1. more information © 2015 Denver Public Health Michelle K Haas, Kaylynn Aiona, Pete Dupree, Ellen Brilliant, Robert Belknap Improving access to Tuberculosis evaluation and care: a path to Tuberculosis elimination for Colorado

2. more information © 2015 Denver Public Health Understand the Epidemiology of Tuberculosis in Colorado Describe the challenges in eliminating Tuberculosis in Colorado Discuss barriers to access to Tuberculosis care, including prevention Goals of this Session

3. more information © 2015 Denver Public Health Tuberculosis is a leading cause of preventable death globally National efforts aimed to identify and treat both latent and active Tuberculosis (TB) have been associated with a decrease in TB incidence over time TB elimination, defined as 1 case/million, is a key goal for public health professionals engaged in prevention of communicable diseases Background

4. more information © 2015 Denver Public Health United States, 2013: 9,582 TB cases (incidence 3.0/100,000 persons) U.S.-born vs. Foreign-born Persons, United States, 1993–2013 Data from www.cdc.govwww.cdc.gov

5. more information © 2015 Denver Public Health TB Incidence Rates, Metro Denver

6. more information © 2015 Denver Public Health TB Incidence Rates by Nativity in Metro Denver CDC goal of 1 case/million Total Foreign-born Population in Metro Denver, (American Community Survey 2013): 342,310

7. more information © 2015 Denver Public Health Countries of Origin for Foreign-born Persons with TB in Colorado, 2010-2014Country # cases Mexico85 Ethiopia21 India15 Somalia13 Philippines11 Vietnam10 76% of total TB cases among individuals born outside of the US TB incidence in 2014: 1.2/100,000

8. more information © 2015 Denver Public Health Objectives Objective 1: Identify which active cases were preventable Objective 2 : Determine the proportion of individuals diagnosed with latent TB who complete therapy

9. more information © 2015 Denver Public Health Objective 1: Identify which active cases were preventable Proportion of active TB cases that were preventable among foreign-born individuals seen at the Denver Metro TB clinic preventable case: foreign-born, tuberculin skin test (TST) or interferon-gamma release assay (IGRA) positive and in the US > 6 months

10. more information © 2015 Denver Public Health Retrospective cohort review of active and latent TB cases in the Denver Metro area from 2009-2014 We assessed country of origin, IGRA or TST positivity and length of time in the US Methods-Objective 1

11. more information © 2015 Denver Public Health At least 44% of TB cases in Denver Metro are preventable Preventable cases of reported active TB from 2009-2014, Denver Metro Area N % Total Cases307- Foreign-born24680 Report date > 6 months from arrival18761 TST or QFT positive at diagnosis135 44 Median years in US until diagnosis=7.5 55% 45%

12. more information © 2015 Denver Public Health Objective 2: Determine the proportion with latent TB who complete therapy Determine the proportion of individuals with latent TB (LTBI) who initiate and complete therapy Evaluate individuals identified with latent TB who were offered treatment – Proportion who began treatment for latent TB – Proportion who did not complete therapy for latent TB Risk factors for not completing LTBI therapy

13. more information © 2015 Denver Public Health Among latent TB cases we describe the proportion of individuals who initiated therapy from 2009-2014 2013: the proportion who completed therapy over time – Risk factors for not completing LTBI therapy were evaluated among adults – Treatment completion: pharmacy refill data; excluded if found to have active TB (n=2) or had missing data (n=76). Analysis was performed using a multivariable log binomial regression in SAS. Methods-Objective 2

14. more information © 2015 Denver Public Health Only half of individuals diagnosed with LTBI complete therapy 35% never start treatment Once treatment is started, 77% complete* *national average for completion of LTBI therapy among contacts is 67%

15. more information © 2015 Denver Public Health 481 individuals initiated LTBI therapy in 2013, with 403 meeting our inclusion criteria 90 patients (22%) did not complete LTBI therapy. Individuals were more likely to discontinue therapy if : – Primarily English-speaking English vs. other-non Spanish: RR (1.8 95% CI 1.2-2.7) Spanish vs. other-non Spanish: RR (1.34 95% CI.82, 2.2) – Were ever homeless (RR= 2.4, 95%CI 1.3, 4.4) – Had a normal CXR (RR= 2.15, 95% CI 1.3, 3.6) Risk factors for not completing LTBI therapy: few targets for interventions Data collected and analyzed by Hillary Dunlevy, Kaylynn Aiona and Will Eaton

16. more information © 2015 Denver Public Health The vast majority of TB cases in Colorado and Denver Metro are among foreign-born individuals 44% of active TB cases in Denver Metro were preventable – 55% of preventable cases among foreign-born individuals Only ½ of individuals seen at Denver Metro TB Clinic completed preventative therapy Summary

17. more information © 2015 Denver Public Health Determine factors associated with not initiating LTBI therapy Share this information with local providers and representatives of communities at risk for TB – Assess current knowledge, attitudes toward TB and current screening practices – Gain a greater sense of barriers to TB care for individuals at risk Next Steps

18. more information © 2015 Denver Public Health How can we: – Increase access to TB infection evaluation for the estimated ½ a million individuals at risk in Colorado? – Strengthen community engagement? – If we strengthen community engagement, how do we sustain this as TB becomes an increasingly rare disease? Bundle with other public health packages? – Will this allow us to achieve TB elimination or will we need to do more? Your thoughts?

19. more information © 2015 Denver Public Health Thank you! Contact information: Michelle Haas, M.D. Denver Metro Tuberculosis Clinic Denver Public Health 605 Bannock Street Denver, CO 80230 Ph: 303-602-5052 Michelle.Haas@dhha.org