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Wisconsin Department of Health Services Division of Medicaid Services Julie Tans-Kersten Director, Wisconsin Tuberculosis Program WMLN Conference October 10, 2018 Tuberculosis Update
51

Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

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Page 1: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Wisconsin Department of Health Services

Division of Medicaid Services

Julie Tans-Kersten

Director, Wisconsin Tuberculosis

Program

WMLN Conference

October 10, 2018

Tuberculosis Update

Page 2: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Learning Objectives

Discuss TB epidemiology worldwide, in the US

and Wisconsin.

Discuss reporting requirements for latent TB

infection (LTBI).

Discuss a targeted testing and treatment

program.

2

Page 3: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Global TB

Page 4: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

4

Page 5: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

5 Source: WHO Global Tuberculosis Report 2018

The Global Burden of TB 2017

Page 6: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

6 Source: WHO Global Tuberculosis Report 2018

The Global Burden of MDR-TB 2017

Page 7: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

TB in the

United States

Page 8: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Trends in TB

What is the provisional number of people

identified with tuberculosis in the United States for

2017?

A. 9,093

B. 15,994

C. 5,443

8

Page 9: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

9

Reported Tuberculosis (TB) Cases

United States, 1982–2016*

0

5,000

10,000

15,000

20,000

25,000

30,000

1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015

No.

of cases

Year

*As of June 21, 2017.

Page 10: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

*Cases per 100,000; As of June 21, 2017

DC, District of Columbia; NYC, New York City (excluded from New York state)

< 2.9 (2016 national average)

>2.9

DC

TB Case Rates,* United States, 2016

NYC

Page 11: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Number of TB Cases Among U.S.-Born versus Non-U.S.–Born Persons, United States, 1993–2016*

No

. of

cases

0

5,000

10,000

15,000

20,000

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

U.S.-born Non-U.S.–born

Year

*As of June 21, 2017.

Page 12: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Reported TB Cases by Origin and

Race/Ethnicity*, United States, 2016†

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

Hispanic-Latino 31%

Asian 48%

Black African-

American 14%

Native Hawaiian –

Pacific Islander

1%

White 5%

Multiple race 1%

Hispanic- Latino 21%

American Indian

Alaskan Native 4%

Asian 5%

Black African-

American 37%

Native Hawaiian-

Pacific Islander

1%

White 31%

Multiple race 1%

* 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; as of June 21, 2017. § American Indian/Alaska Native accounted for <1% of cases among non-U.S.–born persons and are not shown.

Page 13: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

World TB Day Key Messages

TB remains under control in the United States, but

reaching the goal of TB elimination requires and

increase in prevention efforts.

A total of 9,093 TB cases were reported in the

United States in 2017 according to data from CDC

National TB Surveillance System.

13

Page 14: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

World TB Day Key Messages

The overall TB rate decreased slightly to

approximately 2.8 cases per 100,000.

Eliminating TB in the United States requires a

continued effort to control TB disease, and

expanding testing and treatment of latent TB

infection to prevent the development of TB disease.

14

Page 15: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

TB in

Wisconsin

Page 16: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Trends in TB

How many people were identified with TB in

Wisconsin in 2017?

A. 102

B. 28

C. 49

16

Page 17: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

TB Morbidity Wisconsin, 2011–2017

Year No. Rate*

2011 70 1.2

2012 71 1.2

2013 50 0.87

2014 48 0.83

2015 69 1.2

2016 40 0.69

2017 49 0.86 *People with TB per 100,000

17

Page 18: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

18

0

50

100

150

200

250

No. of

Ca

ses

Reported TB Cases Wisconsin,

1982–2017

Year

Page 19: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Douglas Bayfield

Ashland

Saywer

Washburn

Burnett

Polk Barron

Rusk

Price

Iron

Vilas

Oneida

Lincoln

Taylor

Chippewa St. Croix

Pierce

Dunn

Pepin

Eau Claire

Buffalo

Tre

mpe

alea

u Jackson

Monroe

Clark Marathon

Wood Portage

Juneau

Adams

Sauk

La Crosse

Vernon

Crawford Richland

Grant

LaFayette Green Rock

Dane

Iowa

Columbia Dodge

Jefferson Waukesha

Walworth

Kenosha

Racine

Oza

ukee

Sheboygan Fond du Lac Green

Lake

Marquette

Waushara Winnebago

Cal

umet

Manitowoc

Kew

aune

e

Brown Outagamie

Waupaca

Shawano

Menominee

Oconto Langlade

Forest Marinette

Florence

Door

Milw

auke

e

Was

hing

ton

0.51-1.0

1.1-1.5

1.6-2.0

>2.0

≤ 0.50

10-year average rate

2007-2016

TB Case Rates, Wisconsin, 2007-2016

19

Page 20: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

20

Number of TB Cases in U.S.-born vs. Foreign-

born Persons, Wisconsin, 2005–2017

0

10

20

30

40

50

60

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Num

ber

of C

ases

Year

US-Born Foreign-Born

Page 21: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

21

Reported TB Cases by Origin and

Race/Ethnicity, Wisconsin, 2005-2017

U.S.-born Foreign-born Hispanic or

Latino 12%

White 31%

American Indian or Alaska Native

3%

Asian 6%

Black or African

American 37%

Hispanic or Latino

28%

White 4%

Asian 57%

Black or African

11%

Page 22: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

22

Countries of Birth of Foreign-born Persons

Reported with TB, Wisconsin, 2005-2017

Mexico 27%

Hmong (Laos/Thai)

