general session posey april 19, 2017 - ntca · tuberculosis cases, united states, 1996 ‐ ......

General Session II ‐ Drew Posey April 19, 2017

2017 National TB Conference, Atlanta, Georgia National TB Controllers Association www.tbcontrollers.org 1

Immigrant, Refugee, and Migrant Health Branch Update

Division of Global Migration and Quarantine

National Center for Emerging and Zoonotic Infectious Diseases

Medical Assessment and Policy TeamImmigrant, Refugee, and Migrant Health Branch

2017 National TB ConferenceApril 19, 2017

Drew L. Posey, MD, MPH

DGMQ Public Health Mission

To reduce morbidity and mortality among immigrants, refugees, travelers, expatriates, and other globally mobile

populations, and to prevent the introduction, transmission, and

spread of communicable diseases through regulation, science, research,

preparedness, and response

Immigration & Nationality Act

1968

Refugee Act1980

Federal Quarantine Regulations

1798• Prevent & control infectious diseases at

origin • Diseases of PH significance• Meet at ports of entry• Notification of state/local HD

• International & interstate movement of people, animals, & cargo

• Prevent importation & spread of cholera, yellow fever, plague, viral hemorrhagic fevers, smallpox, diphtheria, pandemic influenza, infectious TB, SARS

• Required medical exam• Inadmissible conditions (TB, Hansen’s disease, STIs, harmful behavior, drug abuse)• Vaccines required

DGMQ’s Regulatory Authority



Source: U.S. Department of Homeland Security

Estimated Annual International Arrivals, U.S.A. 2015

Non‐immigrant admissionsTemporary Workers and Families – 3.7 M

Students Visa – 1.9 M Others ‐ 175 M

Immigrants>1,000,000

Refugees69,920

Tuberculosis Cases, United States, 1996‐2015

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

199

6

199

7

199

8

199

9

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

201

0

201

1

201

2

201

3

201

4

201

5

Proportio

n Fo

reign‐BornN

o.

of

Ca

se

s

U.S.‐born Foreign‐born % Foreign‐born

2015 TB rates:Total 3.0 per 100,000

US‐born 1.2 per 100,000Foreign‐born 15.1 per 100,000MDR TB: 86.3% Foreign‐born



Immigration and Refugee Health Working Group* Analysis

*Australia, Canada, New Zealand, United Kingdom, United States

White Z, et al. Tuberculosis Research and Treatment. 2017: https://doi.org/10.1155/2017/8567893.

0.00% 5.00% 10.00% 15.00% 20.00%

Nigeria

Thailand

Myanmar

Sudan

Afghanistan

Sri Lanka

Zimbabwe

Indonesia

Ethiopia

Somalia

Mexico

China

India

Birth Country for TB Cases, 2005‐2009

US proportion

AUS proportion

NZ proportion

CAN proportion

UK proportion

0.00% 5.00% 10.00% 15.00%

Vietnam

Fiji

Thailand

Turkey

France

Canada

Australia

United States

Pakistan

Mexico

Philippines

New Zealand

India

Birth Country of Arrivals, 2005‐2009

US proportion

AUS proportion

NZ proportion

CAN proportion

UK proportion

Immigrants2.7 M screen overseas

26K Active TB smear (-)B1 rate = 961/100K

23K Inactive Old TBB2 rate = 837/100K

Refugees279K screen overseas

3.9K Active smear (-)B1 rate = 1,036/100K

10.7K Inactive Old TBB2 rate = 2,838/100K

U.S TB Dz diagnosisB1 f/u = 7% Pulm TBB2 f/u = 2% Pulm TB

Prevalence of smear‐negative & inactive TB in U.S.‐bound Immigrants / Refugees, 1999‐2005

Susan Maloney et. al. Arch Intern Med. 2006;166:234-240



Culture and Directly Observed Therapy TB Technical Instructions

Sputum smears and cultures (3)

All (‐) One or more (+)Valid for travel within 3 months

DOT until cured

Class A Waiver

If TB rate ≥20/100,000 or2‐14 years of age:TST ≥10 mm or positive IGRA

HIV orTB signs or symptoms

NoninfectiousClass B1

InfectiousClass A

Implementation Strategy

Globally

Initially target large‐volume, high‐burden source countries

Ultimately implement in all countries

In country

Develop culture and DOT infrastructure

Link panel physician programs with broader control efforts



2016



Laboratory Capacity Building

New laboratories China (5), India (5), Kenya, Mexico, Nepal, Thailand (2), Vietnam

