epidemiology of tuberculosis: global, national & wyomingnid]/1._tb... · tuberculosis in...

Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center

Epidemiology1

Epidemiology of Tuberculosis: Global, National & Wyoming

Randall Reves, MD, MScVolunteer Clinician Denver Metro TB Program and Division of Infectious Diseases, Department of MedicineUniversity of Colorado Denver

Disclosure

Randall Reves doses not have any financial disclosures.


Epidemiology2

Brief reminder about TB: 19 y.o. student in septic shock in ED

Sudden onset of severe abdominal pain Negative past medical history except for

outpatient UTI treatment with ciprofloxacin 6 months earlier

Arrived in U.S. from Nepal in past year No known TB exposure, no prior + TST Chest X-ray “negative for TB” at prior

clinic visit, follow-up recommended but could not be accomplished

19 y.o. student in ED

•X-ray abnormalities?

•Diagnostic studies?

•Emergent treatment?


Epidemiology3

19 y.o. student in ED

Perforated colon at laparotomy

Granulomatous inflammation

Sputum AFB smear +

Expired despite I.V. levofloxacin, amikacin, rifampin & antibiotics

News Alerts

Colorado Springs Student From Nepal Dies From TBWoman Was International Student At CSU-PuebloPOSTED: 1:16 pm MDT June 11, 2007

COLORADO SPRINGS, Colo. -- Tuberculosis was confirmed as the cause of death of a patient who died at Colorado Springs' Memorial Hospital shortly after arriving at the emergency room on Friday.

It was not known what type of TB killed the 19-year-old student from Nepal but officials held an afternoon news conference to discuss the case.


Epidemiology4

19 y.o. student: X-ray 6 mo earlier

Was TB the diagnosis then?

Was it partially treated with ciprofloxacin?

Was this illness and death preventable?

Reminder: TB can be deadly in healthy persons

Global TB Burden, 2016 estimates*

Estimated number of cases

Estimated number of deaths

1.7 million^• 1,070,000 in males

• 601,000 in women

• 253,000 in children

10.4 million140 per 100,000

• 6.7 million males

• 3.7 million females

• 1.4 million children

490,000 (4.1% of new TB)

600,000 (incl. RR‐TB)

Total TB

Multidrug‐resistant TBMDR/RR

HIV‐associated TB 1 million (10%) 374,000 (22%)

240,000(14%)

^Includes HIV/TB deaths*WHO Global TB Report 2017


Epidemiology5

WHO Global TB Report 2017 (for 2016)

30 high-burden countries: top 20 by number & top 10 by rates in smaller countries

For details see: http://www.who.int/tb/country/data/profiles/en/

WHO Estimated TB Incidence Rate, 2016


Epidemiology6

WHO Estimated TB Incidence, 2016

Global Impact of TB Deaths

WHO Global TB Report 2017


Epidemiology7



Global Trends in TB Incidence, Notification and Deaths

Notes: 39% of estimated TB not notified in 201686% of HIV deaths in African region


Epidemiology8

If this is true today, why is progress slowing?

We have yet to adequately respond -


Epidemiology9

Reported Tuberculosis (TB) Cases United States, 1982–2016*

*As of June 21, 2017.

No. o

f cases

Year

26,673 TB cases in 1992

9,272 TB cases in 2016

TB Morbidity United States, 2011–2017*

Year No. Rate

2011 10,509 3.4

2012 9,940 3.2

2013 9,561 3.0

2014 9,398 3.0

2015 9,547 3.0

2016 9,272 2.9

2017 9,092 2.8

*MMWR 3 23 2018: Decrease of 2.5% from 2016


Epidemiology10

TB Case Rates,* United States, 2016

*Cases per 100,000; as of June 21, 2017.DC, District of Columbia; NYC, New York City (excluded from New York state)

≤2.9 (2016 national average)

>2.9

DC

NYC

WY: Cases 1 & 4 in ’16 & ’15Rates 0.2 & 0.7

Map of U.S.‐Affiliated Pacific Islands, by TB Case Rates:* Total TB cases 471, pop. 3.8 million, rate 12.3 in 2016

*Cases per 100,000 population; as of June 21, 2017.

Federated States of

Micronesia

Marshall Islands

Northern Mariana Islands

American Samoa

Guam

Palau

≥5010–49.9≤9.9


Epidemiology11

TB Case Rates* by Age Group, United States, 1993–2016


Cases per 100,000 population

Age (yrs.)

