Mortality Among a Tuberculosis OutbreakLos Angeles County, 2007–2013

Brian Baker, MD

Amit Chitnis, MD MPH

Leslie Henry, BSN RN PHN

48th CTCA Educational Conference

April 24, 2014

Mortality Among Patients with Tuberculosis

• Most cases of tuberculosis (TB) are curable with appropriate treatment for 6 to 9 months

• However, an estimated 7–10% of patients with TB die prior to diagnosis or during treatment

• Better understanding of deaths is needed to guide future strategies to reduce mortality

Objectives

• Describe deaths among outbreak cases, including frequency and timing

• Assess demographic and clinical factors among outbreak deaths

• Identify possible opportunities for intervention

Methods

• Reviewed reported cases of tuberculosis in Los Angeles County during 2007–2013

• Defined outbreak cases based upon:– Genotype results from a Mycobacterium tuberculosis isolate

OR– Epidemiologic link to a confirmed outbreak case

• For outbreak patients who died, medical records were reviewed

Methods

• Timing of death was measured from TB treatment start date (for those alive at diagnosis)

• Severity of TB disease was assessed using standardized tool

Outbreak CasesLos Angeles County, 2007–2013

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 42007 2008 2009 2010 2011 2012 2013

0

1

2

3

4

5

6

7

8

9

No

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ses

Outbreak CasesLos Angeles County, 2007–2013

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 42007 2008 2009 2010 2011 2012 2013

0

1

2

3

4

5

6

7

8

9

No

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Timing of Outbreak Deaths(n=21)

Dead at diagnosis

0 to 1 1 to 2 2 to 4 4 to 6 > 60

10

20

30

40

50

14.3

42.9

23.8

4.8

14.3

0

Months

Pe

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nt

of

case

s

Demographic and Clinical Characteristics Among Outbreak Deaths (n=21)

No. (%)

Age <25 0 (0.0)

25–44 9 (42.8)

45–64 8 (38.1)

>65 4 (19.1)

Sex Male 21 (100.0)

Female 0 (0.0)

Demographic and Clinical Characteristics Among Outbreak Deaths (n=21)

No. (%)

Origin U.S.-born 9 (42.9)

Foreign-born 10 (47.6)

Unknown 2 (9.5)

Race/Ethnicity Hispanic 15 (71.4)

Black 5 (23.8)

White 1 (4.8)

Asian / Other 0 (0.0)

Demographic and Clinical Characteristics Among Outbreak Deaths (n=21)

No. (%)

Homeless Yes 15 (71.4)

No 4 (19.1)

Unknown 2 (9.5)

Substance abuse Yes 9 (42.9)

No 3 (14.3)

Unknown 9 (42.9)

Incarceration at diagnosis

Yes 1 (4.8)

No 20 (95.2)

Demographic and Clinical Characteristics Among Outbreak Deaths (n=21)

No. (%)

HIV Positive 8 (38.1)

Negative 8 (38.1)

Unknown 5 (23.8)

Sputum smear Positive 12 (57.1)

Negative 8 (38.1)

Not done 1 (4.8)

Chest radiograph Cavitary 3 (14.3)

Non-cavitary 17 (81.0)

Normal 0 (0.0)

Not done 1 (4.8)

Demographic and Clinical Characteristics Among Outbreak Deaths (n=21)

No. (%)

Site of disease Pulmonary 17 (81.0)

Extrapulmonary 1 (4.8)

Both 3 (14.3)

TB severity index Mild 1 (4.8)

Moderate 1 (4.8)

Severe 19 (90.5)

Co-morbid conditions Cirrhosis 3 (14.3)

Diabetes 3 (14.3)

Cancer 2 (9.5)

Adherence Among Outbreak Deaths

No. (%)

Type of non-adherence

Left against medical advice 3 (14.3)

Eloped 2 (9.5)

Refused treatment 1 (4.8)

Any of above 6 (28.6)

Deaths Among Patients with TB and HIV

n=8 No. (%)

CD4 count, median (range) 54 (2–154)

New HIV diagnosis 3 (37.5)

Already receiving ART at TB diagnosis 0 (0.0)

Received ART during TB treatment 2 (25.0)

Poor adherence 5 (62.5)

ART = antiretroviral therapy

Time from hospital admission to first specimen collection

Days

Median Mean Range

Hospitalized patients with suspected TB (n=20)

1 2 0–12

Time from first specimen collection to initiation of treatment, by AFB smear status

Initial smear resultsDays

Median Mean Range

AFB smear positive (n=11) 1 4 1–26

AFB smear negative (n=7) 17 24 4–80

Treatment among patients with initially smear negative specimens (n=9)

Precipitating factor No. (%)

Subsequent positive smear 4 (44.4)

Positive culture 3 (33.3)

Never initiated treatment 2 (22.2)

NAAT performed 0 (0.0)

Received empiric treatment 0 (0.0)

NAAT = nucleic acid amplification test

Limitations

• Some data missing, particularly among patients dead at diagnosis or during initial hospitalization

• Deaths were not necessarily related to TB

Summary

• Most deaths occurred early among patients with severe disease at the time of diagnosis

• Large number of patients with other contributing medical conditions (e.g., HIV)

• Patients were evaluated for TB, but treatment only started after positive smear or culture

• Adherence to TB treatment is a substantial challenge

Areas of Opportunity

• Implementing policies and practices to diagnose homeless patients earlier

• Connecting HIV-infected homeless persons to HIV-related care and treatment before TB diagnosis

• Improving availability of rapid diagnostics for active TB disease (i.e., NAATs)

• Continuing use of public health resources to support patients during treatment

Acknowledgments

• Los Angeles County Department of Public Health– Tuberculosis Control Program– Community Health Services

• California Tuberculosis Control Branch

• Partners in shelters, clinics, and hospitals

Questions?