TB Elimination in California

Can We Get There?

Navigating the Landmines CTCA April 28, 2011 Jennifer Flood MD MPH Chief, Tuberculosis Control Branch California Department of Public Health [email protected]

Outline • Is TB controlled?

• Who is involved in TB control? • Where are the landmines?

2 • Way forward?

3

TB Case Trends

4

California Population and Tuberculosis Cases, 2001-2010 3,332 2,329

40 38 36 34 32 30

34 Million

2001

39 Million

2010

5 Change in TB cases by race/ethnicity, 2001-2010 Race/ethnicity White Black Hispanic Asian 2001-2010 365  187 292  1252  1399  % Change -49 151 -48 874 -30 1109 -20

6 TB Cases by Place of Birth Place of Birth 2001-2010 % Change U.S.- born 824  498 Foreign-born 2482  1802 -40 -27

Tuberculosis Cases in Foreign-born and U.S.-born Persons by Race/Ethnicity: California, 2010 5% 95% 25% 75% 64% 36% 71% 29% 7 Note: Excludes 29 cases with unknown race or birthplace

8 TB cases by age group • Age group

0-4

• • 5-14 • 15-24 • 25-44 • 45-64

65+

2001-2010 133  55 92  45 318  215 1109  680 953  736 727  593 % Change

-59

-51 -32 -39 -23

-18

Foreign-born with active TB within one year of U.S. arrival, 2001-2010 9 Year

10 Is TB controlled?

• Lowest case count in California history • Success in – interrupting TB transmission and – TB disease importation

suggested by decline in

: • pediatric cases • US born cases • new arrivers

11

TB Case Characteristics

12 2010 Foreign-born TB Cases: Immigration status • Immigrant • Refugee/asylee • Tourist • Student • Worker • Other* • Unknown** 40% 5% 2% 2% 2% 16% 31% 45% • * without above visa but not unknown • ** patient does not know status on entry, refused response, or local policy restricts response

4000 TB cases among B notification arrivers with abnormal chest radiograph on pre-immigration exam from Mexico, the Philippines, or Vietnam, reported <6 months after U.S. arrival 6,0

4.2%

5,0 3000 4,0 2000 3,0 1000 0

1.4%

2,0 1,0 2006 2007 B notification arrivals 2008 2009 2010 (Jan-Jun) 0,0 % cases among arrivals

2010 TB Cases: Comorbid conditions 480 (21%) 145 (6%) 83 (4%) 17 (.73%) 14 (.60%) Diabetes Immunosuppressed End-stage renal disease TNF Antagonist Post-organ transplant 14 *Nearly 1/3 with co-morbidities; does not include HIV

15 TB Diagnosis and Treatment

2010 TB Cases: Reason for Presentation Passive case-finding • TB symptoms • Abnormal CXR * • Incidental lab * 1455 (63%) 396 (17%) 211 (9%) Active case-finding • Contact investigation • Employee Screening 84 (3.6%) • Immigration screening 78 (3.4%) • Targeted Testing 44 (1.9%) 28 (1.2%) 89% 16 * purpose of CXR or lab was for something other than TB

Provider: TB diagnosis and treatment, TB cases, California, 2008* 17 *Randomly selected TB patients; N=280. Source: TBCB 2008 HIV status field study

18 What interventions are high impact?

Diagnosis • Rapid MTB and drug resistance tests • HIV test of TB patients Treatment • Effective TB treatment • HAART

19 Use of new diagnostics 2010 TB cases (n=2314) • NAAT 892 (39%) • IGRA 475 (22%)

HIV Status Determination is not Universal in CA 20

CDC standard is universal testing of all TB cases

21 Timing of HIV diagnosis (Dx) in HIV positive TB patients, 2008 131 HIV co-infected TB patients 64 (50%) Previously known HIV + 129 Alive at Diagnosis 65

(50%) Newly diagnosed HIV +

44

(68%) 2 weeks prior – 2 weeks after TB Dx

22 Where was HIV test done for HIV/TB co-infected patients?

• 67% • 16% • 17% Hospital Outpatient Unknown

Stage of immunosupporession: HIV-positive TB patients, 2008* CD4 count 83% with count <250 (most below 150) Viral load 88% with VL ≥10,000 23 *New HIV status at time of TB diagnosis

