Tuberculosis surveillance and control control Ibrahim Abubakar FFPH FRCPE PhD Ibrahim Abubakar, FFPH, FRCPE, PhD Tuberculosis Section Health Protection Services Colindale Health Protection Services Colindale Health Protection Agency
Tuberculosis surveillance and controlcontrol
Ibrahim Abubakar FFPH FRCPE PhDIbrahim Abubakar, FFPH, FRCPE, PhDTuberculosis Section
Health Protection Services ColindaleHealth Protection Services ColindaleHealth Protection Agency
PlPlan
• TB infection and disease
Gl b l• Global occurrence • EW&NI surveillanceEW&NI surveillance• UK recent epidemiology• TB control (Practical)
What is tuberculosis?The disease is causedby Mycobacteriumby Mycobacteriumtuberculosis complex:
M t b l iM tuberculosis• M. tuberculosis• M. bovis• M africanum
• M. tuberculosis• M. bovis• M africanum• M. africanum
Not other mycobacterial
• M. africanum
yinfections:
• M. marinuma u• M. avium intracellulare• M. xenopip• M. kansasii• M. leprae
Epidemic proportionsEpidemic proportions
In 1815
one in four deaths
in Englandin England
disease of the urban poor
overcrowding and unsanitary
living conditions
Pathogenesisg
3rd die3rd chronic infection3rd cured
Kaufmann et al, Nature Medicine 2005
Global burden of TB
Annually:Annually:
- over 9 millionover 9 million new cases of TB
- nearly 2 million deaths from TBdeaths from TB
Estimated number of new cases, 2010Estimated number of new cases, 2010
AFR 28%WPR 22%
AFR 28%
AMR 4%SEAR 34%
EUR 5%EMR 7%
© WHO 2011. All rights reserved
Estimated TB incidence rates, 2010Estimated TB incidence rates, 2010
© WHO 2011. All rights reserved
Estimated HIV prevalence in new TB cases, 2010
© WHO 2011. All rights reserved
HIV testing for TB cases, by country, 2010
© WHO 2011. All rights reserved
E ti t d TB i id t litEstimated TB incidence, mortality and prevalence rates, 1990–2010
Excl TB deaths among HIV positive
All TB incl. HIV-positive (green)
Excl. TB deaths among HIV-positive
HIV-positive only (red)
© WHO 2010
Estimated incidence rates by WHO region, 1990-2010
Incidence, all forms
Notifications
HIV+
© WHO 2010
TB notification rates Europe 2008TB notification rates, Europe, 2008
Source: ECDC.
Proportion of TB cases of foreign i i E 2008origin, Europe, 2008
Source: ECDC.
TB notification rates EU/EEABy incidence grouping*, 1995-2001 and 2002-2008
Source: ECDC.
TB notification rates EU/EEA*Mean annual percentage change 2004 2008Mean annual percentage change, 2004 - 2008
United KingdomSweden
SpainIreland
ItalyFrance
Finland
LithuaniaNorwayDenmark
BulgariaSpain
BelgiumSlovenia
PolandGreece
Slovakia
NetherlandsEstonia
PortugalRomania
Czech Republicg
LatviaHungaryGermany
Netherlands
-10 -8 -6 -4 -2 0 2 4 6
* Excluding countries without data or with <60 cases in 2008 (Cyprus, Iceland, Luxembourg, Malta)
Source: ECDC
10 8 6 4 2 0 2 4 6
% change
SurveillanceSurveillance (EW&NI)
TB Surveillance: aims and objectives
Reducing the burden of morbidity and mortality from TB
• Local:mortality from TB
– Identification & treatment of cases– Identification & management of contacts
• Local/ Regional/ National: D t ti f tb k– Detection of outbreaks
– Evaluate treatment programs– Evaluate control & prevention– Policy and guidance– Epidemiology
1913 LEGISLATION -1913 LEGISLATION
NOTIFICATION OF TB
TB Surveillance systemsTB Surveillance systems
INCIDENT CASES TREATMENT INCIDENT CASES• ETS• NOIDS
OUTCOMES
Death RegistrationsRegistrations
FINGERPRINTSNational strain
typing databaseISOLATESMycobNettyping database
INCIDENTS & OUTBREAKS
TB surveillance – data flowTB surveillance data flow
Clinician& nurse:
CCDC in HPU
Regional Coordinator
& nurse: case of TB
g
HPASpecimen Feedback
Web based national database
Local Matching
Web-based
Locallaboratories
Reference Labs
MycobNetCultureMatching
LabsSpecies,sensitivities
