Tuberculosis (TB) Update National IMAC workshop Sept 2018 · 2018-11-22 · Tuberculosis (TB) Update National IMAC workshop Sept 2018 ... • Burden of MDR TB • Burden of HIV co

Auckland Regional Public Health Service Rātonga Hauora ā Iwi o Tamaki Makaurau

Working with the people of Auckland, Waitemata and Counties Manukau

Tuberculosis (TB) Update National IMAC workshop

Sept 2018

Dr Lavinia PerumalPublic Health Medicine Specialist

Medical Officer of Health- TB Portfolio Lead


www.arphs.govt.nz @aklpublichealthTB Update : National IMAC Workshop September 2018Dr Lavinia Perumal, PHMS, MOH, ARPHS

Take Home messages

• A brief history of TB• TB / LTBI• ARPHS role in TB control• Epidemiology on TB Disease

– global/national• NZ trends

– Population profiles– Risk profiles– Emerging trends



The TB Story – the people, the communities

• Patient A– Frail 93 year old Cantonese

speaking lady. 38 kg.– 1/12 hx back pain– CXR - Right pleural effusion.– Sputum 4+ AFB, PCR Mtb +ve– Anti TB meds and isolation– ARF. Hypothermic,

bradycardic, hypotensive– Died 14 days post admission

• Patient B– 20 year old Somali male.

Student. Born in NZ.100kg– HH contact of a pulmn TB– CXR - mediastinal widening. – CT Chest - necrotic nodes– Developed cough - sputum

AFB –ve, Culture positive– On treatment- well tolerated-

managed in the community



https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwj5kpjPprbdAhWQFogKHXuLBN0QjRx6BAgBEAU&url=https://www.avert.org/professionals/hiv-programming/hiv-tb-coinfection&psig=AOvVaw1LdipIpBT_yhLVuQF4x-ZY&ust=1536870424123967

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwj5kpjPprbdAhWQFogKHXuLBN0QjRx6BAgBEAU&url=https://www.avert.org/professionals/hiv-programming/prevention/prevention-mother-child&psig=AOvVaw1LdipIpBT_yhLVuQF4x-ZY&ust=1536870424123967

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=https://www.results.org.uk/blog/so-you-think-tb-doesn%E2%80%99t-affect-people-europe&psig=AOvVaw1JsmElcPcoBkuUXJzejaCj&ust=1536872690037311

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwjQ4bOpsLbdAhUVPXAKHd7WDbwQjRx6BAgBEAU&url=http://www.immune.org.nz/diseases/tuberculosis&psig=AOvVaw1TVy87K7-x-hiTJtisB7nf&ust=1536873029340100



IS TB still relevant today?



Global movement



End TB Strategy 2014: 3 Pillars

• Pillar 1: integrated patient-centred care and prevention

• Pillar 2: bold policies and supportive systems

• Pillar 3: intensified research and innovation.



End TB Strategy :Pillars 2 and 3



History of tuberculosis• 460 BC: ‘Phthisis’;

– Hippocrates (hereditary) vs. Aristotle (contagion)

• Middle Ages: ‘scrofula’– lymph node disease – England and France - ‘king’s evil’

• 18th C: ‘consumption– 25% of all deaths in Europe. Urban

centres. High fatality• 1882: ‘infectious disease’

– M.tb bacillus isolated (R Koch). Won the 1905 Nobel Prize in Medicine.

– 1/7 died from TB in USA and Europe

• 19th C: Sanatoria – Isolation + improv hygiene, rates

decreasing

• 1921: BCG vaccine • 1946: Streptomycin- First effective

antibiotic: became resistant due to monotherapy

• 1952: Isoniazid - originally an antidepressant

• 1980s: Increase in rates- HIV/AIDS• 1990s to now: MDR TB and global

movement/migration



https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwjzubLHsLbdAhVHPHAKHRwuBmIQjRx6BAgBEAU&url=https://en.wikipedia.org/wiki/Health_stamp&psig=AOvVaw2e_9jLMOB46yQiU58li2Hq&ust=1536873092317905