18%

India 15% Philippines

5%

China 5%

Myanmar (Burma)

4%

Somalia 4%

West Africa 4%

Viet Nam 2%

Nepal 2%

Ethiopia 2%

Korea 1%

Other Countries

11%

Page 23: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Wisconsin TB Summary

49 new patients were identified with TB in 2017.

The 10-year average number of cases is 58.8

cases per year.

Wisconsin TB incidence for 2017 (0.86) is below

the national rate.

No MDR-TB was identified for 2016–2017.

TB rates are very low for homeless, long-term

care, and correctional populations in Wisconsin.

23

Page 24: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Wisconsin TB Challenges

Although Wisconsin is identifying fewer patients

with TB, case complexity is emerging as a new

challenge:

TB and HIV co-infection (4 patients in 2016–

2017)

Patients with diabetes

Patients with alcohol, drug, or tobacco use

24

*2013–2017 five year average

Page 25: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Wisconsin TB Challenges

Wisconsin’s percentage of multidrug resistant TB

(3.9%*) is nearly 3.5 times the national average

rate.

There are challenges associated with diagnosis

and treatment of TB in Wisconsin’s high-risk,

foreign-born populations.

Wisconsin is experiencing a loss of TB expertise

in health care facilities and local health

departments.

25

*2013–2017 five year average

Page 26: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Reporting LTBI in

Wisconsin

Page 27: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Reporting TB Disease in Wisconsin

Wis. Admin. Code § DHS 145.04 Appendix A lists

diseases of public health importance that must be

reported.

Tuberculosis is a Category 1 communicable

disease (urgent public health importance).

Upon identification of a case or suspected case:

Report immediately by telephone or fax to

patient’s local health officer.

Enter information into the Wisconsin Electronic

Disease Surveillance System (WEDSS) within 24

hours.

Page 28: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Why Report LTBI in Wisconsin?

TB epidemiology in low incidence areas is

characterized by a low rate of transmission. The

majority of cases are generated from

progression of LTBI to active TB disease.

28

Page 29: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Why Report LTBI in Wisconsin?

To progress toward TB elimination, it is

important to identify and treat LTBI reservoirs.

Current LTBI surveillance data is based on

patients that use the Wisconsin TB

Dispensary Program.

Universal reporting would provide more robust

surveillance data for the purpose of targeted

programming and improved prevention and

control of TB.

29

Page 30: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Reporting LTBI in Wisconsin

As of July 1, 2018, changes went into effect for

Wis. Admin. Code § DHS 145.04.

LTBI is a category II reportable condition.

Within 72 hours of recognition of a case or

suspected case:

Report through WEDSS or

Report via the LTBI Confidential Case Report

(form F-02265) or the Acute and

Communicable Disease Case Report (form F-

44151).

30

Page 31: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Case Definition for LTBI:

Laboratory Criteria

Immunologic:

Positive IGRA or

Positive tuberculin skin test

Microbiologic:

Culture negative for M. tuberculosis complex

(if specimen collected)

31

Page 32: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Case Definition for LTBI:

Clinical Criteria

No signs or symptoms consistent with TB

disease AND

Chest imaging without abnormalities consistent

with TB disease

If chest imaging is abnormal and could be

consistent with TB disease, then TB disease

must be clinically ruled out.

32

Page 33: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Reporting LTBI to the Local Health

Department

Reports will arrive in the following formats:

Laboratory report (interferon gamma release

assay results) in WEDSS staging area, faxed or

mailed

Web report from physician in WEDSS staging

area

Paper report from physician

LTBI Confidential Case Report form (F-02265)

Acute and Communicable Disease Case

Report (F-44151)

33

Page 34: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Local Health Department (LHD) Follow-

up for LTBI

Assure all results are documented.

Check interpretation of test results, risk factors,

and clinical information.

Assure that the patient receives follow-up

medical evaluation that could include chest

imaging and sputum collection.

Assure that active TB disease is ruled out before

LTBI therapy is recommended and initiated.

Administer LTBI medications with directly

observed therapy as necessary.

