthal– Varsha Hampole

• TB Registry Chief– Janice Westenhouse

• Surveillance and Epidemiology Section Chief

– Pennan Barry

• Program Development Section Chief– Kristen Wendorf

• You can reach me at lisa.pascopella@cdph.ca.gov


National and California resourcesDivision of Tuberculosis Elimination National Center for HIV/AIDS, Viral Hepatitis,

STD, and TB PreventionCenters for Disease Control and Preventionhttp://www.cdc.gov/tb/

• National data slidesethttps://www.cdc.gov/tb/statistics/surv/surv2018/default.htm

• Core curriculum on TB https://www.cdc.gov/tb/publications/slidesets/corecurr/default.htm

Tuberculosis Control Branch

Division of Communicable Disease Control

Center for Infectious Diseases

California Department of Public Health• https://www.cdph.ca.gov/Programs/CID/DCDC

/Pages/TBCB.aspx

• https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/TBCB-Program-Liaison-Epi-Assignments.pdf

• https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/TBCB-RVCT-Death-Algorithm-v1.0.pdf

Acknowledgements

CDC DTBE slidesetCDPH TBCB:• Pennan Barry• Phil Lowenthal• Melissa Ehman

Tuberculosis epidemiology: Using data to inform TB control ... · Tuberculosis epidemiology: using data to inform tuberculosis control approaches and priorities 8 U.S. TB Cases by

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