tuberculosis surveillance and control - faculty of · pdf filetuberculosis surveillance and...

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