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Tuberculosis Epidemiology 1
Tuberculosis EpidemiologyTB CL IN ICAL INTENS IVE COURSE
Curry Internat ional Tuberculos is Center
October 18, 2017
Varsha Hampole, MPH
Tuberculos is Control Branch
Cal i fornia Department Of Publ ic Health
Outline
TB epidemiology
• Global burden
• United States California
Summary of surveillance data
Demographic characteristics
Clinical characteristics
• Summary
Tuberculosis Epidemiology 2
Estimated Global TB Burden, 2015
• 10.4 million incident cases; 1.2 million HIV positive
• 142 cases per 100,000
• 1.8 million deaths • 400,000 deaths among HIV+
• 480,000 developed MDR
WHO, Global Tuberculosis Control 2016
4
WHO, Global Tuberculosis Control 2016
Tuberculosis Epidemiology 3
TB Epidemiology United States
5
Reported Tuberculosis Cases United States, 1982–2015*
No. of Cases
*Cases per 100,000 population; as of June 9, 2016.
Division of Tuberculosis Elimination, CDC
Tuberculosis Epidemiology 4
TB Morbidity
United States, 2010–2015
*Cases per 100,000; as of June 9, 2016
Division of Tuberculosis Elimination, CDC
*Cases per 100,000 population; as of June 9, 2016.
TB Case Rates,* United States, 2015
Division of Tuberculosis Elimination, CDC
Tuberculosis Epidemiology 5
Which populations in the U.S. developed TB?
Reported TB Cases by Age Group, United States, 2015*
*As of June 9, 2016.
Division of Tuberculosis Elimination, CDC
Tuberculosis Epidemiology 6
TB Case Rates by Age Group and Sex, United States, 2015*
Cases per 100,000 Population
Age Group (Years)
Division of Tuberculosis Elimination, CDC
Reported TB Cases by Race/Ethnicity,*United States, 2015
*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. Unknown race consisted of 0.3% and is not shown.
† As of June 9, 2016.
Division of Tuberculosis Elimination, CDC
Tuberculosis Epidemiology 7
Number of TB Cases AmongU.S.‐born vs. Non‐U.S.‐born Persons,
United States, 1993–2015*No. o
f Cases
*As of June 9, 2016.
Division of Tuberculosis Elimination, CDC
TB Case Rates in U.S.‐born vs. Non‐U.S.‐born Persons, United States,1993 – 2015*
Cas
es p
er 1
00,0
00
*As of June 9, 2016.
Cases per 100,000 Population
Division of Tuberculosis Elimination, CDC
Tuberculosis Epidemiology 8
Countries of Birth of Non‐U.S.‐born Persons Reported with TB, United States, 2015*
*As of June 9, 2016.
Division of Tuberculosis Elimination, CDC
What is the prevalence of TB drug resistance in U.S.?
16
Tuberculosis Epidemiology 9
Primary Anti‐TB Drug Resistance,United States, 1993 – 2015*
% R
esis
tant
*As of June 9, 2016.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 (%
)
Division of Tuberculosis Elimination, CDC
Primary MDR‐TB,United States, 1993 – 2015*
%R
esis
tant
*As of June 9, 2016.Note: Based on initial isolates from persons with no prior history of TB; multidrug resistant TB (MDR‐TB) defined as resistance to at least isoniazid and rifampin.
No. o
f cases P
erce
ntage
Division of Tuberculosis Elimination, CDC
Tuberculosis Epidemiology 10
Primary MDR TB Among U.S.‐born vs. Non‐U.S.‐born Persons
United States, 1993 – 2015*% Resistan
t
*As of June 9, 2016.Note: Based on initial isolates from persons with no prior history of TB; multidrug resistant TB (MDR‐TB) defined as resistance to at least isoniazid and rifampin.