Death by Consumption Nearly 1 in 10 die with TB in California In the last decade in California: Total TB deaths……………………………2,715 Dead before diagnosis or treatment………657 24 Death during treatment…………………...2,058

Time to Death for Patients Starting Therapy, California 2008 25

Median time to death = 48 days

TB Deaths during Therapy, by Provider Type, 1994-2009

10 8 6 4 20 18 16 14 12 2 0 Private Provider Health Department

26

1994199519961997199819992000200120022003200420052006200720082009 Year

27 Why are TB deaths occurring?

28 Is TB a contributor to Death?

Preliminary Results: Mortality Study TBESC • In 75%, TB contributed to death !

29 Who is diagnosing and treating TB in California?

• Private providers are most likely to diagnose TB and start TB treatment • TB diagnosis often occurs in a hospital or emergency room • Public providers provide the majority of care during treatment

30 Who are our cases?

• 40% of foreign-born underwent pre departure screening • A sizeable fraction with comorbid conditions • Opportunity to prevent TB and detect disease earlier • TB deaths = compelling reason to intervene

31 Navigating Landmines

32 Waning TB Control Capacity • Less TB control funds and positions • Increase # cases per case-manager • Decreased oversight of private providers • Jeopardized safety net activities • Upstream activities (eg surveillance, evaluation) Overshadowed daily pressures

33 Too busy killing alligators to drain the swamp?

Treating TB is an excellent investment of public health dollars 34 • Every $614 invested in treating TB cases and contacts saves a year of life • Far more cost-effective than other well accepted public health interventions* – Cervical or colorectal cancer screening cost $12,000 per year of life saved – Cholesterol screening costs $19,000 per year of life saved *Recommended by the

U.S. Preventive Services Task Force

35 Prevention: Can we afford it?

Can we afford not to do it?

Horsburgh CR Jr, Rubin EJ. Clinical Practice: Latent Tuberculosis Infection in the United States. NEJM 2011;364 (15):1441-8.

36

Case Prevention: Which Regimen for Whom?

Problem INH x 9 months: limited by poor completion Purpose Evaluated cost and cost-effectiveness of 4 LTBI regimens Regimens Rifampin x 4 months (SAT) Rifapentine and INH x 12 doses weekly (DOT) INH daily (SAT) x 9 months INH twice-weekly (DOT) x 9 months Findings Rifampin is less costly, increased benefits, cost-saving INH and Rifapentine is cost-saving for extremely high risk patients and cost-effective for lower risk patients 37 Source: Holland et al.

Am J Respir Crit Care Med

2009;179

PREVENT TB Study: TB Trials Consortium Study 26 Study design • Daily INH x 9 months – Vs. Once weekly Rifapentine + INH x 12 weeks (DOT) • Randomized open-label • 33 months follow-up Study population • Contacts and TST converters • Small group of HIV+, children, TB4s Findings • 3RPT/INH is noninferior to 9INH • Completion rate of 3RPT/INH (81.9%) is significantly higher thank 9INH (69.5%) 38 Source: Sterling et al. International Union Meeting, presented November 2011

What is the Evidence?

Evaluation of individuals with B-notification (abnormal CXR) COST-SAVING COST-EFFECTIVE Percent of active cases 3% and above 4% - 1.5% 39 Source: Porco et al.

BMC Public Health

2006;6

40 Case Prevention Should we prioritize LTBI treatment for arrivers with B-notification of TB2 and TB4?

41 The Way Forward?

• Prioritize the most effective activities • Engage partners • BOTH upstream and more direct TB control activities needed • TB funds are a required ingredient • Examining outcomes is paramount

42 What Strategic Direction is Under Consideration?

• Adopt cost-effective diagnostic and treatment approaches • Abandon ineffective unproven approaches • Tackle case prevention as cases decline

Hot Off the Press 43 Source: Bindman AB, Schneider AG. Catching a Wave – Implementing Health Care Reform in California.

N Engl J Med

April 21, 2011; 364(16):1487-89