sydney local health district notifications 2008 2017 · 2018-07-19 · page 4 of 14 1. executive...

SydneyLocalHealthDistrictTuberculosisnotifications

2008‐2017

Sydney Local Health District Public Health Unit

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Disclaimer

This report is produced by the Sydney Local Health District (SLHD) Public Health Unit using the NSW

Notifiable Conditions Information Management System (NCIMS), accessed through SaPHARI (Secure

Analytics for Population Health Research and Intelligence). Information in the database is obtained

from the diagnosing doctor. Data were extracted on 19 April 2018 based on the earliest received

date in NCIMS through custom task functionality. The notification date and earliest received date

are likely to be the same. Counts and rates are presented based on diagnosis year, which is the year

in which the majority of actions relating to the clinical and public health management of the case

occurred. This variable is used for all state tuberculosis data reporting.

Rates were calculated using the Australian Bureau of Statistics’ estimated resident population data

extracted in SaPHARI through custom task functionality. Note that numbers may vary depending on

the date the data were extracted from the database.

The data within this report may be subject to revision and should not be published or distributed

further without approval of the Director, SLHD Public Health Unit.

Please note: due to the late release of updated 2016 census population estimates from NSW Health

(i.e. end of April 2018), the rates of disease by LGA in this series of annual reports are by the 2011

LGA boundaries only.

Report date: 04 June 2018

Authors: Emma Quinn, Zeina Najjar and Leena Gupta

Sydney Local Health District Public Health Unit

Mailing address: PO Box 374, Camperdown 1450

Phone: (02) 9515 9420

Fax: (02) 9515 9440

Secure Fax: (02) 9515 9467

Contents

Disclaimer................................................................................................................................................ 2

1. Executive Summary ......................................................................................................................... 4

2. Demographic trends in TB notifications ......................................................................................... 5

a) Notifications and age‐standardised rates by year ...................................................................... 5

b) Age‐standardised rates of TB: NSW vs SLHD .............................................................................. 5

c) Notifications by age group and sex ............................................................................................. 6

d) Five year average notification rates for TB by Local Government Area (LGA) ............................ 6

e) Notifications by Local Government Area (LGA) ........................................................................... 7

f) Trends in TB notifications by Country of Birth (COB): NSW vs SLHD ........................................... 8

3. Risk factors for TB ........................................................................................................................... 9

4. Diagnosis of TB .............................................................................................................................. 10

a) Reason for testing and confirmation ........................................................................................ 10

b) Principal site of infection ........................................................................................................... 10

c) Numbers of TB cases who undertook a HIV test at diagnosis ................................................... 11

5. Outcomes for TB treatment and management ............................................................................ 12

a) Treatment management ........................................................................................................... 12

b) Treatment outcomes ................................................................................................................. 13

c) Drug susceptibility testing ......................................................................................................... 13

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1. ExecutiveSummaryThis report provides a description of the epidemiology of tuberculosis (TB) cases notified in Sydney

Local Health District (SLHD) during the period 2008 to 2017.

The number of notifications in 2017 (71) was lower than the ten year annual average (78

cases/year).

Age‐standardised rates of TB have remained consistently higher than those of NSW, with

males experiencing the highest rates. Notifications of TB were most common in the 20‐34

year old age group.

Burwood Local Government Areas (LGA) had the highest rates of TB in SLHD from 2008 to

2012, with the rates subsequently decreasing from 2013. Rates of TB in Marrickville LGA have

decreased significantly during the last ten years. Leichhardt and Canada Bay LGAs have had

the lowest rates of TB in SLHD during the last ten years.

Nearly three quarters of all TB notifications between 2008 and 2017 were of people born in

Southern and Central Asia (38%), South‐East Asia (26%), or North‐East Asia (17%). In SLHD

during 2017, there was an increase in the proportion of cases born in Southern and Central

Asia compared to the previous ten years, 38% vs 50%.

During the last ten years, slightly higher proportions of TB cases in SLHD were born in a high‐

risk country or had in the past resided (greater than three months) in a high‐risk country,

compared to the NSW average.

Between 2008 and 2017, over 85% of all new TB cases in SLHD were confirmed via culture

(including concomitant smear negative and positive cases). During this time, the proportion of

TB cases with pulmonary involvement (i.e. with site of infection as pulmonary or pulmonary

plus other sites) reporting microbiological confirmation via PCR or culture on a respiratory

specimen increased from 95% to 100%.

From 2008 to 2017, the proportion of TB cases who undertook a HIV test increased from 59%

to 97%.

In the last ten years, TB cases with pulmonary involvement in SLHD experienced a shorter time

to treatment (median 19 days, IQR 7‐51) compared to cases with extrapulmonary involvement

(median 28 days, IQR 13‐61). However, during 2017, both pulmonary and extrapulmonary TB

cases experienced a reduction in time to treatment, with a median reduction of 10 and 18

days, respectively.

