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Tuberculosis surveillance: overview, new directions and challenges 1
TB SURVEILLANCE:OVERVIEW, NEW DIRECTIONSAND CHALLENGES
Phil Lowenthal, MPH
Epidemiologist
California Department of Public Health
Curry International Tuberculosis CenterTB Program Manager’s IntensiveNovember 18, 2019
SESSION OUTLINE
Introduction to surveillance
National TB surveillance systems Report of Verified Case of Tuberculosis (RVCT)
California Reportable Disease Information Exchange (CalREDIE)
B-notification & Electronic Disease Notification (EDN)
Uses of surveillance data
National Tuberculosis Indicators Project (NTIP)
Annual Report on TB in California
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Tuberculosis surveillance: overview, new directions and challenges 2
LEARNING OBJECTIVES
Upon completion of this session participants will be able to:
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Describe the pre-immigration screening process for immigrants arriving in the United States
Explain the purpose and the types of indicators that are evaluated by using the national tuberculosis indicators project
Apply the key components of a TB surveillance system to improve program efficiencies
4
SURVEILLANCE: WHAT IS IT?
Systematic collection of pertinent information on cases of disease
Dissemination of results to those who use data for TB control activities
Analysis and interpretation of data
Tuberculosis surveillance: overview, new directions and challenges 3
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SURVEILLANCE: WHY DO IT?
Detect trends in disease or health-related behaviors
Identify groups at risk
Identify outbreaks
Direct public health action
Evaluate interventions
Generate hypotheses; stimulate research
Justify funding for continuing surveillance effort
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Deaths in Persons with TBCalifornia, 2007-2016
8.1%8.4%
9.4%
8.4%
9.5%9.8% 10.1%
9.2% 9.1%
11.4%
0.0
2.0
4.0
6.0
8.0
10.0
12.0
0
50
100
150
200
250
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Pe
rce
nt
of
case
s
Nu
mb
er
of
de
ath
s
Muerte durante tratamiento Muerte al diagnosis Porcentaje de meurtes con TBDeath during treatment Dead at diagnosis Percent of all TB cases
Tuberculosis surveillance: overview, new directions and challenges 4
REPORTS OF VERIFIED CASE OF TUBERCULOSIS (RVCT)
OBJECTIVES RVCT
- Overview
- When to report a case of TB?
- Data quality control
- How is data used?
CalREDIE- Overview
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Tuberculosis surveillance: overview, new directions and challenges 5
The RVCT consists of three forms:
Report of Verified Case of Tuberculosis Required for all verified, countable TB cases
Recommended for non-countable cases that do not have a CA RVCT number
Submitted within 2 weeks of active TB disease confirmation
Initial Drug Susceptibility Report (Follow-Up 1)Required for culture-positive cases Submitted within 2 months of RVCT, or as soon as
susceptibilities are available
Case Completion Report (Follow-Up 2)Required for cases that were alive at diagnosis Submitted when case completes therapy, transfers out of
jurisdiction, or has another outcome9
COUNTED case:
• Meets the TB case definition
• Has NOT been counted by another reporting area
• >12 months since completing treatment (previous TB)
• Examination and diagnosis occurred in the U.S. (recent arriver)
Submit an RVCT for allcounted cases
NON-COUNTED case:
• Meets the TB case definition
• Counted by another state or country OR <12 months since completing treatment (previous TB)
Submit an RVCT if:
• Patient is treated in your jurisdiction
• Patient does not already have a CA RVCT for this episode
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Tuberculosis surveillance: overview, new directions and challenges 6
QC list sent quarterly as Excel workbookMissing data, unknown data, other data quality issues
Reminders to submit FU1 and FU2
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Year end processYear end training held early December
Case reporting deadline mid-January for provisional count
Final data for publication in annual report finalized April-May
Timely reportingRVCT data is required for CDC to link genotyping data and
generate cluster alerts for early outbreak detection
National and CA-specific TB Indicator Reports
RVCT trainings offered yearly and upon requestWebinar recording also available
Report on TB inCalifornia (CDPH)
Reported TB in the United States (CDC)
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Tuberculosis surveillance: overview, new directions and challenges 7
CA TB Indicator ReportsNational TB Indicators Project Reports (NTIP)
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RVCT variables are used to determine, in part, funding level from CDC to California and from California to local health jurisdictions:
Place of birth
Race and ethnicity
Sputum smear positivity
HIV co-infection
Alcohol or drug abuse
Homelessness
Multidrug resistance
Drug susceptibility tests completed
Treatment completion14
Tuberculosis surveillance: overview, new directions and challenges 8
CALIFORNIA REPORTABLE DISEASE INFORMATION EXCHANGE
CALREDIE OVERVIEW
Centralized web-based reporting and surveillance system
