Transcript Tuberculosis in Foreign-born Persons, United States 1993-1997

Northeast TB Controllers Meeting
Princeton, New Jersey
October 24, 2006
Epidemiology of Tuberculosis in
Northeastern United States, 1993-2005
Kenneth G. Castro, M.D.
Assistant Surgeon General, USPHS
Director, Division of Tuberculosis Elimination
National Center for HIV, Hepatitis, STD, and TB Prevention*
Coordinating Center for Infectious Diseases
* Proposed
Acknowledgements
•
•
United States TB controllers, state and local health
departments
CDC, DTBE, SEOIB and FSEB
– Lori Armstrong
− Sandy Althomsons
– Elvin Magee
− Val Robison
– Tom Navin
− Dave Crowder
– Dan Ruggiero
− John Jereb
– Mark Lobato
− Margaret Oxtoby
– Edwin Rodriguez
− Tracy Agerton
– Farah Parvez
− Sonal Munsiff
– Vernard Green
− Tom Privett
– Zach Taylor
TB Cases Analyzed
• National TB Surveillance System
• Reported 1993 to 2005
• Northeastern States: Maine, New Hampshire,
•
Vermont, Connecticut, Massachusetts,
Rhode Island, New York, New Jersey
Compared to all other states in the U.S.
TB Case Rates,* United States, 2005
NE states
D.C.
< 3.5 (year 2000 target)
3.6–4.8
> 4.8 (national average)
*Cases per 100,000.
Rate TB Cases/ 100,000
Reported TB Case Rates in U.S.,
NE vs. Other States, 1993-2005
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
2000
2001
NE States
2002
2003
All other states
Year
2004
Nationwide
2005
Percent of Case Count
Reported TB Cases by Age Group,
NE States vs. Others, 1993–2005
50
40
30
20
10
0
0-14
15-24
25-44
45-64
Age at Diagnosis
NE States
Other states
65+
Reported TB Cases by Race/Ethnicity,*
NE States vs. Others, 1993–2005
Amer Indian/Nat Alaskan
(<1%)
Nat
Hawaiian/
Pacific
(<1%)
White
(18%)
Hispanic
(25%)
Amer Indian/Nat Alaskan
(1%)
Asian
(20%)
Black
(36%)
NE States
Nat
Hawaiian/
Pacific
(<1%)
White
(25%)
Hispanic
(23%)
Asian
(19%)
Black
(31%)
Other States
*All races are non-Hispanic. Persons reporting two or more races
accounted for less than 1% of all cases. Unknown not included.
Reported TB Cases by Birth Origin,
NE States vs. Others, U.S., 1993–2005*
Birth Origin
NE States
n (%)
Other States
n (%)
US-Born
21,051 (49.2)
116,601 (59.7)
Foreign-born
21,769 (50.8)
78,741 (40.3)
Note: Unknown not included
TB Cases, by Previous Diagnosis,
NE States vs. Others, U.S., 1993–2005*
NE States
n (%)
Other states
n (%)
Previous
diagnosis of TB
1,695 (4.0)
10,785 (5.5)
No previous
diagnosis of TB
41,153 (96.0)
183,777 (94.5)
Note: Unknown and missing not included
*Updated as of March 29, 2006.
HIV Test Results of TB Cases,
NE States vs. Others, U.S., 1993–2005*
HIV Status
NE States
n (%)
Other states
n (%)
HIV Positive
8,357 (19.4)
18,025 (9.2)
HIV Negative
15,180 (35.3)
64,023 (32.6)
Missing or
Unknown
19,456 (45.3)
114,511 (58.2)
Mode of Treatment Administration in
Persons Reported with TB,
NE States vs. Others, U.S., 1993–2003*
100%
80%
60%
40%
20%
0%
NE States
DOT only
Other
States
DOT + SA
* Excludes unknown and missing.
Directly observed therapy (DOT); Self-administered therapy (SA)
SA only
Percent Completion of TB Therapy,*
NE States vs. Others, U.S., 1993-2005
Percent
100
80
60
40
20
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
NE States
Other US
Year
*Healthy People 2010 target: 90% completed in 1 yr or less.