Over the last ten years, an average of 85% of TB cases had their treatment fully supervised

(regardless of classification or site of infection).

At the time of this report, 87% of all SLHD TB cases notified between 2008 and 2017 had

completed their treatment. Of note, during the last ten years in SLHD, there were no cases of

TB treatment failure.

During the last ten years, 33 cases of TB died, with only one of these (in 2016) having their

death recorded as being due to TB.

Of all SLHD TB cases between 2008 and 2017 (n=775), 64% were reported as fully sensitive to

first line TB drugs and 7% were resistant to one or more TB drugs, with cases most frequently

reported as resistant to isoniazid mono‐therapy. All ten multi drug resistant (MDR) TB cases

between 2008 and 2017 were born overseas.

2. DemographictrendsinTBnotifications

a) Notificationsandage‐standardisedratesbyyearThe number of notifications in 2017 (71) was lower than the ten year annual average (78 cases/year)

(Figure 1).

Figure 1: Number of notifications of TB in SLHD by year of diagnosis, 2008 – 2017

b) Age‐standardisedratesofTB:NSWvsSLHDAge‐standardised rates of TB in SLHD have remained consistently higher than those of NSW, with

males experiencing the highest rates (Figure 2).

Figure 2: Age ‐ standardised notification rates per 100,000 population of TB by sex and year of

diagnosis, 2008 ‐ 2017

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c) NotificationsbyagegroupandsexPeople aged between 20‐34 years are most likely to be infected by TB in SLHD (Figure 3).

Figure 3: Number of notifications of TB in SLHD, by age group and sex, 2008 ‐ 2017

d) FiveyearaveragenotificationratesforTBbyLocalGovernmentArea(LGA)

Burwood LGA had the highest rates of TB in SLHD from 2008 to 2012, but since 2013, the rates have

almost halved. Rates of TB in Marrickville LGA have decreased significantly during the last ten years.

During the last ten years, Leichhardt and Canada Bay LGAs have had the lowest rates of TB in SLHD

while there was a significant decrease in TB rates in Marrickville LGA (Figure 4).

Figure 4: Five year average annual notification rates per 100 000 population for TB by LGA*, SLHD, 2008‐2017

*OnlytheportionofSydneyLGAwithintheSLHDboundaryisincluded.Fiveyearcrudeaverageannualnotificationrates(per100000population)areshownabovebytheredandbluedotsrespectively.MovingaverageannualrateshavebeencalculatedtobetterrepresentanychangesinnotificationratesbyLGAovertimeduetosmallnumbers.The95%confidenceintervalsprovideanindicationoftheprecisionofestimatingtherateoverthefiveyearperiod.

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e) NotificationsbyLocalGovernmentArea(LGA)Table 1: Five year average annual notification rates of TB per 100 000 population in SLHD by

LGA*, 2008‐2012 vs 2013‐2017

Local Government Area (LGA)

Five year average annual crude notification rate (95% CI#)

2008‐2012 2013‐2017 Ashfield 17.1 (12.1‐23.7) 16.1 (11.2‐22.2) Burwood 30 (22.4‐39.5) 16.5 (11.2‐23.4) Canada Bay 7.2 (4.8‐10.4) 5.9 (3.8‐8.6) Canterbury 15.3 (12.6‐18.5) 16.1 (13.4‐19.2) Leichhardt 4.7 (2.5‐8.1) 3.8 (1.9‐6.8) Marrickville 17.5 (13.6‐22.1) 9.1 (6.5‐12.5) Strathfield 16.9 (11.5‐23.9) 20.8 (15‐28.1) Sydney* 12.9 (10‐16.4) 10 (7.6‐12.8)

*OnlytheportionofSydneyLGAwithintheSLHDboundaryisincluded.#The95%confidenceintervals(CI)provideanindicationoftheprecisionofestimatingtherateoverthefiveyearperiod.

f) TrendsinTBnotificationsbyCountryofBirth(COB):NSWvsSLHDNearly three quarters of all TB notifications between 2008 and 2017 were from people born in

Southern and Central Asia (38%), South‐East Asia (26%), or North‐East Asia (17%) (Table 2). This

pattern is fairly consistent with NSW data, with slight differences regarding the proportion of cases

from Oceania and North‐East Asia. During 2017, there was an increase in the proportion of SLHD

cases born in Southern and Central Asia compared to the last ten years, 38% vs 50%.

In SLHD over the last ten years, cases born in the Southern and Central Asia (n=296) region were

predominantly from India (n=116) and Nepal (n=115). Of those from the South East Asia (n=199)

region, cases were predominantly from Vietnam (n=73) and Indonesia (n=46). Of those from the

North‐East Asia (n=128) region, cases were predominantly from China (n=88) (excludes SARS and

Taiwan) and the Republic of Korea (n=23).