TB Case Rates by Age Group and Sex, United States, 2016*




Epidemiology12

TB Case Rates by Race/Ethnicity,* United States, 2003–2016†

* All races are non‐Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† As of June 21, 2017.


TB Case Rates by Age Group and Race/Ethnicity,*United States, 2016†


* All races are non‐Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† As of June 21, 2017.


Epidemiology13

Number of TB Cases Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*

No. o

f cases

*As of June 21, 2017.

Non‐U.S. born: 29.5% to 68.5% from 1994 to 2016

Reported TB Cases by Race/Ethnicity,*United States, 2016†

Hispanic/Latin 28%

Native Hawaiian/Pacific Islander 1%

American Indian/Alaskan Native 1%

Black/African American 21%Asian 35%

Multiple race 1%

White 13%

* All races are non‐Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† Percentages are rounded; as of June 21, 2017.


Epidemiology14

Reported TB Cases by Origin and Race/Ethnicity*, United States, 2016†

U.S.‐born persons Non‐U.S.–born persons§

* All races are non‐Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† Percentages are rounded; as of June 21, 2017.§ American Indian/Alaska Native accounted for <1% of cases among non‐U.S.–born persons and are not shown.

TB Case Rates Among U.S.‐Born versus Non‐U.S.–Born Persons, United States*, 1993–2016†


* Includes the same data as previous slide, but rates are presented on a logarithmic scale.† As of June 21, 2017.


Epidemiology15

Countries of Birth Among Non‐U.S.–Born Persons Reported with TB, United States, 2016

*Percentages are rounded; as of June 21, 2017.

Primary Anti‐TB Drug Resistance, United States, 1993–2016*

* As of June 21, 2017. Note: Based on initial isolates from persons with no prior history of TB; multidrug‐resistant TB (MDR‐TB) is defined as resistance to at least isoniazid and rifampin.

Resistan

t (%

)

Year


Epidemiology16

Primary MDR‐TB, United States, 1993–2016*


Primary Isoniazid Resistance Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*

Resistan

t(%

)

* As of June 21, 2017. Note: Based on initial isolates from persons with no prior history of TB.


Epidemiology17

Primary MDR‐TB Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*


Resistan

t(%

)

Epidemiology of MDR TB in the U.S.

168 cases in 8 states, 86% foreign-born, 15% with clustered isolates by genotyping

92 in-depth interview: 22% imported active MDR TB (within 3 mo.)

22% due to transmission within USA

41% due to reactivation of latent TB infection, with 15% previously treated outside USA

5% relapse of TB previously treated in USA

10% unknown

Moonan P, et al Lancet Infection 2013: TBESC TO 8


Epidemiology18

XDR‐TB* Case Count, Defined on Initial DST,†

by Year, 1993–2016§

* XDR‐TB , extensively drug‐resistant TB.† DST, drug susceptibility test.§As of June 21, 2017.Note: XDR‐TB is defined as resistance to isoniazid and rifampin, plus resistance to any fluoroquinolone and at least one of three injectable second‐line anti‐TB drugs.

Case count

Year of diagnosis

US-born and Foreign-born Prevalence of LTBI & Case Rates by Age,

1999-2000 Bennett 2007, CDC 2000LTBI Prevalence

0.3 0.6 1.23.4 4.8

11.9 12.8

20.6

25.3

11.9

0

5

10

15

20

25

30

< 15 15- 25- 45- 65+

%

US-B FB

TB Case Rate

1.3 1.4 3.6 5.88.37.3

19.9 19.122

35.8

05

10152025303540

<15 15- 25- 45- 65+

Rate

US-B FB


Epidemiology19

Estimated TB Infection in the U.S.LTBI prevalence 6 million to 13 million.

Foreign born TST 20.5%

QFT 15.9%

Both positive 9.3%

US-born

TST 1.5%

QFT 2.8%

Both positive 0.6%

Reported TB 9 years in WY’ 2009-17

Cases: 25, range 0 (’13) -7 (’10), ave 2.8

Nativity (missing 3): US 8

Africa 2: Ethiopia, Kenya

Asia 7: China, India, Nepal 3, Philippines 2

Latin America 5: Mexico 3, Peru 2

Site (missing 1): Pulmonary 17

Extra-pulmonary 7


Epidemiology20

How can you use epidemiologic data in the clinic? What questions are more important in assessing a patient’s risk of TB?

Country of birth or length of residence in a TB-endemic country?

Age or years of residence in TB-endemic country?

Race/ethnicity or country of birth/residence?

epidemiology of tuberculosis: global, national & wyomingnid]/1._tb... · tuberculosis in...

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