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwj1z626sLbdAhWXbN4KHcQbC94QjRx6BAgBEAU&url=http://oldcambridgenzimages.blogspot.com/2015/09/the-waikato-sanatorium-maungakawa-hill.html&psig=AOvVaw2VZTo1WTYwGd2LA0tysptS&ust=1536873064958744

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwiy7La4sLbdAhVIM94KHZTnBtAQjRx6BAgBEAU&url=https://teara.govt.nz/en/photograph/30319/cashmere-hills-sanatorium&psig=AOvVaw0fLRX_Jfn7vu0vWAv081Eb&ust=1536873060833354



The Bug: Mycobacterium tuberculosis

• Rod shaped, slow growing• Cell wall is very acidic,

absorbs a dye used in staining slides for microscopy and the red colour cannot be removed -acid fast baccilli (AFB)

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjv7tDZr7bdAhXDAYgKHfBiC0wQjRx6BAgBEAU&url=https://www.medscape.com/viewarticle/883623&psig=AOvVaw1JsmElcPcoBkuUXJzejaCj&ust=1536872690037311



The disease: Tuberculosis

Symptoms Signs

• Cough, Shortness of Breath• Night sweats• Chills/Fevers• Loss of appetite• Lethargy• Weight loss• Confusion/delirium

• Pneumonia:– Consolidation on CXR– Crackles on auscultation

• Enlarged lymph nodes• Swollen joints• Blood in sputum

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwjr6urI17bdAhXCdd4KHVugByYQjRx6BAgBEAU&url=https://www.epainassist.com/back-pain/spinal-tuberculosis-or-potts-disease&psig=AOvVaw0Vid0KnfZ0eWdZ2L6IAs1q&ust=1536883563835963

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjx-7WQ2LbdAhUPUd4KHSf_AXIQjRx6BAgBEAU&url=https://emedicine.medscape.com/article/358610-overview&psig=AOvVaw1zEHMdGV9ES2eIokdUpz94&ust=1536883695770891



TBD vs. LTBI• Active vs. sleeping• Symptoms vs.

asymptomatic• Infectious vs. non

infectious• Testing- blood

tests/cultures/imaging/skin tests

• Both treatable• 1 in 10 LTBI→TBD (lifetime)

• RF: Immunosupressed, elderly, HIV, Diabetes, alcoholism, hepatitis

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwic-93mprbdAhXXZt4KHbe_B5wQjRx6BAgBEAU&url=https://www.pinterest.ca/pin/481885228856706005/&psig=AOvVaw2YoHNuvgB1t6buHuHpYasN&ust=1536870473535205



Why does TB matter

• Leading cause of death and disability– TB leading cause of death from single

infectious agent– Global data, 2016:

• 10.4 million cases (1 million children)• 253,000 children died (i.e. 1 in 4)

• Can affect anyone, any body part• Infectious: Aerosolised transmission• LTBI - 1 in 10 lifetime risk of

developing active disease– Immunosuppression: HIV, DM, elderly





• TB incidence and estimated case numbers

• Burden of MDR TB

• Burden of HIV co infection

Global Tuberculosis epidemiology









MDR TB- A global challenge

• 1 in 5 new TB case in European region had MDR TB, 2016.

• Every 5th MDR TB in the world is in Europe







TB/HIV Co Epidemic (Double Trouble)• 2014: 1.2 million (12%) TB

cases were also HIV positive• 25% of all TB deaths are HIV-

associated• TB accounts for 33% of all

HIV/AIDS deaths• Need better coverage of ART,

CPT, IPT• In Europe, 1 in 8 new TB cases

notified were HIV positive (2016)- unprecedented rise-260% increase in 10 years







Global TB pressures

• Funding gap

• MDR-TB detection and treatment gap

• TB and HIV co-epidemics

• Diabetes, other diseases, smoking

• Lack of laboratory capacity



Tuberculosis epidemiology in New Zealand

• TB incidence in New Zealand

• Epidemiology of TB cases notified in past 10 years born in NZ

• Epidemiology of TB cases notified in past 10 years born outside of NZ



TB in NZ• + 250-300 TB cases annually

• Auckland – 1/3rd of population, 1/2 of TB cases

• 80% born overseas

• NZ born , overseas born –migration

• TB notification rate fairly static since 2007

• Transmission within NZ: declining trend

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjOotyq2rbdAhUEiLwKHakJDysQjRx6BAgBEAU&url=http://justnzholidays.com/new-zealand-destinations/&psig=AOvVaw0-8S-XPj4dmoVPghm1Uelk&ust=1536884291124303



