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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology1
Epidemiology of Tuberculosis: Global, National & Wyoming
Randall Reves, MD, MScVolunteer Clinician Denver Metro TB Program and Division of Infectious Diseases, Department of MedicineUniversity of Colorado Denver
Disclosure
Randall Reves doses not have any financial disclosures.
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology2
Brief reminder about TB: 19 y.o. student in septic shock in ED
Sudden onset of severe abdominal pain Negative past medical history except for
outpatient UTI treatment with ciprofloxacin 6 months earlier
Arrived in U.S. from Nepal in past year No known TB exposure, no prior + TST Chest X-ray “negative for TB” at prior
clinic visit, follow-up recommended but could not be accomplished
19 y.o. student in ED
•X-ray abnormalities?
•Diagnostic studies?
•Emergent treatment?
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology3
19 y.o. student in ED
Perforated colon at laparotomy
Granulomatous inflammation
Sputum AFB smear +
Expired despite I.V. levofloxacin, amikacin, rifampin & antibiotics
News Alerts
Colorado Springs Student From Nepal Dies From TBWoman Was International Student At CSU-PuebloPOSTED: 1:16 pm MDT June 11, 2007
COLORADO SPRINGS, Colo. -- Tuberculosis was confirmed as the cause of death of a patient who died at Colorado Springs' Memorial Hospital shortly after arriving at the emergency room on Friday.
It was not known what type of TB killed the 19-year-old student from Nepal but officials held an afternoon news conference to discuss the case.
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology4
19 y.o. student: X-ray 6 mo earlier
Was TB the diagnosis then?
Was it partially treated with ciprofloxacin?
Was this illness and death preventable?
Reminder: TB can be deadly in healthy persons
Global TB Burden, 2016 estimates*
Estimated number of cases
Estimated number of deaths
1.7 million^• 1,070,000 in males
• 601,000 in women
• 253,000 in children
10.4 million140 per 100,000
• 6.7 million males
• 3.7 million females
• 1.4 million children
490,000 (4.1% of new TB)
600,000 (incl. RR‐TB)
Total TB
Multidrug‐resistant TBMDR/RR
HIV‐associated TB 1 million (10%) 374,000 (22%)
240,000(14%)
^Includes HIV/TB deaths*WHO Global TB Report 2017
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology5
WHO Global TB Report 2017 (for 2016)
30 high-burden countries: top 20 by number & top 10 by rates in smaller countries
For details see: http://www.who.int/tb/country/data/profiles/en/
WHO Estimated TB Incidence Rate, 2016
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology6
WHO Estimated TB Incidence, 2016
Global Impact of TB Deaths
WHO Global TB Report 2017
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology7
WHO Global TB Report 2017
WHO Global TB Report 2017
Global Trends in TB Incidence, Notification and Deaths
Notes: 39% of estimated TB not notified in 201686% of HIV deaths in African region
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology8
If this is true today, why is progress slowing?
We have yet to adequately respond -
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology9
Reported Tuberculosis (TB) Cases United States, 1982–2016*
*As of June 21, 2017.
No. o
f cases
Year
26,673 TB cases in 1992
9,272 TB cases in 2016
TB Morbidity United States, 2011–2017*
Year No. Rate
2011 10,509 3.4
2012 9,940 3.2
2013 9,561 3.0
2014 9,398 3.0
2015 9,547 3.0
2016 9,272 2.9
2017 9,092 2.8
*MMWR 3 23 2018: Decrease of 2.5% from 2016
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology10
TB Case Rates,* United States, 2016
*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
NYC
WY: Cases 1 & 4 in ’16 & ’15Rates 0.2 & 0.7
Map of U.S.‐Affiliated Pacific Islands, by TB Case Rates:* Total TB cases 471, pop. 3.8 million, rate 12.3 in 2016
*Cases per 100,000 population; as of June 21, 2017.
Federated States of
Micronesia
Marshall Islands
Northern Mariana Islands
American Samoa
Guam
Palau
≥5010–49.9≤9.9
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology11
TB Case Rates* by Age Group, United States, 1993–2016
*Cases per 100,000 population; as of June 21, 2017.
Cases per 100,000 population
Age (yrs.)
TB Case Rates by Age Group and Sex, United States, 2016*
*Cases per 100,000 population; as of June 21, 2017.