34

Page 35: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

LHD Questions for Laboratory

Patient address

Numeric results for QuantiFERON (TB antigen

minus nil) or T-SPOT

Interpretation

Indeterminate or borderline results

Positive results in patients with no risk for TB

infection

35

Page 36: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Wisconsin Department of Health Services

36

TST positive in patient with no or low risk for TB infection

Repeat test using IGRA Wait 3–6 months to avoid potential

boosting from TST.¥*

Positive IGRA or TST in Low Risk Patients

IGRA positive in patient with no or low risk for TB infection

Repeat IGRA (especially if QuantiFERON result is within the “high reversion” range of

0.36 to 1.11)§ £

¥Dorman SE et al. AJRCCM 2014; 189(1) online supplement. §Lewinsohn et al., CID 2017; 64(2): 111-5, figure 2. £Thanassi et al., 2012; Pulm Med 291294 *Van Zyl-Smit et al. AJRCCM 180;49 2009.

• Interpret results based on patient’s risk for infection.

• Weigh risks and benefits of treatment with risk for infection.

• Contact the WI TB Program for consultation.

Page 37: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

2018 WI TB Program Update

Wisconsin Department of Health Services

Labs Reporting QuantiFERON Results

Laboratory Type of QFT Result

ACL, West Allis Interpretation only

ARUP, Salt Lake City, UT Interpretation only

Aspirus, Wausau Interpretation only

Beloit Clinic Interpretation only

LabCorp TB Ag-Nil, Mitogen-Nil, Nil and Interpretation

Mayo Rochester and hospitals/clinics in Wisconsin

TB1 Ag-Nil, TB2 Ag-Nil, Mitogen-Nil, Nil and Interpretation

Mercy, Janesville TB Ag-Nil, Mitogen-Nil, Nil and Interpretation

Quest Diagnostic Labs Interpretation only

St. Vincent/St. Mary’s Prevea, Green Bay Interpretation only

Wisconsin Diagnostic Laboratory, Milwaukee

TB Ag-Nil, Mitogen-Nil, Nil and Interpretation

37

Page 38: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

A Targeted TB Testing

Program in Wisconsin

Page 39: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Today, about 35% of Wisconsin farm workers

are immigrants from high TB prevalence

counties.

Immigrant workers may have little access to

health care.

Interactions between livestock and humans may

pose an elevated risk of TB transmission.

Farm-related TB exposures could threaten the

Wisconsin dairy and beef industries.

Overview: Targeted Testing

17

Page 40: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Partners in Health and Safety

The 2011 pilot project provided clinics for livestock

workers in northwest Wisconsin.

University of Wisconsin-Eau Claire – College of

Nursing and Health Sciences

Buffalo County Public Health

Pepin County Public Health

Bridges/Puentes

Dairy Producers

Chippewa Valley Free Clinic

18

Page 41: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Students and faculty prepared for clinics.

Students developed teaching plans.

Students participated in clinics on farms.

Clinics included screening, testing,

immunizations, and education.

Partners in Health and Safety

19

Page 42: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

229 individuals were tested for TB using IGRA.

LTBI was identified in 16 individuals (7%).

No active TB was identified.

15 individuals treated for LTBI.

One individual was lost to follow-up.

Partners in Health and Safety

20

Page 43: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

In 2018, the Wisconsin Tuberculosis Program

(WTBP) offered funding to perform targeted

testing in livestock workers.

St. Croix County

Madison/Dane County

Buffalo County

Expansion of Targeted Testing

21

Page 44: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Identification of farms for testing

Communication with farm owners and other

partners

Development of educational materials for farm

owners and livestock workers

Coordination of interpretation services

Coordination of health clinics

Coordination of follow-up services

Coordination of LTBI treatment

Expansion of Targeted Testing

22

Page 45: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Summary

Page 46: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Summary

The incidence of tuberculosis is slowly decreasing.

Diagnosis and care of patients with tuberculosis remains challenging.

LTBI is now a category II reportable condition.

Universal reporting will help gather surveillance data for better targeted testing.

Pilot sites are performing TB screening and testing for livestock workers.

46

Page 47: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Wisconsin TB Program

Contact Information

Page 48: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

TB Program Contact Information

Phone: 608-261-6319

Fax: 608-266-0049

Email: [email protected]

Website:

https://www.dhs.wisconsin.gov/tb/index.htm

48

Page 49: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

49

TB Program Staff

Julie Tans-Kersten

Dr. Lina Elbadawi

Savitri Tsering

Pat Heger Taylor LaBorde

Philip Wegner

Page 50: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

Southeastern National Tuberculosis

Center (SNTC)

The new CDC-funded TB Center of Excellence

located at University of Florida at Gainesville.

The SNTC goal is to support domestic TB

control and prevention efforts with a focus on

two major activities:

Medical evaluation and management of

persons with TB or LTBI

Education and training activities

http://sntc.medicine.ufl.edu/

50

Page 51: Tuberculosis Update · Source: WHO Global Tuberculosis Report 2018 6 The Global Burden of MDR-TB 2017 . TB in the United States . Trends in TB What is the provisional number of people

51

Questions?