Surveillance data qualitySurveillance data quality
WHO Global TB Report 2011
TB in the UK
350 160.0
300
atio
n 140.0
on
Housing and hygiene
200
250
0,00
0 po
pul
100.0
120.0
00 p
opul
atio
BCG
Chemotherapy
150
200
rate
per
100
60.0
80.0
e pe
r 100
,00BCG
Pasteurisation
100
otifi
catio
n r
40.0
60.0
Dea
th ra
te
Short course therapy
0
50
1913 1916 1919 1922 1925 1928 1931 1934 1937 1940 1943 1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000
No
0.0
20.0
1913 1916 1919 1922 1925 1928 1931 1934 1937 1940 1943 1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000
Year
Tuberculosis case reports, rates and percentage change, UK 2000-9
CI - confidence interval
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS) mid-year population estimates
Tuberculosis case reports and /rates by region/country, UK, 2009
3500 50
44.43000
3500
40
45
50
2000
2500
r of c
ases
25
30
35
r 100
,000
)
18.7
13.412.311.8
1000
1500
Num
ber
15
20
Rat
e (p
e
8.46.1
9.37.1
3.1
11.89.3
6.5
0
500
0
5
10
London WestMidlands
NorthWest
SouthEast
Yorkshireand theHumber
EastMidlands
East ofEngland
SouthWest
NorthEast
Scotland Wales NorthernIreland
Region/ Country
Number of cases Rate (per 100,000 population) and 95% CI
Sources: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS) mid-year population estimates
(p , p p )
Three-year average TB rates by primary care y p yorganisation*, UK 2007-2009UK, 2007-2009
*England – Primary Care Trusts (PCTs), Northern Ireland – Health and Social Services Boards, Scotland – NHS Boards, Wales – Local Health Boards
Sources: Enhanced Tuberculosis Surveillance (ETS) Enhanced Surveillance of Mycobacterial(ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS) mid-year population estimates
TB case reports and rates by age group and sex, UK, 2009
40800
30
35
40
600
700
800
0)s
15
20
25
300
400
500
(per 100,000
mbe
r of case
5
10
15
100
200
300
Rate
Num
00
Age group (years)
Male cases Female cases
Rate in males Rate in females
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS) mid-year population estimates
Rate in males Rate in females
TB case reports by place of birthand region/country, UK, 2009
8 1
100%
1,938
17
183
102
52
184
144
134
322
218
266
46 103
60%70%80%90%
e of cases*
5,703
21
181
89
2,756
528
354
304
639
410
493
69 150
20%30%40%50%
Percen
tage
0%10%
Country/Region (% where place of birth known)
Non‐UK‐Born UK‐born*Where place of birth was known
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS) mid-year population estimates
Non‐UK‐Born UK‐bornNumbers of cases stated in bars
TB case reports and rates by place fof birth, England, 2000-2009
1206,000
80 80
89 9196
10194
87 89 89 1005,000
60
80
3,000
4,000
er 100,000)
ber o
f cases
402,000 Rate (p
Num
b
4 4 4 4 4 4 4 4 4 4
0
20
0
1,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
UK‐born cases Non‐UK‐born cases
UK b t N UK b t
Sources: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS) mid-year population estimates
UK‐born rate Non‐UK‐born rate
Non-UK-born TB case reports by fworld region of birth, UK, 2009
North Africa East EuropeEast
M di
Central America,East Asia1.8%
1.0%East Europe
0.8%Mediterranean
0.9%
North America Central America, and the
Caribbean2 0%
1.8%and Oceania
0.2%
2.0%
Central Europe2.2%
West Europe2.4%
South Asia54.8%
South East Asia4.5% Sub‐Saharan
Africa
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
29.5%
Most frequent countries of birth for non-UK-born TB cases, UK, 2009
Number Percentage ofCountry of birth
Number of cases
Percentage of cases*
India 1,615 28Pakistan 982 17Somalia 551 10Somalia 551 10Bangladesh 247 4Nigeria 186 3Zimbabwe 168 3Phili i 119 2Philippines 119 2Nepal 117 2Kenya 112 2Eritrea 101 2fAfghanistan 98 2
Sri Lanka 94 2Uganda 81 1South Africa 80 1China 60 1Others (each <1%) 1182 20Total 5,793 100
