Value of TB Screening Among Foreign Born Persons: U.S. (California) Perspective

February 27, 2015

Pennan Barry, MD, MPH

Outline

• Foreign born / Immigration in California

• TB in California among foreign-born

• Current screening programs

• Gaps / Opportunities

• TB in longstanding foreign born residents

Immigrants in California

• > 10 million immigrants (27% of CA pop.)

– ~25% of foreign-born in U.S.

• 50% of children with an immigrant parent

• 53% from Latin America; 37% from Asia

– 2007-2011: 53% from Asia; 31% from Latin America

• Estimated 2.5 million undocumented

From Public Policy Institute of California (http://www.ppic.org/main/publication_show.asp?i=258)

Sources: U.S. Census Bureau Decennial Censuses, American Community Survey, and the Department of Homeland Security.

3

TB Cases in US- and Foreign-born Persons, California, 1993-2014

0

500

1000

1500

2000

2500

3000

3500

TB C

ase

s

US-born

Foreign-born

Countries of Birth for Foreign Born Persons with TB

California, 2014

0% 20% 40% 60% 80% 100%

N=1,666

Mexico 446

India 96

China 145

Vietnam 205

Philippines 354

Other 420

Immigration Status at First US Entry persons with TB ― California, 2014

* Includes persons from counties with policies against collecting immigration status information

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Immigrant Visan=683

Refugee/Asylee/Familyn=150

Student/Worker/Touristn=117

Other(includes

undocumented)n=383

Unknown*n=300

Immigration Status at First US Entry persons with TB ― California, 2014

* Includes persons from counties with policies against collecting immigration status information

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Immigrant Visan=683

Refugee/Asylee/Familyn=150

Student/Worker/Touristn=117

Other(includes

undocumented)n=383

Unknown*n=300

Not screened

Screened (for active disease)

Probably Not screened

Newcomers to California

New immigrants Nonimmigrant

Admissions No legal status

Examples “Green Card” holders

Refugees

Tourists Students Workers

Undocumented

Number per year

200,000

11,000,000 (640,000 students/ workers)

?

TB screening required?

Yes No N/A

Source: U.S. Dept of Homeland Security. Yearbook of Immigration Statistics 2013 8

TB Screening of New Immigrants Legal Permanent Residents

“B-notification”

• Apply Overseas

• N=100,000 / year

• Active case finding only – Evaluated overseas

– CXR (TST for children)

– Abnormal CXR 3 sputa smear and cx

– If no active TB Domestic follow-up by health department

• Data easily available

“Status adjustors”

• Apply in US

• N=100,000/year

• Active and latent testing – Evaluated by “civil surgeons”

– TST or IGRA

– CXR for positives (>5mm)

– No requirement for treatment or referral if no active TB

– Is LTBI treatment given?

• Data not available

9 Source: U.S. Dept of Homeland Security. http://www.dhs.gov/profiles-legal-permanent-residents

Arrivers with abnormal pre-immigration CXR

California

149 146 64 49 74 54 38 24 0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

2006 2007 2008 2009 2010 2011 2012 2013*

Arrivers Cases of TB within 6 months of arrival

*Jan-June only 10

% of Arrivers* with active TB within 6 mos of arrival ― California

*B1 notification arrivers: abnormal pre-immigration CXR

**Jan-June only 11

4.1%

3.4%

1.6%

1.2%

1.7% 1.4%

0.9%

1.3%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

2006 2007 2008 2009 2010 2011 2012 2013**

Pre-immigration sputum culture

MDR among Arrivers* with Active TB

within 6 months of US arrival

*B1 notification arrivers: abnormal pre-immigration CXR

**Jan-June only 12

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

2006 2007 2008 2009 2010 2011 2012 2013**

Treatment for arrivers with abnormal pre-immigration CXR

California, 2012-2013

Persons evaluated in California including with a CXR *Arrivers evaluated to Class 3 have not been matched to RVCT

13

0%

20%

40%

60%

80%

100%

ATS Class 2n=1191

ATS Class 4n=2505

Unknown

LTBI treatment

No treatment

New Arriver Screening Gaps

• Many not screened at all (visitors, undocumented)

• Of those screened great majority not screened for LTBI

• Even among those screened by health departments >40% don’t start treatment

– No data from civil surgeons

14

What about longstanding foreign born residents in

California?

15

TB cases by years in US at TB report California, 2010–2014

0

100

200

300

400

500

600

700

800

2010 2011 2012 2013 2014

≤1 yr 1-10 yrs 11-20 yrs >20 yrs

16

+5%

-14%

-30%

-12%

Years in US at TB Diagnosis California, 2010-2014

0

100

200

300

400

500

600

700

800

900

TB C

ase

s

17 Years in US

Years in US at TB Diagnosis California, 2010-2014

0

100

200

300

400

500

600

700

800

900

TB C

ase

s

18 Years in US

*Cases diagnosed in domestic evaluation of abnormal preimmigration CXR

B-notification cases*

Years in US at TB Diagnosis California, 2010-2014

0

100

200

300

400

500

600

700

800

900

TB C

ase

s

Median 16.0 yrs 25Q 5.9 75Q 28.1 90Q 37.3

19 Years in US

75% in US > 5.9 years

Years in US at TB Diagnosis California, 2010-2014

0

100

200

300

400

500

600

700

800

900

TB C

ase

s

Median 16.0 yrs 25Q 5.9 75Q 28.1 90Q 37.3

50% in US >16 years

20 Years in US

75% in US > 5.9 years

Constant rate of reactivation from TB infection after immigration

Filipino immigrants to California

Walter et al AJRCC 2014

Years after immigration with a normal pre-immigration chest radiograph

Avg rate per 100,000 = 31.8

How to reach long standing foreign-born residents of

California?