Division of Tuberculosis Elimination, CDC
TB Epidemiology California
Tuberculosis Epidemiology 11
Number of Tuberculosis Cases: California, 1988‐2016
California Department of Public Health, Tuberculosis Control Branch
2,062
Number of Tuberculosis Cases and Case Rates: California, 2006‐2016
Cas
e R
ate
per
100
,000
California Department of Public Health, Tuberculosis Control Branch
Tuberculosis Epidemiology 12
Tuberculosis in California, 2016
<= 2.9 (national average)
>= 5.2 (state average)
3.0‐ 5.1
< 5 cases
California Department of Public Health, Tuberculosis Control Branch
CA Epidemiology Reflects Global Epidemiology
Tuberculosis Epidemiology 13
Tuberculosis Cases by Country of Origin: California, 2016*
U.S.-born463 (21.6%)
Foreign-born1,670
(77.8%)
Unknown14 ( 0.7%)
Philippines355 (21.3%)
Mexico450 (26.9%)All Others
404 (24.2%)
Vietnam205 (12.3%)
California Department of Public Health, Tuberculosis Control Branch
China160 (9.6%)
India96 (5.7%)
Tuberculosis Cases by Race/Ethnicity: California, 2016
Asian/Pacific Islander1,081 (50.3%)
Hispanic776 (36.1%)
Black118 (5.5%)
American Indian/Alaska Native4 (0.2%)
White Non-Hispanic165 (7.7%)
California Department of Public Health, Tuberculosis Control Branch
7
Asian/Pacific Islander(53.2%)
Hispanic(34.3%)
Black(5.2%)
American Indian/Alaska Native (0.2%)
White, Non‐Hispanic(7.1%)
Tuberculosis Epidemiology 14
TB Case Rates by Race/Ethnicity: California, 2007 ‐ 2016
California Department of Public Health, Tuberculosis Control Branch
Tuberculosis Cases by HIV/AIDS Diagnosis: California, 2011‐2016
Nu
mb
er o
f C
ases
wit
h H
IV/A
IDS
California Department of Public Health, Tuberculosis Control Branch
Tuberculosis Epidemiology 15
Nu
mb
er o
f M
DR
Tu
ber
culo
sis
Cas
es
*Cases with resistance to at least isoniazid and rifampin reported on the Initial Drug Susceptibility Report (Follow‐up 1) or on the Case Completion Report (Follow‐up 2)
California Department of Public Health, Tuberculosis Control Branch
34
4136 37
2832 33
25
36
16
Tuberculosis Cases with Multidrug Resistance (MDR)*: California, 2005‐2016
Deaths in Persons with Tuberculosis: California, 2005‐2014
Per
cen
t o
f C
ases
Nu
mb
ero
f D
eath
s
California Department of Public Health, Tuberculosis Control Branch
Tuberculosis Epidemiology 16
What are the implications for public health practice?
Continued vigilance, surveillance, and active prevention measures are needed to reach the TB elimination. To continue making strides toward elimination, alignment of domestic TB control activities with international TB control initiatives is needed to address increasing disparities between U.S.‐born and foreign‐born persons. Treatment of persons at high risk with latent Mycobacterium tuberculosis infection is also needed to address this disparity.
‐ CDC MMWR 2015; 64(10); 265‐269
The Challenges of Latent TB Infection• Preventing TB disease by detecting and treating those
with latent TB infection (LTBI) is a cornerstone of the U.S. strategy for TB elimination.
• TB infection is not currently reportable.
• It is estimated that more than 2 million Californians have latent TB infection (~13 million people in the U.S.)
• If not treated, persons with TB infection have a 5‐10% lifetime risk of developing TB disease.
Tuberculosis Epidemiology 17
California Department of Public Health, Tuberculosis Control Branch
Plan to Eliminate TB
• California Tuberculosis Elimination Plan
– TB Free California
• California TB risk assessment
Tuberculosis Epidemiology 18
Summary
Case count• ~ Over 9,000 new cases of TB per year in the U.S.• ~ ¼ of cases in the U.S. occur in California
Disease incident rate• Declining, but the pace of decline has slowed since ~2000• California’s TB incidence rate nearly twice that of the U.S.
Certain groups disproportionately affected• Men (e.g., among 45+ years)• Persons born outside the U.S.• Race/ethnicity disparities
TB Deaths• ~9‐10% of TB case patients die in California
Summary
HIV• ~6% of TB cases in the U.S. and 4% of cases in CA are HIV positive
Drug Resistance• Multidrug resistance in 1‐2% of TB cases
• Isoniazid and multidrug resistance are higher among non‐U.S.‐born than among U.S. born
LTBI• An estimated 13 million people in the U.S. (2.4 million in CA)
have LTBI
• Prioritizing TB screening for groups with elevated LTBI prevalence and medical risk of progression from LTBI to TB may help prevent future TB cases
Tuberculosis Epidemiology 19
References• Centers for Disease Control and Prevention. Reported
Tuberculosis in the United States, 2016. Atlanta, GA: U.S. Department of Health and Human Services, CDC
• Tuberculosis Control Branch. Report on Tuberculosis in California, 2017. Richmond, CA: California Department of Public Health
• World Health Organization. Global Tuberculosis Report, 2016. Geneva, Switzerland