Epidemiology of Tuberculosis in Northeastern United States, 19932005

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Epidemiology of Tuberculosis in Northeastern
United States, 1993-2005
Northeast TB Controllers Meeting Princeton, New
Jersey October 24, 2006

• Kenneth G. Castro, M.D.
• Assistant Surgeon General, USPHS
• Director, Division of Tuberculosis Elimination
• National Center for HIV, Hepatitis, STD, and TB
  Prevention
• Coordinating Center for Infectious Diseases

Proposed
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Acknowledgements

• United States TB controllers, state and local
  health departments
• CDC, DTBE, SEOIB and FSEB
• Lori Armstrong - Sandy Althomsons
• Elvin Magee - Val Robison
• Tom Navin - Dave Crowder
• Dan Ruggiero - John Jereb
• Mark Lobato - Margaret Oxtoby
• Edwin Rodriguez - Tracy Agerton
• Farah Parvez - Sonal Munsiff
• Vernard Green - Tom Privett
• Zach Taylor

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TB Cases Analyzed

• National TB Surveillance System
• Reported 1993 to 2005
• Northeastern States Maine, New Hampshire,
  Vermont, Connecticut, Massachusetts, Rhode
  Island, New York, New Jersey
• Compared to all other states in the U.S.

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TB Case Rates, United States, 2005
NE states
D.C.
lt 3.5 (year 2000 target)
3.64.8
gt 4.8 (national average)
Cases per 100,000.
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Reported TB Case Rates in U.S.,NE vs. Other
States, 1993-2005
Rate TB Cases/ 100,000
Year
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Reported TB Cases by Age Group, NE States vs.
Others, 19932005
Percent of Case Count
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Reported TB Cases by Race/Ethnicity,NE States
vs. Others, 19932005
Amer Indian/Nat Alaskan (lt1)
Amer Indian/Nat Alaskan (1)
Nat Hawaiian/Pacific (lt1)
Asian (20)
White (18)
Asian (19)
White (25)
Nat Hawaiian/Pacific (lt1)
Hispanic (25)
Black (36)
Black (31)
Hispanic (23)
Other States
NE States
All races are non-Hispanic. Persons reporting
two or more races accounted for less than 1 of
all cases. Unknown not included.
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Reported TB Cases by Birth Origin,NE States vs.
Others, U.S., 19932005
Note Unknown not included
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TB Cases, by Previous Diagnosis, NE States vs.
Others, U.S., 19932005
Note Unknown and missing not included Updated
as of March 29, 2006.
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HIV Test Results of TB Cases,NE States vs.
Others, U.S., 19932005
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Mode of Treatment Administration in Persons
Reported with TB,NE States vs. Others, U.S.,
19932003
Excludes unknown and missing. Directly observed
therapy (DOT) Self-administered therapy (SA)
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Percent Completion of TB Therapy, NE States
vs. Others, U.S., 1993-2005
Percent
Year
Healthy People 2010 target 90 completed in 1
yr or less.Note Excludes persons with initial
isolate resistant to rifampin and children lt15
years old with meningeal, bone or joint, or
miliary disease excluded.
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Reason Therapy Stopped in TB Cases, NE States vs.
Others, U.S., 19932005
Percent
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MDR TB in NE States vs. Others,U.S., 1993-2005
MDR TB
Year of Reporting
MDR TB cases no. of TB cases with
Mycobacterium tuberculosis isolates resistant to
isoniazid and rifampin, among all cases tested
to isoniazid and rifampin
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MDR TB by Birth Origin, NE States vs. Others,
U.S., 1993-2005
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TB Epidemiology Summary in NE States

• Heterogeneous states (high, medium, low
  incidence)
• Consistently higher rates
• Majority (58.6) younger than 44 years
• Most (82) racial/ethnic minorities
• Lower proportion (49.2) U.S.-born
• Higher prevalence (19.2) HIV infection
• Larger proportion on DOTSA and SA only treatment
• COT improving (82), room for improvement
• MDR decreased 1993-2000, recent stagnation

Compared with other states, U.S., 1993-2005
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(No Transcript)
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Second-Line Drug Classes for MDR TB Treatment
Aminoglycosides
Amikacin, Kanamycin
Polypeptides
Capreomycin
Fluoroquinolones
Ciprofloxacin, Ofloxacin
First line drugs