Public health staff can securely collect data, investigate cases/contacts and manage outbreaks
Designed for reporting data for all communicable diseasesReporting a case of TB in CalREDIE requires a TB
incident and a complete RVCT
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Tuberculosis surveillance: overview, new directions and challenges 9
Provider Portal - Health care providers can submit confidential morbidity reports (CMRs) via CalREDIE
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Electronic Lab Reporting - Laboratories can electronically send lab results via HL7 messaging into CalREDIE
Data Distribution Portal – State and local public health staff can extract data entered in CalREDIEusing the portal
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RVCT:Maria CarterSurveillance AssociateE-mail: [email protected] or [email protected]: (510) 620-3026
CalREDIE:Varsha HampoleSurveillance & Informatics CoordinatorE-mail: [email protected]: (510) 620-3994
Contact
Tuberculosis surveillance: overview, new directions and challenges 10
B-notification and the Electronic Disease Notification System
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OUTLINE
Origin of non-US-born TB cases in CA
Strategies in place to prevent importation of infectious TB to the U.S.
Process for overseas TB screening of immigrants and refugees
Electronic Disease Notification (EDN)
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Tuberculosis surveillance: overview, new directions and challenges 11
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STRATEGIES TO PREVENT IMPORTATION OF INFECTIOUS TB TO THE U.S.
1) Overseas screening: persons screened for TB prior to U.S. arrival using CDC’s pre-immigration screening and treatment algorithm
2) Domestic follow-up evaluation: state and local health departments are notified by CDC of persons at risk of developing TB
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Tuberculosis surveillance: overview, new directions and challenges 12
Class A: applicant with active TB disease who was granted a waiver
Class B0, Pulmonary: applicant who completed directly observed therapy (DOT) for TB disease at a panel site prior to immigration. Travel clearance valid for 3 months
Class B1, Pulmonary: medical history, physical exam, or CXR findings suggestive of TB but applicant has negative sputum smears and cultures. Travel clearance valid for 3 months
Class B1, Extrapulmonary: applicant diagnosed with EPTB with normal CXR, negative sputum smears and cultures. Travel clearance valid for 3 months
Class B2 (LTBI): applicants with positive IGRA, otherwise negative evaluation for TB. Travel clearance valid for 6 months
Class B3 (Contact): recent contact to a known TB case. Information about source case (contact info, drug resistance) must be documented. Travel clearance is for 6 months
23
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2018 Technical Instructions for TB Screening and Treatment for Panel Physicians
https://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/tuberculosis-panel-technical-instructions.html
Tuberculosis surveillance: overview, new directions and challenges 13
Overseas TB Screening of Immigrants and RefugeesPersons > 15 years old
IGRA positive
If medical history, physical exam, or CXR suggestive ofTB or HIV, AFB sputum smears (3) and cultures (3)
Persons 2-14 years old
Infectious TB: Class ADST on positive culture andDOT until therapy complete,
reclassify as B0
Noninfectious TB: Class B1
All (-)(at least one + smear or culture)
Medical history, physical examand IGRA
CXR negative:2-14 y/o: B2 (LTBI)≥15 y/o: No B class
CXRKey
Revisions(2018 TI)
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IGRA
reclassify as B0
Medical history, physical exam
Moving Surveillance into the 21st Century:Electronic Disease Notification System
Tuberculosis surveillance: overview, new directions and challenges 14
AIS - Alien Information System
IMP - Information on Migrant Populations
EDN - Electronic Disease Notification
*limited medical data collected
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AIS*
1995 20102000 2005
IMP* EDN200719991995
2008—100% centralization
DGMQ Quarantine Stations mail to state/LHJs (paper)
Electronic no�fica�on CDC → State/LHJs
2015 2020
eMedical & EDN2019
Electronic notification overseas → US
EDN - OVERVIEW
Electronically notify refugee programs and health departments of all newly arriving refugees and immigrants
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Provide access to scanned overseas medical evaluation forms for refugees with/without B class and immigrants with B class
Inform EDN system users of alien arriver’s secondary migration
Provide useful database functions for arrivers including batch print, data download and report generation
Tuberculosis surveillance: overview, new directions and challenges 15
EDN - DATA FLOW
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Scan Forms
Enter Data
Data Entry CenterCDC HQ - Atlanta
Data Entry Web
State / Local Refugee And Health Departments
New Alien Notification
OverseasScreening
OverseasForms
Overseas
View Overseas
Data
Perform Domestic
Evaluation (WS)SubsequentMigration
Notification
Reports
Downloads
EDN System
U.S.
