the epidemiology of human tuberculosis in south...

The Epidemiology of Human Tuberculosis in

South Dakota and Elsewhere

Kristin Rounds – Tuberculosis Control Program

South Dakota Department of Health

Presentation Outline

I. Review of global TB

II. Epidemiology of TB in the United States

III. Epidemiology of TB in South Dakota

IV. Review of TB cases with suspected or

confirmed Mycobacterium bovis

Review of Global TB

Review of Global TB

In 2013, there were ~9 million new TB cases and ~1.5 million deaths (80,000 were children).

1/3 of the world’s population is already infected with TB.

TB is the leading cause of death for HIV infected patients worldwide.

In 2013, there were ~480,000 MDR-TB cases.

The global TB mortality rate has dropped 45% since 1990.

The global TB prevalence rate has dropped 41% since 1990.

Estimated 2013 Global TB Incidence rates

2014 New Global MDR-TB Cases

Epidemiology of TB in the United States

Reported TB Cases United States, 1953–2013*

*Updated as of June 11, 2014.

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

No

. of

Cas

es

Year

Reported TB Cases United States, 1982–2013*


0

5,000

10,000

15,000

20,000

25,000

30,000

No

. of

Cas

es

Year

Year No. Rate*

2008 12,893 4.2

2009 11,519 3.8

2010 11,164 3.6

2011 10,509 3.4

2012 9,940 3.2

2013 9,582 3.0

*Cases per 100,000. Updated as of June 11, 2014.

TB MorbidityUnited States, 2008–2013

TB Case Rates,* United States, 2013

*Cases per 100,000.

< 3.0 (2013 national average)

>3.0

D.C.

TB Case Rates* by Age Group United States, 1993–2013

* Updated as of June 11, 2014.

Cas

es p

er 1

00

,00

0

2.9 2.9 2.6 2.3 2.1 1.8 1.7 1.6 1.5 1.6 1.5 1.6 1.4 1.3 1.3 1.3 1 1 0.9 0.8 0.8

5 5 4.6 4.4 4.5 4.1 3.9 4.1 4 3.7 3.8 3.8 3.6 3.6 3.7 3.4 3 2.7 2.4 2.3 2.2

11.5 10.79.7 8.9 8 7.4 7.1 6.6 6.6 6.3 6.1 5.9 5.7 5.6 5.2 5.1 4.7 4.5 4.1 3.8 3.6

12.411.9

11.310.2

9.48.5 8.1 7.4 7 6.3 6.3 5.9 5.7 5.4 5.3 5

4.3 4.2 4 3.8 3.6

17.716.6

15.8

14.913.6

12.611.5

10 9.38.8 8.3 7.8 7.7 7.2 6.8 6.4

5.8 5.55.4 5.1 4.9

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

0 - 14 15 -24 25 - 44 45 - 64 ≥65

Reported TB Cases by Age Group, United States, 2013

<15 years (5%) 15-24 years

(10%)

25-44 years (31%)

45-64 years (31%)

≥ 65 years(23%)

TB Case Rates by Race/Ethnicity,* United States, 2003–2013**

*All races are non-Hispanic. **Updated as of June 11, 2014.

Cas

es p

er 1

00

,00

0

8.2 7.1 6.8 7.2 5.8 5.9 4.3 6.7 5.8 6.3 5.4

29.928 26 26.1 26.5 25.4

23.4 20.9 20.2 19 18.7

11.711.4

10.9 10.2 9.4 8.8

7.6 76.3 5.8 5.4

16.215.6

13.1 12.322.1

15.7

16.3 19.216.1

12.111.3

1.4

1.3

1.3 1.2

1.1

1.1

0.9 0.9

0.8

0.80.7

10.3

10.2

9.5 9.2

8.5

8.1

7.0 6.4

5.8

5.35.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

American Indian or Alaska Native Asian

Black or African-American Native Hawaiian or Other Pacific Islander

Hispanic or Latino White

TB Percentage and TB Case Rates per 100,000 by Race/Ethnicity,* United States, 2013