TB disease notification rates, 1980-2017

0

2

4

6

8

10

12

14

16

1980

1983

1986

1989

1992

1995

1998

2001

2004

2007

2010

2013

2016

Rate

per

100,

000

popu

latio

n

Year

TB screening introduced for international students staying over 6 months at the end of 2004

Graph courtesy of Liza Lopez, ESR, Sept 2018



TB disease cases, born in NZ or overseas 2008-2017


0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

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2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

% bo

rn o

ut o

f NZ

Num

ber o

f not

ificat

ions

Year

Born out of NZ Born in NZ % born out of NZ



TB cases born in NZ by ethnicity and DHB, 2008-2017

0

20

40

60

80

100

120

Num

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ifica

tions

DHB

Māori Pacific Peoples Asian MELAA European or Other




TB cases born in NZ by age group and ethnicity

0

10

20

30

40

50

60

70

<1 1-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70+

Num

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f not

ifica

tions

Age group

2008-2012


0

10

20

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<1 1-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70+

Num

ber o

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ifica

tions

Age group

2013-2017





TB cases by birth region, 2008-2017

0

100

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1000

Australia PacificIslands

NAfrica SSAfrica NEAsia SEAsia SCAsia Europe Americas

Num

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ifica

tions

Birth RegionGraph courtesy of Liza Lopez, ESR, Sept 2018



TB notification rate by birth region, 2008-2017

0

20

40

60

80

100

120

140

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Rat

e by

regi

on

Year

Pacific Islands SSAfrica NEAsia SEAsia SCAsia




South & Central Asia by age group and years since arrival 2008-2017

0

50

100

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<1 yr 1-5 yrs 6-10 yrs >11+ yrs

Num

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f not

ifica

tions

Years since arrival 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70+




Tuberculosis – Auckland Region

• ARPHS Role in TB Control

• Regional Surveilance data on TB



Auckland Regional Public Health: TB Prevention and Control

• Case management – Health Act , Multidisciplinary

team– Surveillance – Direct Lab Notifications– Liaison– Successful treatment: DOT/

education, support and care – Advocacy

• Contact tracing and investigation – Identification and screening– targeted LTBI treatment

• BCG vaccination– targeted for at risk children

Pillar one of End TB Strategy



TB in Auckland

• Auckland has a third of NZ’s population, but has half of NZ’s TB cases annually

• Reflects Auckland’s diverse demography and migration trends/countries of origin of migrants

• Up to 90-95% of TB cases in Auckland are overseas-born

• Most MDR-TB cases that occur are in Auckland



ARPHS Weekly TB Surveillance

ARPHS Surveillance Team12 September, 2018



Auckland Region: TB Disease summary of cases











Current / Future Developments

• Reintroduction of Auckland BCG Programme after national absence for two years – restarted July 2018

• Updated NZ Guidelines on TB Case and Contact Management 2018- Draft for external consultation Aug 2018…..

• Australasian TB Conference in Wellington August 2018

• Whole Genome Sequencing (LabPlus)- quicker outbreak recognition, drug sensitivity testing, resistance identification

• TeleDOT access- already in Auckland

• Latent TB Infection Screening and Treatment-NZ guidance and leadership



Acknowledgments

• ESR – Liza Lopez, Helen Heffernan, Jill Sherwood• ARPHS- Surveillance team• WHO TB Reports

Tuberculosis (TB) Update National IMAC workshop Sept 2018 · 2018-11-22 · Tuberculosis (TB) Update National IMAC workshop Sept 2018 ... • Burden of MDR TB • Burden of HIV co

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