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© 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


• 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


• 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


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.gov

http://www.cdc.gov/


TB Incidence Rates, Metro Denver


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


Countries of Origin for Foreign-born Persons with TB in Colorado, 2010-2014

CountryCountry # cases # cases Mexico 85Ethiopia 21India 15Somalia 13Philippines 11Vietnam 10

76% of total TB cases among individuals born outside of the US

TB incidence in 2014: 1.2/100,000


Objectives

• Objective 1: Identify which active cases were preventable

• Objective 2 : Determine the proportion of individuals diagnosed with latent TB who complete therapy


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


• 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


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 Cases 307 -Foreign-born 246 80

Report date > 6 months from arrival 187 61

TST or QFT positive at diagnosis 135 44 Median years in US until diagnosis=7.5

55%45%


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


• 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


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%


• 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


• 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


• 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


• 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?


Thank you!Contact information:Michelle Haas, M.D.Denver Metro Tuberculosis ClinicDenver Public Health605 Bannock StreetDenver, CO 80230Ph: [email protected]

mailto:[email protected]

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