Percentage of Cases TB Case Rate per 100,000

22%

1%

31%

28%

1%

15%

Black or AfricanAmerican

American Indian orAlaska Native

Asian

Hispanic or Latino

Native Hawaiian orOther Pacific Islander

White

0% 20% 40%

5.4

5.4

18.7

5.0

11.3

0.7

Black or African American

American Indian or AlaskaNative

Asian

Hispanic or Latino

Native Hawaiian or OtherPacific Islander

White

0 5 10 15 20

Number of TB Cases in

U.S.-born vs. Foreign-born Persons,

United States, 1993–2013*


No

. of

Cas

es

1743516191

1467513398

1193510633 9805

8647 7872 7282 6861 6632 6306 5888 5481 5282 4543 4381 3981 3656 3375

74017751

79987739

77427599

76027619

80107718 7929 7844 7724 7815 7731 7602

6956 6773 6522 6274 6193

0

5,000

10,000

15,000

20,000

25,000

30,000

U.S.-born Foreign-born

Trends in TB Cases in Foreign-born Persons,United States, 1993 – 2013*


No. of Cases Percentage

74017751

79987739 7742 7599 7602 7619

80107718

7929 7844 7724 7815 7731 7602

69566773

65226274 6193

0%

10%

20%

30%

40%

50%

60%

70%

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Number of Cases Percent of Total Cases

2003 2013

DC


Percentage of TB Cases Among Foreign-born Persons, United States*

DC

>50%

25%–49%<25%No cases

Risk Factors of Reported TB Cases United States, 2013*


Contact to TB 8% Incomplete LTBI Rx

2%

INF-α Inhibitors 14%

Post-organ Transplant 2%

Diabetes or Renal Disease 1%

Immunosuppression 4%

Other risk factor 20%

No reported risk factor 48%

Primary Anti-TB Drug Resistance,United States, 1993 – 2013*


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.

% R

esis

tan

t

0

5

10

15

20

Isoniazid MDR-TB

XDR TB Case Count Defined on Initial DST* by Year, 1993 – 2013**

* Drug susceptibility test.** Updated as of June 11, 2014.Note: Extensively drug-resistant TB (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.

Cas

e C

ou

nt

Year of Diagnosis

10

6

1

3

2

1

6

1

4

6

4

3

4

2

6

1

5

2

4

0

2

4

6

8

10

12

Summary of Epidemiology of TB in the US

1) In 2013, the US reported the lowest ever number of TB cases.

2) Since the TB resurgence in 1992, the US has seen consecutive decreases annually for 21 years.

3) TB remains mainly a disease of adults.

4) Drug resistance rates remain low.

5) TB case rates remain highest in foreign-born persons accounting for 65% of all cases.

6) Decreases have been reported across all ages and races but the rate of decline is slowest in foreign-born cases.

7) In 2013, 34 states reported that foreign-born TB case accounted for 50% or more of their cases.

Epidemiology of TB in South Dakota

South Dakota TB Cases by Year1913-2014

0

50

100

150

200

250

300

350

400

450

500

550

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

2003

2006

2009

2012

SD TB Cases by Year2000-2014

16

13 13

20

11

16

14

13

16

18

15 15

19

9

8

0

5

10

15

20

25

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

SD TB Suspects by Year 2000-2014

9194

66

72

79 79

72

60

83

118

126

139147

124

109

0

20

40

60

80

100

120

140

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

SD TB Contacts by Year2000-2014

159

298

165

597

1405

264

67

218

482

727

233

139

350

85

246

-50

100

250

400

550

700

850

1000

1150

1300

1450

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

SD Latent TB Infections by Year2000-2014

930

885

815

597

809

663

561587

643

744

625595

460

356 352

0

100

200

300

400

500

600

700

800

900

1000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

South Dakota TB Cases by Site of Disease, 2001-2014

Pulmonary 66%

Non-pulmonary

26%

Both 8%

South Dakota TB Case Rates (per 100,000) by Race

2001-2014

0

20

40

60

80

100

120

140

160

180

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

White American Indian Black Asian

South Dakota TB Cases by Race/Ethnicity, 2001-2014

46%

21%

19%

10%

4%

American Indian

White

Black

Asian

Hispanic

0% 10% 20% 30% 40% 50%

South Dakota TB Cases by County of Residence

2001-2014

Minnehaha 33%

Pennington9%

Shannon9%

Charles Mix 10%

Todd 6%

Ziebach 5%

All other counties 28%

TB Case Rates per 100,000 US and Select States, 2013

3

1.1

1.7

2.8

1.5

1.1

0

0.6

0

1

2

3

U.S. SD ND MN IA NE WY MT

Drug Resistance TB Cases South Dakota, 2001-2014

1 1 1 1 1

1 1

1

3

1

2

1

1

11

1

0

1

2

3

4

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

INH & Streptomycin INH & PZA

Streptomycin Resistance Ethambutol Resistance

PZA Resistance INH Resistance

Risk Factors of South Dakota TB Cases, 2001-2014

4%

4%

9%

12%

22%

23%

24%

33%

0% 5% 10% 15% 20% 25% 30% 35%

No risk factor reported

HIV

Elderly

Immunosuppression or Cancer

Substance Abuse

Contact to Infectious TB

Diabetes/Renal Disease

Foreign-born

*Some TB patients reported 2 or more risk factors.