*Wh t f bi th k
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
*Where country of birth was known
Non-UK-born TB case reports by time since entry, UK, 2009
600
500
600
400
of cases
200
300
Num
ber o
100
0
0 5 10 15 20 25 30 35 40 45 50+
Years since entry to diagnosis
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
TB case reports and rates ethnic f
273 3001,800
group and place of birth, UK, 2009273
218
235 234
200
250
300
1 200
1,400
1,600
1,800
0)s
Number of cases
Rate (per 100,000)
133 150
200
800
1,000
1,200
e (per 100,000
mbe
r of cases
321
4355
3042
2211 9 7
3859 59
50
100
200
400
600
Rate
Num
3 9 7
00
White
Caribb
ean
k‐African
k –othe
r
Indian
Pakistani
nglade
shi
Chinese
ed/other
White
Caribb
ean
k‐African
k –othe
r
Indian
Pakistani
nglade
shi
Chinese
ed/other
Black‐C
Blac
Blac Ban
Mix
Black‐C
Blac
Blac Ban
Mix
UK‐born Non‐UK‐bornPlace of birth/Ethnic groupPlace of birth/Ethnic group
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS) Labour Force Survey population estimates
Tuberculosis case reports by siteTuberculosis case reports by site of disease, England, 2009
Number of cases % Number of cases %
Site of disease
Total**YearExtra‐pulmonary onlyPulmonary*
u be o cases % u be o cases %2000 3604 59 2476 41 60802001 3679 59 2588 41 62672002 3907 59 2712 41 66192003 3821 58 2824 42 6645
otaea
2004 3962 57 2996 43 69582005 4227 55 3440 45 76672006 4227 55 3459 45 76862007 4053 53 3528 47 75812008 4222 54 3644 46 78662008 4222 54 3644 46 78662009 4401 54 3816 46 8217
* With or without extra-pulmonary disease** Where site of disease was known Where site of disease was known
Sources: Enhanced Tuberculosis Surveillance (ETS)
TB-HIV co-infection, England, Wales and Northern Ireland, 1999-2008
800 12.0
600
70010.0
Number Proportion (%)
500
600
f cas
es
8.0
on (%
)
300
400
Num
ber o
f
4.0
6.0
Prop
ortio
100
200
2.0
02000 2001 2002 2003 2004 2005 2006 2007 2008
Year
0.0
Sources: Enhanced Tuberculosis Surveillance, HIV/AIDS database
Prevalence of diagnosed TB in Londonamong different population groups
900
1000
g p p g p
600
700
800
r 10
0,00
0
300
400
500
vale
nce
per
0
100
200
300
Prev
0
HIVste
l/on s
treet
mDrug
users
Prison
Black A
frican
arrive
d <1yr)
nese
or ot
her
South
Asian
Foreign
Born Male
ck C
aribb
eanOve
rallFem
aleBorn
UK
Whit
e
Living
in H
ostProb
lem Bl
Recent
migran
t (ar
Chine S Fo
Black
Risk group
ReSource: London TB Nurses Case Load Profile, Story et al. Thorax 2007
Prevalence of social risk factors among tuberculosis cases
• England, Wales and Northern Ireland, 2009:4 6% l h l i / b– 4.6% alcohol misuse/abuse
– 3.3% drug use2 8% i– 2.8% prison
– 2.6% homeless
– 9% of cases had at least one social risk factor
Based on cases with known information for each risk factor (69-74%)
Source: Enhanced Tuberculosis Surveillance
Treatment outcomes (at 12 months)f TB t d i 2008 UKfor TB cases reported in 2008, UK
transferred out1% treatment not completed
treatment stopped
treatment stopped 1%
lost to follow-up5%
1% treatment not completed0%
outcome unknown1%
transferred out
5%
died
still on treatment5%
6%
completed81%
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Proportion completing treatment in 12 th b t / i UK 2008months by country/region, UK, 2008
100.0
81.575.4 75.3
82.3 82.378.3
83.378.2
83.178.7
70.7
81.879.3
70.0
80.0
90.0
s (%
)
CMO's target of 85%
40.0
50.0
60.0
rtio
n of
cas
es
10 0
20.0
30.0
Prop
or
0.0
10.0
Eng
land
n Ire
land
Sco
tland
Wal
es
Mid
land
s
Eng
land
Lond
on
orth
Eas
t
rth W
est
uth
Eas
t
uth
Wes
t
Mid
land
s
hire
and
mbe
r
E
Nor
ther
n S
Eas
t M
Eas
t of E No
Nor Sou
Sou
Wes
t M
Yor
ks Hu
Country/ Region
*Department of Health. Stopping Tuberculosis in England: An Action Plan from the Chief Medical Officer. 2004. London, Department of Health.