22

2.5 Million Estimated TB Infections California

US Born 0.5

Million

Foreign Born

2 Million

0% 20% 40% 60% 80% 100%

TBI infections estimated by applying nativity and race/ethnicity-specific TB infection rates from NHANES (Bennett et al 2008 and Shea et al 2014) to the California population

23

Medical Risk Factors among persons with TB by nativity ― California, 2014

Total n (%) US-born %

Foreign-born %

Diabetes 508 (24.7) 13.9% 27.3%

ESRD 82 (4.0) 2.9% 4.2%

HIV positive 86 (4.2) 9.9% 3.5%

Other immuno-suppression

124 (6.0) 5.0% 6.3%

Post-organ transplantation

23 (1.0) 0.5% 1.3%

TNF-antagonist rx 20 (1.0) 0.5% 1.1%

1+ co-morbidity 723 (35.2) 30.2% 36.5%

Persons aged ≥15

TB Rate by Diabetes, Age, and Nativity California, 2010–2012

(Persons aged ≥18)

0

20

40

60

80

100

18-44 45-64 65-74 75+ 18-44 45-64 65-74 75+

United States or Canada Foreign-born

Cas

e R

ate

pe

r 1

00

,00

0 Diabetes No Diabetes

Sources: Denominator: 2011-2012 California Health Interview Survey | Numerator: CA TB Registry

25

Number Needed to Screen (and treat)

to prevent one case of TB in next 5 years 9551

7930

2740

1526 596

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

U.S.-bornadults with

diabetes

All adults All adults withdiabetes

All foreign-born adults

Foreign-bornadults with

diabetes

Calculated using increased risk of TB conferred by diabetes and published estimates for LTBI prevalence, risk of progression, test sensitivity, LTBI treatment efficacy, and proportion of persons starting and completing treatment. 26

Number Needed to Screen other examples

Sources: Rembold 1998 BMJ | Cochrane http://summaries.cochrane.org/CD001877/screening-for-breast-cancer-with-mammography; http://summaries.cochrane.org/CD004720/screening-for-prostate-cancer 27

2000 1961

1307

1055

596 418 354

0

500

1000

1500

2000

2500

Mammogram10yr

BP measurement- beta blocker

5yr

BP measurement- diuretics

5yr

PSA11yr

hemoccult(colon cancer)

5yrs

lipid screening -statin5yrs

Ask about CAD -aspirin

5 yr

NNS to prevent one death

Mammo-gram (10yr)

Measure BP

β blocker (5yr)

Measure BP

diuretic (5yr)

PSA (11yr)

Hemoccult (colon cancer)

(5yr)

Lipid screeningstatin

(5yr)

Ask re CAD aspirin (5yr)

Estimated LTBI burdens by selected TB medical risk population and nativity, California

Diabetes Rheumatoid arthritis

HIV/

AIDS

Renal

dialysis

Crohn’s Disease

Organ

transplant

Population size

2,330,000 201,300 111,100 53,000 35,900 26,700

Foreign-born with LTBI*

177,300 6,400 4,200 2,900 1,000 1,200

U.S.-born

with LTBI*

25,000 3,000 1,600 700 600 400

Total with LTBI

202,300 9,400 5,800 3,600 1,600 1,600

~ 193,000 Foreign born with LTBI * Assuming 18.7% of foreign-born and 1.8% of U.S.-born persons have LTBI. (Bennett et al, Am J Respir Crit Care Med 2008;177:348-55)

Transmission of TB Among Foreign Born

• Likely at least 20% of cases

• Importance often overlooked

• In 2013, 62% of patients in new California outbreaks were foreign born

Ricks et al 2011 PLoS ONE

*LLR score ≥10 and ≥10 cases 29

Opportunities to reduce TB in foreign born

• Alter new arriver screening? – Identify TB infection for overseas evaluations – Expand to other types of arrivers – Linkage to TB infection treatment for domestic

evaluation

• Alter longterm resident screening? – Use risk assessments and clinical reminders – Prioritize persons with medical risks – Screen beyond 5 years after arrival

• Ensure treatment started and completed • Make latent TB infection reportable?

30

Modeling TB in the U.S.

• Increasing proportion of TB Infection that is treated (baseline=5%)

Hill et al 2012 Modeling TB Trends in the USA 31

Modeling TB in the U.S.

• Increase proportion of TB Infection that is treated (baseline=5%)

• AND

• Reduce proportion of foreign born with TB Infection to 25% of baseline

Hill et al 2012 Modeling TB Trends in the USA 32

Acknowledgements

Phil Lowenthal

Janice Westenhouse

Tambi Shaw

Peter Oh

Ellen Demlow

Jenny Flood

33