Note: Excludes persons with initial isolate resistant to rifampin and children <15 years old with
meningeal, bone or joint, or miliary disease excluded.
Reason Therapy Stopped in TB Cases,
NE States vs. Others, U.S., 1993–2005*
Percent
80
70
60
50
40
30
20
10
0
NE States
Completed
Moved
Lost
Other States
Uncoop/Refused
Died
Other
Missing/Unk
MDR TB* in NE States vs. Others,
U.S.,
1993-2005
8
7
5
4
3
2
1
0
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
% MDR TB
6
NE States
Other US
Year of Reporting
%MDR TB cases = no. of TB cases with Mycobacterium tuberculosis isolates
resistant to isoniazid and rifampin, among all cases tested to isoniazid and rifampin
MDR TB by Birth Origin,
NE States vs. Others, U.S., 1993-2005
Birth Origin
Foreign-born
U.S.-born
Unknown origin
Total
NE States
n (%)
390 (34.5)
Other US
n (%)
1082 (64.2)
735 (65.1)
589 (35.0)
4 (0.4)
13 (0.8)
1129 (100.0)
1684 (100.0)
TB Epidemiology Summary in NE States*
• Heterogeneous states (high, medium, low incidence)
• Consistently higher rates
• Majority (58.6%) younger than 44 years
• Most (82%) racial/ethnic minorities
• Lower proportion (49.2%) U.S.-born
• Higher prevalence (19.2%) HIV infection
• Larger proportion on DOT+SA and SA only treatment
• COT improving (82%), room for improvement
• MDR decreased 1993-2000, recent stagnation
* Compared with other states, U.S., 1993-2005
Second-Line Drug Classes for MDR TB Treatment
Aminoglycosides
Polypeptides
First line
drugs
Fluoroquinolones
Amikacin, Kanamycin
Capreomycin
Ciprofloxacin, Ofloxacin
+
Thioamides
Serine analogues
Ethionamide, Prothionamide
Cycloserine
PAS
WHO. Guidelines for the programmatic management of drug-resistant tuberculosis. 2006.
Characteristics of KZN XDRTB Patients
Characteristics
No. (%)
• No prior TB Treatment
26 (51)
• Prior TB treatment
– Cure or Completed treatment
14 (28)
– Treatment Default or Failure 7 (14)
• HIV-infected (44 tested)
• Dead (Includes 34% on ARV)
• Identical M. tb spoligotype
44 (100)
52 (98)
26/30
* Moll A, Gandhi NR, Pawinski R, Lalloo U, Sturm AW, Zeller K, Andrews J, Friedland G.
HIV associated Extensively Drug-Resistant TB (XDR-TB) in Rural KwaZulu-Natal
(South Africa MRC Expert Consultation Sept 8, 2006)
HIV-related MDR TB Outbreak Investigations
by CDC & Health Departments, USA, 1988–92
Total
Cases
% HIV
Infected
%
Deaths
65
93
72
7
B
51
100
89
16
C
70
95
77
4
D
29
91
83
4
E
7
14
43
4
F
16
82
82
4
I
13
100
85
4
J
28
96
93
4
42
98
79
4
Hospital
A
Prison
Median Wks
Dx to Death
U.S. Response to TB Resurgence
Updated Diagnostic Labs,
National MDR-TB Action Plan
Improved Case
Real-time Drug Resistance,
& New Resources
Identification & Training
& Strain Fingerprinting
Rebuilt Research
Capacity
DOT & Improved Rx Completion
Updated Infection Control
and Rx Recommendations
AJRCCM 1994;149:1359-74
Global 7-point Action Plan to Combat XDR TB
Emphasizes Essentials of Proper TB Control
1. Conduct rapid surveys of XDR-TB (determine burden)
2. Enhance laboratory capacity (emphasis on rapid DST)
3. Improve technical capacity of clinical and public
health practitioners to effectively respond to XDR-TB
outbreaks and manage patients
4. Implement infection control precautions (PLHA focus)