Thioamides
Ethionamide, Prothionamide
Serine analogues
Cycloserine
PAS
WHO. Guidelines for the programmatic management
of drug-resistant tuberculosis. 2006.
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Characteristics of KZN XDRTB Patients

• Characteristics No. ()
• No prior TB Treatment 26 (51)
• Prior TB treatment
• Cure or Completed treatment 14 (28)
• Treatment Default or Failure 7 (14)
• HIV-infected (44 tested) 44 (100)
• Dead (Includes 34 on ARV) 52 (98)
• Identical M. tb spoligotype 26/30

Moll A, Gandhi NR, Pawinski R, Lalloo U, Sturm
AW, Zeller K, Andrews J, Friedland G. HIV
associated Extensively Drug-Resistant TB (XDR-TB)
in Rural KwaZulu-Natal (South Africa MRC Expert
Consultation Sept 8, 2006)
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HIV-related MDR TB Outbreak Investigations by
CDC Health Departments, USA, 198892
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U.S. Response to TB Resurgence
Updated Diagnostic Labs, Real-time Drug
Resistance, Strain Fingerprinting
National MDR-TB Action Plan New Resources
Improved Case Identification Training
DOT Improved Rx Completion
Rebuilt Research Capacity
Updated Infection Control and Rx Recommendations
AJRCCM 19941491359-74
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Global 7-point Action Plan to Combat XDR
TBEmphasizes Essentials of Proper TB Control

• Conduct rapid surveys of XDR-TB (determine
  burden)
• Enhance laboratory capacity (emphasis on rapid
  DST)
• Improve technical capacity of clinical and public
  health practitioners to effectively respond to
  XDR-TB outbreaks and manage patients
• Implement infection control precautions (PLHA
  focus)
• Increase research support for anti-TB drug
  development
• Increase research support for rapid diagnostic
  test development
• Promote universal access to ARVs under joint
  TB/HIV activities

MRC Consultation, Johannesburg, South Africa.
Sept 7, 2006
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Revised WHO Case Definition for XDR TB (Oct 10,
2006)

• Goals
• Public health surveillance
• Reliable DST methodology
• Clinical relevance
• Relatively simple

Resistance to at least isoniazid and
rifampin (MDR) plus resistance to
fluoroquinolones and one of the second-line
injectable drugs (amikacin, kanamycin, or
capreomycin)
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TB Treatment Outcomes, by Selected Drug
Resistance Patterns, Latvia, 2000-2003
Percent
Leimane V, et al. WHO XDR TB Task Force
Meeting. Oct 9, 2006 (from N 820 evaluated)
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XDR(WHO) TB Cases in U.S.,Northeast vs. Other
States, 1993-2005
No. XDR TB Cases
Year of Report
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XDR(WHO) TB Cases in U.S.,Foreign-born vs.
U.S.-born, 1993-2005
No. XDR TB Cases
Year of Report
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XDR(WHO) TB Cases in Northeast States,
Foreign-born vs. U.S.-born,1993-2005
No. XDR TB Cases
Year of Report
28
XDR(WHO) TB Cases in Other States, Foreign-born
vs. U.S.-born,1993-2005
No. XDR TB Cases
Year of Report
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XDR(WHO) TB Cases in U.S.-born vs. Foreign-born
Persons, 1993-2005
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TB Clinical Development Pipeline
Diarylquinoline TMC207
Nitroimidazo-oxazole OPC-67683
Nitroimidazole PA-824
Pyrrole LL-3858
Institut de Recherche pour le Developement ?
World Health Organization, Tropical Disease
Research ? Centers for Disease Control and
Prevention
Novel compounds, highlighted in blue boxes, are
active against MDR/XDR TB
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Examples of Rapid Drug Resistance Methods
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Microscopic-Observation Drug Susceptibility Assay
for the Diagnosis of TB
Moore DAJ, et al. N Engl J Med 20063551539-50
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Actual and BRDPI-Adjusted Federal Funds for TB,
CDC, 1990-2006
Actual
BRDPI Adjusted
Adjusted to 1990 US by Biomedical Research
Development Price Index Includes TB/HIV and
lab dollars