TB Elimination in California

Can We Get There?Navigating the Landmines

CTCAApril 28, 2011

Jennifer Flood MD MPHChief, Tuberculosis Control Branch

California Department of Public HealthJennifer.Flood@cdph.ca.gov

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Outline

• Is TB controlled?

• Who is involved in TB control?

• Where are the landmines?

• Way forward?

TB Case Trends

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California Population andTuberculosis Cases, 2001-2010

Tu

ber

culo

sis

Cas

es

30

32

34

36

38

40

2001 2010

Po

pu

lati

on

3,332

2,329

34 Million

39 Million

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Change in TB cases by race/ethnicity,2001-2010

Race/ethnicity 2001-2010 % ChangeWhite 365 187 -49Black 292 151 -48Hispanic 1252 874 -30Asian 1399 1109 -20

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TB Cases by Place of Birth

Place of Birth 2001-2010 % Change

U.S.- born 824 498 -40

Foreign-born 2482 1802 -27

Tuberculosis Cases in Foreign-born and U.S.-born Persons by Race/Ethnicity:

California, 2010

Note: Excludes 29 cases with unknown race or birthplace

95%

5%

25%

75%

36%

64%

29%

71%

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TB cases by age group

Age group 2001-2010 % Change

•0-4 133 55 -59

•5-14 92 45 -51

•15-24 318 215 -32

•25-44 1109 680 -39

•45-64 953 736 -23

•65+ 727 593 -18

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

Year9

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

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TB Case Characteristics

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2010 Foreign-born TB Cases: Immigration status

• Immigrant 40%• Refugee/asylee 5%• Tourist 2%• Student 2%• Worker 2%• Other* 16%• Unknown** 31%• * without above visa but not unknown

• ** patient does not know status on entry, refused response, or local policy restricts response

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45%

1313

2010 TB Cases:Comorbid conditions

480 (21%) Diabetes

145 (6%) Immunosuppressed

83 (4%) End-stage renal disease

17 (.73%) TNF Antagonist

14 (.60%) Post-organ transplant

*Nearly 1/3 with co-morbidities;

does not include HIV 14

TB Diagnosis and Treatment

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Passive case-finding•TB symptoms 1455 (63%)•Abnormal CXR* 396 (17%)•Incidental lab* 211 (9%)

Active case-finding•Contact investigation 84 (3.6%)•Immigration screening 78 (3.4%)•Targeted Testing 44 (1.9%)•Employee Screening 28 (1.2%)

*purpose of CXR or lab was for something other than TB

2010 TB Cases: Reason for Presentation

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89%

Provider: TB diagnosis and treatment, TB cases, California, 2008*

17*Randomly selected TB patients; N=280. Source: TBCB 2008 HIV status field study

What interventions are high impact?

Diagnosis

•Rapid MTB and drug resistance tests

•HIV test of TB patients

Treatment

•Effective TB treatment

•HAART

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Use of new diagnostics

2010 TB cases (n=2314)

•NAAT 892 (39%)

•IGRA 475 (22%)

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HIV Status Determination is not Universal in CA

CDC standard is universal testing of all TB cases20

Timing of HIV diagnosis (Dx) in HIV-positive TB patients, 2008

131 HIV co-infected TB patients

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Alive at Diagnosis

64 (50%) 65 (50%)

Previously known HIV + Newly diagnosed HIV +

44 (68%)

2 weeks prior – 2 weeks after TB Dx

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

• 67% Hospital

• 16% Outpatient

• 17% Unknown

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Stage of immunosupporession: HIV-positive TB patients, 2008*

CD4 count

83% with count <250 (most below 150)

Viral load

88% with VL ≥10,000

*New HIV status at time of TB diagnosis

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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

Death during treatment…………………...2,058

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Time to Death for Patients Starting Therapy, California 2008

Median time to death = 48 days25

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

0

2

4

6

8

10

12

14

16

18

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Year

Per

cen

t

Private Provider

Health Department

Why are TB deaths occurring?

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Is TB a contributor to Death?

Preliminary Results: Mortality Study TBESC

•In 75%, TB contributed to death !

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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

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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

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Navigating Landmines

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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

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Too busy killing alligators to drain the swamp?

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Treating TB is an excellent investment of public health dollars

• 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

Force34

Prevention:

Can we afford it?Can we afford not to do it?

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

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

Source: Holland et al. Am J Respir Crit Care Med 2009;17937

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%)

Source: Sterling et al. International Union Meeting, presented November 201138

What is the Evidence?

Evaluation of individuals with B-notification (abnormal CXR)

Percent of

active cases

COST-SAVING 3% and above

COST-EFFECTIVE 4% - 1.5%

Source: Porco et al. BMC Public Health 2006;639

Case Prevention

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

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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

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What Strategic Direction is Under Consideration?

• Adopt cost-effective diagnostic and treatment approaches

• Abandon ineffective unproven approaches

• Tackle case prevention as cases decline

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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

Hot Off the Press

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