Of the cases born in Australia during the last ten years (n=52), there were 12 (23%) cases where risk

factor status was unable to be determined/not assessed.

Table 2: Tuberculosis notifications by major region of country of birth (COB), NSW vs SLHD: 2008 to

2017*

NSW (2008‐2017) SLHD (2008 ‐2017) SLHD 2017 only

Major region of COB N % N % N %

AMERICAS 56 1 13 2 <5 3

NORTH AFRICA AND THE MIDDLE EAST 113 2 10 1 <5 3

NORTH‐EAST ASIA 636 13 128 17 9 13

NORTH‐WEST EUROPE 69 1 8 1 0 0

OCEANIA AND ANTARCTICA 701 14 71 9 <5 3

SOUTH‐EAST ASIA 1424 29 199 26 17 24

SOUTHERN AND CENTRAL ASIA 1594 33 296 38 35 50

SOUTHERN AND EASTERN EUROPE 131 3 26 3 <5 3

SUB‐SAHARAN AFRICA 172 4 22 3 <5 1

Totals 4896 100 773 100 70 100

* Frequency totals above are based on data only where COB was available. Missing data on COB

only represents 0.3% of NSW and SLHD notifications.

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3. RiskfactorsforTBDuring the period from 2008 to 2017, slightly higher proportions of TB cases in SLHD were born in a

high‐risk country or had in the past resided (greater than three months) in a high‐risk country (Table

3), compared to the average across NSW.

Table 3: Tuberculosis notifications by risk factor, NSW vs SLHD: 2008 to 2017*

NSW (2008‐2017) SLHD (2008 ‐2017)

Risk factors N % N %

Total cases** 4910 775

Born in a HRC# 4013 82 674 87

Past residence (>= 3m) in HRC 1578 32 305 39

Household member or close contact with TB 659 13 79 10

Immunosuppressive condition/therapy 641 13 86 11

Currently/Previously employed in HC 317 6 47 6

Previously diagnosed with TB 312 6 44 6

Not able to be determined 205 4 25 3

Other specified 161 3 15 2

Ever employed in HC O/S 157 3 22 3

Ever employed in HC within Australia 100 2 18 2

Currently employed in HC within Australia 86 2 15 2

Child of parent/s born in a HRC 71 1 <5 <1

Ever homeless / residing in a shelter 51 1 6 1

Ever employed / resided in an institution 53 1 6 1

Ever resided in a correctional facility 28 1 <5 <1

Not assessed 22 <1 <5 <1

Currently employed in HC O/S 16 <1 <5 <1

** Any one case can have multiple risk factors, so the frequencies above do not add up to the total

number of cases.

#High risk country as determined by the attending clinician at the time of diagnosis. HC =

healthcare, HRC = high‐risk country, O/S = overseas

4. DiagnosisofTB

a) ReasonfortestingandconfirmationBetween 2008 and 2017, on average 95% (738/775) of all TB cases in SLHD were classified as ‘new

active’, with the remaining 5% of total cases classified as relapses, similar to that across NSW. Of the

cases classified as relapses (either full or partial) during the last ten years in SLHD, 2.2% (17/775) had

relapsed after treatment in Australia and 2.6% (20/775) had relapsed after treatment overseas.

While across NSW, 1.7% (84/4906) and 3.1% (152/4906) of TB cases relapsed after treatment in

Australia or overseas respectively during the same period.

Over the last ten years in SLHD, approximately 80% of all TB cases were symptomatic at the time of

diagnosis. During this time, over 85% of all new TB cases in SLHD were confirmed via culture

(including concomitant smear negative and positive cases) (Figure 5). However, in 2017, there was

an increase in the proportion of TB cases diagnosed by PCR i.e. 26% in 2017 vs 10% between 2008

and 2017 in SLHD.

Figure 5: Proportion of TB notifications by test for confirmation, 2008 – 2017

b) PrincipalsiteofinfectionOver two thirds of all notifications in 2017 were classified as pulmonary (64%), with the remaining

one third of cases classified as extrapulmonary (Figure 6). This pattern is consistent with the

previous 10 years in SLHD and across NSW.

Between 2008 and 2017, the proportion of all TB cases with pulmonary involvement (i.e. with site of infection as pulmonary or pulmonary plus other sites) and reported microbiological confirmation via PCR or culture on a respiratory specimen increased from 95% to 100%.

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Figure 6: Proportion of TB notifications by site of infection for SLHD, 2008 ‐ 2017

c) NumbersofTBcaseswhoundertookaHIVtestatdiagnosisBetween 2008 and 2017, the proportion of TB cases that were offered and undertook a HIV test at

diagnosis increased from 59% to 97%.