Sources: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Development of drug resistance
Source: WHO
MDR-TB among new TB cases 1994 20091994-2009
© WHO 2010. All rights reserved
Primary MDR-TB, Europe*, 2008y , p ,
Source: ECDC.
Second-Line Drug Classes for MDR-TB TreatmentMDR TB Treatment
Amikacin, KanamycinAminoglycosides
Polypeptides Capreomycin
Ciprofloxacin, Ofloxacin
yp p p y
Fluoroquinolones Ciprofloxacin, Ofloxacin
Ethionamide ProthionamideThioamides
FluoroquinolonesFirst line
drugs+
Ethionamide, ProthionamideThioamides
Serine analogues Cycloserine
PAS
Serine analogues Cycloserine
PAS
WHO. Guidelines for the programmatic management of drug-resistant tuberculosis. 2006.
Countries that have reported at l t f XDR TBleast one case of XDR-TB
© WHO 2010. All rights reserved
MycobNet Reference Laboratories, UK
S tti h M b t iHPA Regional Centre for Mycobacteriology, Newcastle
Scottish Mycobacteria Reference Laboratory, Edinburgh
HPA Regional Centre for Mycobacteriology, Birmingham
Northern Ireland Public Health Laboratory,
HPA National Mycobacterium Reference Unit London
Health Laboratory, Belfast
Wales Centre for Mycobacteriology
Reference Unit, London
Royal Brompton Hospital,Royal Brompton Hospital, London
Proportion of TB cases with first-
Isoniazid resistant
line drug resistance, UK, 2000-2009
10
Multi-drug resistant
Resistant to any first line drug
8
9
10
%)
XDR – Twelve cases 1995 – 2009
5
6
7
on o
f cas
es (%
2
3
4
Prop
ortio
0
1
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Sources: Enhanced Tuberculosis Surveillance (ETS), UK Mycobacterial Surveillance Network (MycobNet), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Transmission of drug resistanceg
• 20% of MDR cases have indistinguishable 15 loci MIRU-VNTR typing profileloci MIRU-VNTR typing profile
» Kruijshaar M et al BMJ 2008
• No evidence of association between HIV and anti TB drug resistance (except MDR in Whites)
» French CE et al ERJ 2008
5. Mycobacterium bovis, UK 2000-2009y ,
M. bovis M. tuberculosis complex*Year
M. bovis M. tuberculosis complexn % n
2000 29 0.7 43532001 30 0.7 42052002 17 0.4 47922003 21 0.4 48482004 19 0.4 51612005 36 0.7 55312006 33 0 6 56022006 33 0.6 56022007 28 0.5 53552008 27 0.5 5529
2009** 29 0.6 5246Total 269 0.5 50622
* Culture confirmed cases: inclusive of M. bovis** Scottish data incomplete
5. Isolates of M. bovis by age group and place of birth UK 1994 2008*place of birth, UK, 1994-2008*
250
300
es
≥65 years
<65 years
200
250
ovis
isol
ate <65 years
100
150
ber o
f M. b
o
0
50Num
b
0UK-born Non-UK-born
Place of birth
* Where place of birth is knownSource: Enhanced M. bovis database
TB Control
Goals - Action Plan
• Reduce the risk of people being newly infected withTB in EnglandTB in England
• Provide high quality treatment and care for all peopleith TBwith TB
• Maintain low levels of drug resistance, particularlymulti-drug resistant TB
TB control in UK: Main elements
• Case findingpassive clinical presentationpassive - clinical presentationactive - contact tracing (source)
& screening (migrants)& screening (migrants)• Treatment of cases
• Chemoprophylaxis (for latent TB)
• BCG
TB control in the UK
• National Response:National Response:– Action plan published in 2004– NICE guidelines in 2006, elements being updated
T lkit f i i i– Toolkit for commissioning– DH TB reference group
• The HPA– A TB Programme Board– National strain typing service– Cutting edge research– Strengthened surveillance and laboratory servicesStrengthened surveillance and laboratory services– Role of Health Protection Units in local control– Supporting international control
BCG vaccinationBCG vaccination
• Vaccine efficacy:– Varies in different studies/ parts of the worldp
• UK BCG policy (since Sept 2005) - target groups atUK BCG policy (since Sept 2005) target groups at highest risk: – All infants (0-12 months) living in areas where TBAll infants (0 12 months) living in areas where TB
incidence ≥40/100,000 – All infants (0-12 months)( )
with a (grand-) parent born in country where TB i id 40/100 000incidence ≥ 40/100,000
Thank you! www.hpa.org.uk