1. Tuberculosis Surveillance and Disease Intersections in California
Jennifer Flood, M.D., M.P.H.
Chief, Surveillance and Epidemiology Section
Tuberculosis Control Branch
Division of Communicable Disease Control
Center for Infectious Diseases
California Department of Public Health
October 15, 2008

2. Outline TB surveillance Disease intersections (HIV/TB)
Opportunities for collaboration
Given this context, what can we glean from epidemiology that may help us with strategy while financing and science catches up?
The key questions are:
1) How does the pressure of migration and global epidemic influence TB control in CA?
What about other diseases (AIDS), drug resistance, systemic challenges posed by uneven access to health care? Is the latent pool or transmission most driver of case count?
2) What new findings can help guide our efforts?
In particular I want to focus on new fepi and research findings that address TB among FB.What are some new paths that build from these data?
3) If the current limitations in Science ( is the most potent force) ;
Is TB control and elimination out of bounds?
Or is there room for optimism?
First examine TB trends in CA
Ask are we making progress in epidemic , at what pace?
Is TB control/elimination out of bounds? Start we grounding us in reality . Where are we? Why , influences, challenges,
What role does migration from endemic areas play in our epidemic?
How do our epidemiology and findings from recent studies help us?
What are the new paths (approaches) informed by these data?
Remaining questions? (what do we need to do differently?) critical questions to have breakthrough in science?

3. Why is TB important? Global
Every second, a new person becomes infected with TB
TB is curable but kills 5000 people every day
TB is the number 1 killer of AIDS patients
2 billion people , 1/3 of world’s population, infected with TB
MDR/XDR TB growing
The focus that deserves headlines is the global burden of TB.
When we look beyond border security and air travel safety, the frequency of TB infection, disease, and TB death is what is impressive. If viewed from this reality , it is not shocking that travel of persons with TB occurs.
None of this is a surprise since infection is virtually ubiquitous.
The surprise (or disappointment) is why have we not gained more foothold;
Afterall, the pathogen is not a new one.
_______________________________________________
What is only recently making some headlines is that science is way behind.
It is this more than all other things, and more than borders, that prevents us from having a stronger public health safety net;
why are we talking about borders as a saftey net when after all TB is curable? We have short course rx, dx tests, vaccine
Or do we?
Day to day-
The work of TB control does not at all sound like somethinf rapid shiny swift and magic bullet like-
It is quite the opposite.and this is where attention should rest and scrutiny should fall: why have we not made more progress? why is TB so common , the leader of death among infectious diseases, why does it persist?

5. Span of TB Control Activities
2727 Californians with Tuberculosis
Over 10,000 Suspect Cases
20,000 – 30,000 Contacts
3 million Californians infected
35 million Californians who breathe

6. Purpose of surveillance
Quantifies disease magnitude and changes in disease over time
Identifies disease characteristics
Provides roadmap for TB control efforts

7. Data Sources TB Case Report (RVCT) Contact evaluation reports
B-notification Registry
MDR/XDR surveillance
Outbreak reports
Universal genotyping database
TB Death Investigations

8. How are TB cases reported?
Providers and laboratories submit confidential morbidity reports (CMR) to local health dept
Health department conducts patient interview
provides direct TB case management
or private provider oversight
through 6-24 month treatment

9. TB Reporting from LHD to TBCB
at initial diagnosis
at time of susceptibility results
at treatment completion
***********
report form with >200 fields
extensive instructions and instructions

10. Features of TB Case Report
Demographic
Country of origin; date of US entry, visa status
Risk factors
Homeless, incarceration, IVDU HCW, HIV, other co-morbidities
Clinical
Disease site, infectious, CXR
Laboratory
Drug resistance, genotype
Provider type
Public, private
Treatment
Regimen, doses, DOT, duration
Outcome
Death, death related to TB, moved-destination, lost, rx completed, relapse

12. Slowing Rate of TB Case Decline California, 1992-2007
2,500
3,000
3,500
4,000
4,500
5,000
5,500
6,000
-5.9% per year
( )
-2.8% per year
( )
Number of Tuberculosis Cases
-1.9% per year
( )
The intersection also manifests as effect on the epidemic we see here
The slowing in the decline of TB.
Although we have successfully reduced the number of TB cases each year since 1992 (except 2 years 2001 and 2003 where we saw increased numbers),
The pace of decline has slowed substantially. After the 1992 peak in cases, we experienced cases dropping nearly 6% per year. Since 200 we have had two years with case increase and our recent case count of 2726 was only a 1.8% drop in cases.
In addition, the degree by which cases dropped has not accelerated evenly.