Figure 7: Proportion of TB cases who undertook a HIV test at diagnosis, SLHD, 2008‐2017

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5. OutcomesforTBtreatmentandmanagement

a) Treatmentmanagement

Overall in the last ten years, TB cases with pulmonary involvement experienced a shorter time to treatment (median 19 days, IQR 7‐51) compared to cases with extrapulmonary involvement (median 28 days, IQR 13‐61) (Figure 8), which is consistent with NSW data. However, during 2017 both pulmonary and extrapulmonary TB cases experienced a much shorter time to treatment, with a median reduction of 10 days and 18 days, respectively (Figure 8).

Figure 8: Median number of days between first health service contact to treatment (where known) for SLHD TB cases, by site of infection: 2008 to 2017

Over the last ten years, on average 85% of all TB cases had their treatment fully supervised (regardless of classification or site of infection), but this decreased in 2017 with around 78% of TB cases having their treatment fully supervised. These trends are consistent with TB cases with pulmonary involvement only.

It should be noted that this difference is linked to a change in definition. In 2016, the classification of full versus partial supervision of TB cases changed as per local SLHD policy, with cases classified as fully supervised if they required to receive treatment three times per week, and partially supervised if they require daily supervision (as SLHD staff do not supervise treatment on the weekends).

b) TreatmentoutcomesAt the time of this report, 87% of all TB cases in SLHD between 2008 and 2017 had completed their

treatment (Table 4), which is slightly higher than the NSW average i.e. 83% (see Table 4 below). Of

note, during the last ten years in SLHD, there were no cases of TB classed as a treatment failure or

missing data on treatment outcomes.

During the last ten years, 33 cases of TB died, with only one case in 2016 having their death recorded

as being due to TB.

Table 4: Tuberculosis notifications by treatment outcome and year, NSW vs SLHD, 2008 ‐ 2017

Year(s) Missing/ unknown

Completed Tx sputum not tested

Cured Defaulted Incomplete ‐ continues

on Tx

Transferred overseas or

NDD

Tx interrupted

Tx failure

2008 0 60 <5 <5 0 <5 0 0

2009 0 79 <5 <5 0 <5 0 0

2010 0 72 <5 <5 0 5 0 0

2011 0 76 <5 0 0 6 0 0

2012 0 59 <5 <5 0 5 0 0

2013 0 60 6 0 <5 <5 0 0

2014 0 57 0 0 5 <5 0 0

2015 0 51 <5 <5 8 <5 0 0

2016 0 64 <5 <5 9 <5 <5 0

2017 0 39 <5 0 23 2 0 0

SLHD totals 2007‐2018*

N 0 617 25 10 48 34 <5 0

%# 0 84 3 1 7 5 <1 0 NSW totals 2007 ‐ 2018*

N 7 3669 194 84 455 219 13 6

(%)# <1 79 4 2 10 5 <1 0

* Missing data not included in the frequency totals above, #total proportions may not exactly add up

to 100.0% due to rounding.

c) DrugsusceptibilitytestingOf all TB cases between 2008 and 2017 (n=775), 64% were reported as fully sensitive to first line TB

drugs and 7% were resistant to one or more TB drugs, with cases most frequently reported as

resistant to isoniazid mono‐therapy (Table 5 below). These data are consistent with trends reported

across NSW. All ten multi drug resistant (MDR) TB cases between 2008 and 2017 were born

overseas, with five of these cases born in South‐East Asia.

Table 5: Tuberculosis notifications by drug susceptibility and year, NSW vs SLHD, 2008 ‐ 2017

Year(s) Not tested/ unknown

Fully sensitive to first

line drugs

MDR‐TB

MonoR*: Ethambutol

MonoR: Isoniazid

MonoR: Pyrazinamide

MonoR: Rifampicin

Resistant to 2>

first line drugs

XDR‐TB

2008 13 57 0 0 <5 <5 0 <5 0 2009 23 56 <5 0 9 0 0 <5 0 2010 22 53 0 0 6 0 <5 0 0 2011 26 54 <5 0 6 0 0 0 0 2012 13 51 0 <5 5 0 0 0 0 2013 17 48 <5 <5 5 0 0 0 0 2014 16 45 0 0 7 <5 0 0 0 2015 18 43 <5 0 <5 0 <5 <5 0 2016 29 50 0 0 6 0 0 0 0 2017 24 42 <5 0 <5 <5 0 0 0

SLHD totals 2007‐2018*

N 201 499 10 <5 55 <5 <5 <5 0

%# 26 64 1 <1 7 <1 <1 <1 0

NSW totals 2007 ‐ 2018*

N 1470 3065 58 <5 261 32 6 13 2

(%)# 30 62 1 <1 5 1 <1 <1 <1

* MonoR = monoresistance. #Total proportions may not exactly add up to 100.0% due to rounding. MDR =

multidrug resistance.

sydney local health district notifications 2008 2017 · 2018-07-19 · page 4 of 14 1. executive...

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