Cases per 100,000 population
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology12
TB Case Rates by Race/Ethnicity,* United States, 2003–2016†
* 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.† As of June 21, 2017.
Cases per 100,000 population
TB Case Rates by Age Group and Race/Ethnicity,*United States, 2016†
Cases per 100,000 population
* 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.† As of June 21, 2017.
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology13
Number of TB Cases Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*
No. o
f cases
*As of June 21, 2017.
Non‐U.S. born: 29.5% to 68.5% from 1994 to 2016
Reported TB Cases by Race/Ethnicity,*United States, 2016†
Hispanic/Latin 28%
Native Hawaiian/Pacific Islander 1%
American Indian/Alaskan Native 1%
Black/African American 21%Asian 35%
Multiple race 1%
White 13%
* 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.
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology14
Reported TB Cases by Origin and Race/Ethnicity*, United States, 2016†
U.S.‐born persons Non‐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; as of June 21, 2017.§ American Indian/Alaska Native accounted for <1% of cases among non‐U.S.–born persons and are not shown.
TB Case Rates Among U.S.‐Born versus Non‐U.S.–Born Persons, United States*, 1993–2016†
Cases per 100,000 population
* Includes the same data as previous slide, but rates are presented on a logarithmic scale.† As of June 21, 2017.
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology15
Countries of Birth Among Non‐U.S.–Born Persons Reported with TB, United States, 2016
*Percentages are rounded; as of June 21, 2017.
Primary Anti‐TB Drug Resistance, United States, 1993–2016*
* As of June 21, 2017. Note: 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.
Resistan
t (%
)
Year
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology16
Primary MDR‐TB, United States, 1993–2016*
* As of June 21, 2017. Note: 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.
Primary Isoniazid Resistance Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*
Resistan
t(%
)
* As of June 21, 2017. Note: Based on initial isolates from persons with no prior history of TB.
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology17
Primary MDR‐TB Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*
* As of June 21, 2017. Note: 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.
Resistan
t(%
)
Epidemiology of MDR TB in the U.S.
168 cases in 8 states, 86% foreign-born, 15% with clustered isolates by genotyping
92 in-depth interview: 22% imported active MDR TB (within 3 mo.)
22% due to transmission within USA
41% due to reactivation of latent TB infection, with 15% previously treated outside USA
5% relapse of TB previously treated in USA
10% unknown
Moonan P, et al Lancet Infection 2013: TBESC TO 8
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology18
XDR‐TB* Case Count, Defined on Initial DST,†
by Year, 1993–2016§
* XDR‐TB , extensively drug‐resistant TB.† DST, drug susceptibility test.§As of June 21, 2017.Note: XDR‐TB is defined as resistance to isoniazid and rifampin, plus resistance to any fluoroquinolone and at least one of three injectable second‐line anti‐TB drugs.
Case count
Year of diagnosis
US-born and Foreign-born Prevalence of LTBI & Case Rates by Age,
1999-2000 Bennett 2007, CDC 2000LTBI Prevalence
0.3 0.6 1.23.4 4.8
11.9 12.8
20.6
25.3
11.9
0
5
10
15
20
25
30
< 15 15- 25- 45- 65+
%
US-B FB
TB Case Rate
1.3 1.4 3.6 5.88.37.3
19.9 19.122
35.8
05
10152025303540
<15 15- 25- 45- 65+
Rate
US-B FB
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Epidemiology19
Estimated TB Infection in the U.S.LTBI prevalence 6 million to 13 million.
Foreign born TST 20.5%
QFT 15.9%
Both positive 9.3%
US-born
TST 1.5%
QFT 2.8%
Both positive 0.6%
Reported TB 9 years in WY’ 2009-17
Cases: 25, range 0 (’13) -7 (’10), ave 2.8
Nativity (missing 3): US 8
Africa 2: Ethiopia, Kenya
Asia 7: China, India, Nepal 3, Philippines 2
Latin America 5: Mexico 3, Peru 2
Site (missing 1): Pulmonary 17
Extra-pulmonary 7
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Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology20
How can you use epidemiologic data in the clinic? What questions are more important in assessing a patient’s risk of TB?
Country of birth or length of residence in a TB-endemic country?
Age or years of residence in TB-endemic country?
Race/ethnicity or country of birth/residence?