Greatly expanded laboratories Dominican Republic, Ethiopia, Ghana, India (2)

Laboratories performing 2nd line DST China (Guangzhou), Kenya, Nepal, Thailand, Vietnam

Tuberculosis and MDR TB Rates, WHO and U.S. Screening

CountryFY 20151

Arrivals

WHO – Country of screening2

US Screening3

TB Rateper 100,000

MDR TBRate

TB Rate per 100,000

MDR TB Rate

Mexico 81,122 21 2.6% 41 2.4%

Dominican Republic 43,187 60 3.0% 66 0%

Philippines 35,935 322 2.6% 1133 1.2%

China 38,025 65 6.6% 255 3.1%

India 27,798 278 2.5% 78 7.7%

Vietnam 24,757 137 4.1% 952 3.8%

1Department of Homeland Security, October 1, 2014 through September 30, 2015 2WHO Country Profiles, 2015. MDR TB rate is rate among new cases. 3TB Indicator data, all Class A TB cases, January 1, 2015 – December 31, 2015

Worldwide, panel physicians diagnose >1,500 cases yearly ≈72% smear-negative, culture-positive

Liu et al. Annals of Internal Medicine 2015.



Recent Upgrades to the TB Screening Infrastructure Confirm It Can Be Successfully Modernized and

Improve Prevention

2007‐2013: New CDC TB Technical Instructions

published and implemented

Number of total cases decreased by 17%

MAP Trips During FY 2016

28 Countries Visited

Americas

Dominican

Republic (2)

El Salvador

Honduras

Mexico

Peru

Bolivia*

Africa

Rwanda (2)

Zambia

Morocco (2)

South Africa

Kenya

Tanzania

Sierra Leone*

Morocco (lab)

Egypt (lab)

Asia Burma India (2) Nepal (2) Malaysia (2) Indonesia (lab) Taiwan (lab) South Korea (lab) Vietnam (lab) Thailand (lab)

Middle East Egypt (lab only) Pakistan (lab only)

Europe Italy Czech Republic Ukraine Greece*

What’s Next for Tuberculosis?



TB Technical Instructions

Update to Tuberculosis Technical Instructions

Update both panel physician and civil surgeon TB TI

Improve readability and clarity

Address important issues:

Role of tuberculin skin test and interferon gamma release assay

LTBI testing of applicants ≥15 years of age

Role of molecular tests

Referrals to health departments

Implementation of Updated TB TI

Receive input from TB TI Working Group

Develop new Technical Instructions over next several months

If changes require additional panel physician resources –

Implement October 1, 2018



Panel physicians use IGRAPanel physicians use TST

Immigrant and Refugee Children with LTBI, 2010

Taylor EM, et al. J Immigrant Minority Health 2015 DOI 10.1007/s10903‐015‐0273‐2

Children diagnosed overseas8,231

Post‐arrival evaluation5,749 (70%)

LTBI diagnosed or confirmed stateside3,299 (57%)

LTBI therapy initiated2,258 (68%)

LTBI therapy completed680 (30%)

Preventing TB Overseas Pilot Study (PTOPS)

Latent Tuberculosis Infection Testing and Voluntary Treatment for U.S‐Bound Immigrants from Vietnam

Purpose: assess the acceptability and feasibility of offering LTBI treatment to U.S.‐bound immigrants prior to U.S.‐arrival

Partners CDC Division of Global HIV/AIDs and Tuberculosis CDC Division of Tuberculosis Elimination CDC Division of Global Migration and Quarantine Cho Ray Hospital Visa Medical Department Vietnam NTP‐ UCSF Research Collaboration



Long‐Term Visitor Screening

Long‐Term Visitors

Persons who will be staying in the United States for ≥6 months

Two main categories:

International students

Workers

Countries that Screen Long‐Term Visitors

Canada

Norway

Jordan

Australia

United Kingdom

France

New Zealand



The United States is Behind

United States

2015: Included in the National Action Plan to Combat Antibiotic‐Resistant Bacteria

TB Among Long‐Term Visitors US foreign‐born cases diagnosed within 6 months after arrival