eMedical
Outcome of Domestic Evaluation of California B-notification Arrivers
Tuberculosis surveillance: overview, new directions and challenges 16
31
TB Cases Reported among Class B1 Arrivers*California 2009-2018
*Reported with active TB <6 months after US arrival
1.6%
0.7%
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
0
1000
2000
3000
4000
5000
6000
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Perc
ent
of
B1
s re
po
rted
wit
h a
ctiv
e TB
Cla
ss B
1 a
rriv
ers
Year
NEXT STEPS
eMedical
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TB care directory (DGMQ pilot)
Expand pre-departure screening to other legal entrants (e.g. students, workers)?
Tuberculosis surveillance: overview, new directions and challenges 17
CONTACT
Varsha Hampole
Surveillance & Informatics Coordinator
Phone: (510) 620-3994
Phil Lowenthal
Epidemiologist
Phone: (510) 620-3051
33
NATIONAL TUBERCULOSIS INDICATORS PROJECT
Tuberculosis surveillance: overview, new directions and challenges 18
35
NTIP OVERVIEW
Purpose: Strengthen the capacity of state and local health departments to improve TB program performance
Participation: 14 local health jurisdictions that report an average of ≥55 TB cases per year (contributes ~89% of CA TB morbidity)
NTIP - INDICATORS
Identification and Reporting
TB Case Rate
Timely Reporting
Complete Reporting
Culture Identification
Completion of Therapy
Recommended Initial Therapy
Timely Treatment
Culture Conversion
Appropriate DOT
Inappropriate SAT
Timely Completion of Therapy
Not Defaulting from Treatment
Contact Investigation
Contact Identification
Contact Evaluation
Contact LTBI Treatment Initiation
Contact LTBI Treatment Completion
Sentinel Events
Pediatric TB Cases
TB Deaths
Infrastructure
Program Capacity (self-assessment)
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Tuberculosis surveillance: overview, new directions and challenges 19
Source: National TB Indicators Project (NTIP)37
SPUTUM CULTURE CONVERSION
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Tuberculosis surveillance: overview, new directions and challenges 20
SPUTUM CULTURE CONVERSIONNext Steps:
Identify areas were improvements can be made
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7.5% of cases don’t have conversion documented
Possible cause for delayed conversions of culture-positive cases (22.1%)
Delayed collection of sputum Inadequate treatment regimen or drug resistance Laboratory delays in reporting results
What patterns do you see over time?
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NTIP PROCESS
Initial assessment Complete Infrastructure Self-Assessment Review indicator data
Analyze and plan (select indicator to target) Verify problem Determine reasons for problem
Develop interventions (action plan)
Implement interventions
Evaluate and reassess
Tuberculosis surveillance: overview, new directions and challenges 21
41
National TB Indicators Project (NTIP)
Centers for Disease Control and PreventionDivision of TB [email protected]
Thank you!
Questions?