13. Tuberculosis Cases in Foreign-born and U. S
Tuberculosis Cases in Foreign-born and U.S.-born Persons: California,
Number of Cases
Percent of Cases

14. TB Disparities: US-born vs. Foreign-born, California, 2007
TB cases Case rate
US-born
Foreign-born *
*Annual case rate decline has been slower for foreign-born than US-born
.The case rate for FB is not declining at same pace as rate for US born. And comparison of case rates show a sharp disparity between FB and US born.
___________________________________.
It is clear to make more rapid progress, need to address/solve TB in high burden regions and ensure when migration occurs those persons gain rapid access to diagnosis and cure
Rate of decrease in incidence of TB among foreignborn has slowed to <1% per year ( US Trends in TB MMWR 2006; published in 2007

15. Adverse Events
Pediatric cases
Drug resistance
Outbreaks

16. Deaths in Persons with Tuberculosis: California, 1996-2005
Number of Deaths
Percent of Cases
Dead at Diagnosis
Died During Treatment
Died Before Starting Treatment
Percent Dying with Tuberculosis

17. Data for Public Health Action (Examples)
Surveillance Data:
Increased importation of infectious MDRTB-> CDC revised overseas TB screening
Multi-jurisdictional case increase and genotype cluster among homeless outbreak detection and containment

18. Data Use: Public Health Action
Cost-effectiveness analyses:
6% of persons arriving with TB B-notification have active TB on CA arrival domestic evaluation is cost effective (vs other control activities)
Universal school children TB testing is not cost-effective
Testing and treatment of HIV infected is highly cost-effective

19. Intersection of TB, HIV and STDs

20. Disease Intersections: TB/STD
Cutaneous Tuberculosis of the Penis and Sexual Transmission of Tuberculosis Confirmed by Molecular Typing
Angus, Yates, Conlon and Byren
CID 2001;33e132-4
TB ulcer

21. HIV/TB Interactions: Transmission, Diagnosis, Pathogenesis, Treatment
100 fold greater risk of progression from latent to active TB in HIV co-infected patients
Rapid TB progression and spread in HIV populations
TB accelerates HIV progression to AIDS (increases viral load)
Mortality much higher before HAART (20-35%)
Increased acquired drug resistance

22. Benefit to patient if HIV status is known
Diagnosis
TB testing can identify LTBI; Rx prevents TB
HIV positive patients frequently have atypical TB presentation
Treatment
Drug selection and dosing differs for HIV positive patients
Complex drug interactions and IRIS anticipated and acquired drug resistance avoided
HIV Care
Early referral to HIV and treatment
TB Contact Investigation (TB Exposure)
HIV positive patients are prioritized (given progression risk)

23. RVCT – HIV Status: CDC required Field

24. Current CA RVCT fields – HIV Status

25. Incident Tuberculosis Cases by AIDS Diagnosis*: California, 1997-2006
No. TB Cases with AIDS
% TB Cases with AIDS
Number of Cases with AIDS
Percent of Cases with AIDS
AIDS epidemic also has a strong influence on TB epidemioogy in CA. And advances in dx and rx AIDS is seen in decline in HIV.TB.
TB AIDS cses reported in CA peaked at 515 (10% of all TB cases in 1992) and decreased to XXX 122 (4% of all TB cases ) in 2004
The proportion of TB AIDS cases that is foreign born rose from 35% in 1993 to 65% in 2004.
HAART may be having a positive impact on the occurrence of TB in HIV infected population
* AIDS Case Registry, California Office of AIDS