5. Increase research support for anti-TB drug
development
6. Increase research support for rapid diagnostic test
development
7. Promote universal access to ARVs under joint TB/HIV
activities
MRC Consultation, Johannesburg, South Africa. Sept 7, 2006
Revised WHO Case Definition for
XDR TB (Oct 10, 2006)
Goals
• Public health surveillance
• Reliable DST methodology
• Clinical relevance
• Relatively simple
Resistance to at least isoniazid and rifampin
(MDR) plus resistance to fluoroquinolones
and one of the second-line injectable drugs
(amikacin, kanamycin, or capreomycin)
TB Treatment Outcomes, by Selected Drug
Resistance Patterns, Latvia, 2000-2003*
Cure
Completion
Death
Default
Failed
Continue Tx
HIV+
HR+AG+FQ
HR+INJ+FQ
HR+3SLD
MDR-TB All
0
10
20
30
40
50
60
70
Percent
* Leimane V, et al. WHO XDR TB Task Force Meeting. Oct 9, 2006 (from N = 820 evaluated)
(WHO)
XDR
TB Cases in U.S.,
Northeast vs. Other States, 1993-2005
No. XDR TB Cases
14
12
10
8
Other States
6
NE States
4
2
0
1993
1995
1997
1999
2001
Year of Report
2003
2005
(WHO)
XDR
TB Cases in U.S.,
Foreign-born vs. U.S.-born, 1993-2005
No. XDR TB Cases
14
12
10
8
Foreign-born
6
US-born
4
2
0
1993
1995
1997
1999
2001
Year of Report
2003
2005
(WHO)
XDR
TB Cases in Northeast States,
Foreign-born vs. U.S.-born,1993-2005
No. XDR TB Cases
14
12
10
8
Foreign-born
US-born
6
4
2
0
1993
1995
1997
1999
2001
Year of Report
2003
2005
(WHO)
XDR
TB Cases in Other States,
Foreign-born vs. U.S.-born,1993-2005
No. XDR TB Cases
14
12
10
8
Foreign-born
US-born
6
4
2
0
1993
1995
1997
1999
Year of Report
2001
2003
2005
(WHO)
XDR
TB Cases in U.S.-born vs.
Foreign-born Persons, 1993-2005
1993-1998 2000-2005
U.S.-born
19
3
Foreign-born
12
12
TB Clinical Development Pipeline
Compound
Development Stage
Sponsor / Coordinator
Phase III
EC / OFLOTUB Consortium; IRD*;
WHO TDR; Lupin Ltd.
Moxifloxacin
Phase II / III
Bayer; TB Alliance; CDC;
University College of London;
Johns Hopkins University
Diarylquinoline TMC207
Early Bactericidal Activity
Johnson & Johnson (Tibotec)
Nitroimidazo-oxazole
OPC-67683
Early Bactericidal Activity
Otsuka Pharmaceutical Co., Ltd.
Nitroimidazole PA-824
Phase I
TB Alliance
Pyrrole LL-3858
Phase I
Lupin Ltd.
Gatifloxacin
* Institut de Recherche pour le Developement
Novel compounds, highlighted in blue boxes,
are active against MDR/XDR TB
 World
Health Organization, Tropical Disease Research
for Disease Control and Prevention
 Centers
Examples of Rapid Drug Resistance Methods
Test
Company
M. tuberculosis detection
Detection RMP resistance
Detection INH resistance
Strip Assay
DNA basis: PCR
Direct assay
GenoType® MTBDR
INNO-LiPA Rif.TB
Hain Lifescience
Innogenetics
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes (modified
version)
RMP resistance:rpoB gene
INH resistance:katG gene
Yes
Yes
Yes
No
Microscopic-Observation Drug Susceptibility
Assay for the Diagnosis of TB*
Moore DAJ, et al. N Engl J Med 2006;355:1539-50
Actual and BRDPI-Adjusted
Federal Funds for TB*, CDC, 1990-2006
$150
Actual $
$100
112
$50
06
20
04
20
02
20
00
20
98
19
96
19
94
19
92
19
90
$0
19
Funding
($ x million)
$200
* Adjusted to 1990 US$ by Biomedical Research & Development Price Index
** Includes TB/HIV and lab dollars