22% are temporary visa holders One‐third reported having symptoms at or before arrival

US international students 48.1 per 100,000 case rate

CDC‐estimated rate among long‐term visitors from high incidence countries: 60.9 per 100,000

Australia screening program Students: 69 per 100,000 Skilled labor: 44 per 100,000

United Kingdom screening program Students: 76 per 100,000 Workers: 68 per 100,000

Davidow AL, et al. Am J Public Health 2015 Sep;105(9):e81‐8. Collins JM, et al. Annals ATS 2015 10.1513/AnnalsATS.201508‐547OC Liu Y, et al. PLoS ONE 2012;7(2): e32158. doi:10.1371/journal.pone.0032158. Aldridge RW, et al. Lanced Infect Dis 2016;16:962‐70.

Cost‐effectiveness of Screening Foreign Students for Tuberculosis

India China Germany

Hypothetical cohort 29,981 58,015 2,795

Cases diagnosed overseas(based on TB Indicators)

29.2 127.8 0

Cases in Class B1 after arrival (based on EDN)

17.9 34.7 0

Difference in US costs with overseas screening costs

Savings of$458,695

Savings of$2,234,411

Additional cost of$5,201

Wingate, et al. PLOS One 2015 10(4): e0124116. doi:10.1371/journal.pone.0124116



Implementation Requirements

Policy

Coordination with other Federal departments

• Department of State (DOS)

Regulatory change may be needed

Overseas

Build panel physician capacity

Train panel physicians

Evaluate and monitor

Cross‐Border Solutions

Identify US‐bound source communities with high burden of tuberculosis

Work directly with TB institutions to provide TB control support in these communities

Posey DL, Marano N, CetronMS. Int J Tuberc Lung Dis 2017;21(5):485.

EDN and eMedical



EDN

Overseas U.S.

Data Entry CenterCDC HQ ‐ Atlanta

EDN – DATA ENTRY

OverseasScreening

OverseasForms

Local/State Health Departments

EDN – WEBEDN‐IOM Interface

Quarantine Stations

eMedical

Overseas U.S.

OverseasScreening

Local/State Health Departments

EDN – WEBEDN‐IOM Interface

eMedical

Data Entry CenterCDC HQ ‐ Atlanta

EDN – DATA ENTRY

About eMedical

System developed by the Australian Department of Immigration and Citizenship

Used by panel physicians that screen for Australia, Canada, and New Zealand

Used by over 600 panel physicians in 140+ countries

Already used by 42% of U.S. panels sites!

Aligns with modernized immigrant visa (MIV) initiative at Department of State

Consular officers to have access (no paper forms)



eMedical Implementation

Phased rollout

Implementation for panel physicians and US Consular Sections

Begin at key posts as early as November 2017

Rollout complete by end of 2018

Acknowledgments• Division of Global Migration

and Quarantine

– Monica Adderley

– Rovonda Bradford

– Heather Burke

– Marty Cetron

– Courtney Chappelle

– Terry Comans

– Annelise Doney

– Silia Herrera

– Emily Jentes

– Katrin Kohl

– Deborah Lee

– Luis Ortega

– Nina Marano

– Pam McSpadden

– Mary Naughton

– Joanna Regan

– Lisa Rotz

– Michelle Russell

– Eric Shropshire

– Diane Simpson

– Sean Toney

– Michelle Weinberg

– Zack White

• Division of Tuberculosis Elimination– Phil LoBue– Ann Cronin– Tom Navin– Phil Talboy

• Department of State, Bureau of Consular Affairs– Kaitlin Keating– Joel Nantais

• Department of State, Bureau of Populations, Refugees, and Migration – Margaret Burkhardt

• International Organization for Migration– Poonam Dhavan– Warren Jones– Davide Mosca

• United States Customs and

Immigration Services

– Bruce Larson

• International Panel Physicians

Association

– Ahmed Jan

– Alexandra Todd

• National Tuberculosis Controllers

Associat5ion

– Donna Wegener

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1‐800‐CDC‐INFO (232‐4636)/TTY: 1‐888‐232‐6348E‐mail: [email protected] Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you

National Center for Emerging and Zoonotic Infectious Diseases

Division of Global Migration and Quarantine

general session posey april 19, 2017 - ntca · tuberculosis cases, united states, 1996 ‐ ......

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