26. AIDS-associated Tuberculosis Cases*
California,
AIDS-associated
Tuberculosis Cases
≥ 100 Cases
50-99 Cases
25-49 Cases
10-24 Cases
1-9 Cases
None
Berkeley
San Francisco
Pasadena
Long Beach
*Match found in AIDS Cases Registry, Office of AIDS

27. Proportion of TB Cases with AIDS by Place of Birth, CA 1994-2006
Decline masks a worrisome trend in HIV epidemic globally. Not everyone has equal access to ARV life-prolonging drugs. Or the proven measures that avert perinatal transmission.
In /3 AIDS/TB cases were US born , now 2/3 are foreign-born reflecting changes in both epidemics; Nearly 20% are now in females;and hispanics. Those with HIV now more likely to come with dual infection , with LTBI given country of origin an dfrequency of infection ( 1 of 3). So potential to add fire to epidemic is there.
2004 AIDS/TB cases :57% ( nearly60%)hispanic vs 17% blacks, 13% white, 11 % asian

28. Reporting Counties: Rank Order by Case Count
As of 2/2008 Cumulative
2007
2006
Rank
AIDS TB
Gonorrhea
Syphilis 1
Los Angeles 2
San Francisco
San Diego 3
Santa Clara 4
Alameda
Orange

29. AIDS/TB Cases Contributed by Selected Local Health Departments
County
1995 – 1999
2000 – 2004
San Diego
147 (11%)
132 (17.2%)
San Francisco
156 (10.7%)
79 (10.3%)
Los Angeles
642 (44.3%)
296 (38.6%)

30. AIDS/TB Case Trends: Socio-demographic Characteristics
2000 – 2004
n (%)
Age
25 – 44
(71)
(64)
45 – 64
( 24)
(30)
65+
(1.8)
(2.3)
Race
White
(21)
(15)
Black
(30)
(19)
Hispanic
(45)
(55)
Asian
(3.9)
(8)
Country of origin
US-born
(56)
(40)
Foreign-born
(43)
452 (59)

31. Risk Factors / Settings AIDS/TB Cases California, 1995 - 2004
TB TB/AIDS
Homelessness (17%) (22%)
Drugs/alcohol (38%) 281(37%)
Corrections (9%) (4%)

32. Clinical characteristics, AIDS/TB Cases, California, 1995-2004
TB AIDS/TB
Smear positive % %
Cavitary % %
Extrapulmonary 10% %
rifampin resistance 0.1% 1%
PZA resistance 2% %

33. AIDS/TB Case Trends: Care and Outcome Characteristics
1995 – 1999
2000 – 2004
n (%)
Provider Type
Health Dept. only
685 (47%)
382 (50%)
Private Provider only
390 (27%)
226 (30%)
Both
371 (26%)
151 (20%)
Therapy Supervision
Directly Observed
723 (52%)
(72%)
Completed Therapy
972 (70%)
608 (82%)

34. Deaths among AIDS/TB Cases in CA, 1995-2006
9% TB vs 18% AIDS/TB cases died
TB/AIDS deaths has declined from 22% in to 11%

35. Opportunities X X Diagnosis TB infection HIV infection
LTBI Treatment HAART
TB Disease / AIDS
Expert Co-management
Death X X

36. Points of Intersection
Populations at risk
Overlapping high incidence areas
Transmission settings
Social networks
Service/points of care intersections
DOT/case management
Housing and drug rehab access

37. Surveillance opportunities in CA
Number of ?
HIV co-infected TB patients
HIV-infected patients with LTBI
Preventable AIDS/TB cases
Preventable AIDS/TB deaths

38. Areas for collaboration
Early identification: HIV testing of TB cases  TB testing of HIV-infected
Timely TB treatment and HAART initiation
Understanding/ preventing TB/HIV deaths
Private provider oversight /guidance
Expert case management of co-morbidities:
TB/ HIV/ hep B/ hep C
Rapid diffusion of science/ innovations
use of quantiFERON and rapid HIV test

39. CDPH TB Control Surveillance Team
TB Control Registry
Janice Westenhouse- Lead
Jen Allen
Bill Elms
Linda Johnson
Phil Lowenthal
Kelly Waldow