South Dakota Foreign-born TB Cases, 2001-2014

19%

38%

8%

20% 18%

38%

50%

15%

(25%)

25%

13%

40%

(37%)

44%

50%47%

69%

(44%)

(10%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2009 2010 2011 2012 2013 2014

Second generation TB cases (US-born cases born to foreign-born parents)

Foreign-born

Number of Years Residence in US Before Diagnosis of TB

SD Foreign-born TB, 2001-2014

53%

16%

8%

23%

0%

10%

20%

30%

40%

50%

60%

0-2 years 3-5 years 6-10 years 10+ years

Age at Diagnosis of US-Born versus Foreign-born TB Cases

South Dakota, 2001-2014

10% 8% 8%

16%

18% 17%

23%

21%

35%

18%16%

7%

1% 1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

0-19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60-69 yrs 70+ yrs

US-Born Foreign-born

Summary of Epidemiology of TB in South Dakota

1) In 2014, South Dakota reported the lowest number of TB cases for the 2nd consecutive year.

2) The majority of TB cases are reported from Minnehaha, Pennington, Shannon, Todd, Charles Mix and Ziebach counties however an additional 28% of cases are reported from all other counties.

3) Drug resistance rates remain low.

4) The most common risk factors are diabetes/renal disease, immunosuppression/cancer, substance abuse and contacts to an infectious case.

5) In 2014, 50% of the TB cases were reported in foreign-born persons.

6) 69% of foreign-born cases develop their disease within 5 years of their arrival in the US.

7) Foreign-born TB cases in South Dakota are on average much younger than US-born TB cases.

Review of TB cases with suspected or confirmed Mycobacterium bovis

Reasons for M. bovis infection in humans

Consumption of unpasteurized dairy products (i.e. raw milk, cheese). Considered the most common.

Inhalation of airborne bacteria exhaled by infected animals (thought to be rare).

Direct contact with a wound (i.e. slaughter of infected animal, hunting).

Person-to-person transmission.

Disseminated disease from BCG vaccine.

** M. bovis disease in humans is reported as a case of

tuberculosis to CDC.

Genotyped TB Cases with Mycobacterium bovis,United States, 2004 – 2013*


No. of Cases Percentage

87

100

129 129

147

131121

134125

113

0.0%

1.0%

2.0%

3.0%

0

20

40

60

80

100

120

140

160

Number of Cases Percent of Total Cases

Genotyped TB Cases with Mycobacterium bovis by Country of Birth, United States, 2004 – 2013*


32% 33%26% 21% 26% 30% 25%

32%25%

33%

68% 67%74% 79% 74% 70% 75%

68%75%

67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

U.S.-born Foreign-born

Suspected and Confirmed Mycobacterium bovis TB Cases

South Dakota, 2001-2014

1 1 1 1 1

0

1

2

3

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Suspected M. bovis Confirmed M. bovis

Review of SD M. bovis TB Cases

2001 TB Case

45 y/o American Indian male, US-born

Pulmonary disease

Resistant to INH & PZA

Reported exposure to his sister 28 years before

2005 TB Case

27 y/o black male, foreign-born (Somalia)

Entered US within 1 year of diagnosis

Pulmonary disease

Resistant to INH & PZA

2006 TB Case

35 y/o black male, foreign-born (Ethiopia), HIV+

Entered the US within 1 year of diagnosis

Non-pulmonary disease (spinal TB)

Resistant to PZA

2009 TB Case

49 y/o white male, US-born

Pulmonary disease

Resistant to PZA - Confirmed M. bovis by CDC laboratory

Travel history to Mexico within the last 1-2 years with consumption of unpasteurized cheese

2014 TB Case

77 y/o white male, reported after death

Non-pulmonary disease (renal)

INH & PZA resistant – Confirmed M. bovis by SD State Lab

Bladder cancer patient receiving BCG treatment

Suspected disseminated M. bovis from BCG

Contact information:

Kristin Rounds

TB Control Program

South Dakota Department of Health

615 East 4th Street

Pierre, SD 57501

Telephone: (605) 773-4784

E-mail: [email protected]

Website: http://doh.sd.gov/diseases/infectious/TB/

mailto:[email protected]

http://doh.sd.gov/diseases/infectious/TB/

the epidemiology of human tuberculosis in south...

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