Global Tuberculosis Epidemiology Pennan Barry, MD, MPH 高百能 Shanghai May 7, 2012

Transcription

1 Global Tuberculosis Epidemiology 2012 Pennan Barry, MD, MPH 高百能 Shanghai May 7, 2012 Image from: WHO, Global Tuberculosis Control 2011

2 Global TB Epidemiology Outline Burden of TB Morbidity Deaths TB Epidemiology in populations Migrants HIV Diabetes Tobacco Drug resistant TB (Examples from California throughout)

3 Burden of Disease

4 Estimated Global TB Burden, million incident cases; 1.1 million HIV+ 128 cases per population 5 countries with most incident cases: India ( million) 38% of all cases China ( million) South Africa ( million) Indonesia ( million) Pakistan ( million) Source: WHO Global Tuberculosis Control Report 2011 ( 4

5 Estimated TB Incidence Rates 2010 WHO, Global Tuberculosis Control 2011

6 Global TB Burden by Region, 2010 Proportion of Cases 3% 7% 5% Asia Africa 26% 59% Eastern Mediterranean Europe Americas Source: WHO Global Tuberculosis Control Report 2011 ( 6

7 Incidence and Case Notification Rates by WHO Region, Africa The Americas E. Mediterranean Europe South-East Asia W. Pacific

8 Rate per 100,000 Global TB Deaths, million: 1.1M among HIV-negative; 0.35M among HIV-positives 20 per 100,000 Except in Africa, all WHO Regions expect to meet 50% reduction target by 2015 Africa South-East Asia W. Pacific Source: WHO Global Tuberculosis Control Report 2011 (

9 TB Case Rates, United States, 2010 DC > <2.0 *Cases per 100,000. 9

10 California Most populous state (38M) Large immigrant population (27% foreign born) Most TB in US (~20%) Largest economy Rural and urban 10

11 Number of Tuberculosis Cases California, , ,000 8,000 6,000 4,000 2,

12 Number of Deaths Deaths in Persons with Tuberculosis: California, Died During Treatment Died Before Starting Treatment 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Percent of Cases Dead at Diagnosis Percent Dying with Tuberculosis

13 Percent 100 Time to Death: Patients Starting Therapy, California 2009 Median time to death = 44 days % 30% 20 18% 10% 0 <1 Month 1-3 Months 3-6 Months >6 Months Duration of Therapy

14 TB Epidemiology: Migrants Credits: 1. AP Photo posted at: 2. Joelnewell:

15 TB and Migration > 150 million people long-term residents of country other than country of birth Most migrants go from high to low TB incidence countries Internal migration: Rural urban Increased vulnerability to TB Increased crowding Decreased access to care; worse treatment outcome Wang, et al, Eur J Clin Microbiol Infect Dis Zhang et al. INT J TUBERC LUNG DIS 10(9): , 2006

16 No. (in thousands) TB Cases and Case Rates among U.S.-born vs. Foreign-born Persons United States, * No. of TB cases U.S. born No. of TB cases foreign born TB rate among U.S. born TB rate among foreign. born Overall national rate Rate per 100,000 *Updated as of March 24, Year 16

17 Tuberculosis among Foreign-born in California, of 2317 (77%) TB cases foreign-born Top 5: China N=121 India N=89 Vietnam N=240 Mexico N=494 Philippines N=375 Other N=463 17

18 No. of Cases Foreign-born TB Cases by Time in U.S. California >20 No. of Years in U.S. 18

19 19 TB Case Rates by Race/Ethnicity and Nativity, CA 2010 Overall CA rate: 6.3 CA Asian Black Foreign born US born Hispanic White Rate (per 100,000)

20 TB cases among immigrants with abnormal CXR, 2006 June 2010 Cases reported <6 months after U.S. arrival 8% 7% 6% 5% 4% 3% 2% 1% 0% 7.0% 5.0% Negative smear and culture requirement phased in 2.1% 1.3% 1.7% 2006 n= n= n= n= * n=1626

21 20% TB cases and Drug Resistance among immigrants with abnormal CXR, 2006 June % 10% INH mono R MDR 5% 0% Cases reported <6 months after U.S. arrival

22 Medical Comorbidities 22

23 Medical risk factors among TB cases >15 years of age, California 2011 Risk Factor All Cases US-born Foreignborn Diabetes 24% 15% 27% End stage renal disease 3.8% 3.8% 3.9% HIV-positive* 4.5% 6.9% 4.0% Other immunosuppression 7% 6% 7% Post-organ transplant <1% <1% <1% One or more risk factor 35% 29% 36% *HIV-positive among all cases, including those not tested 23

24 Proportions of TB disease attributable to medical risk factors, California Factor RR if factor present Prevalence of factor Population attributable risk percent (PAR%) Smoking % % Diabetes % % Renal dialysis % % HIV/AIDS % % Organ transplant % % PAR%: the proportion of TB in the overall population that is attributable to the medical risk and could be eliminated if the risk were eliminated

25 TB Epidemiology: HIV

26 Estimated HIV Prevalence in New TB cases, 2008 (%) WHO/UNAIDS Towards Universal Access, Progress Report 2010

27 WHO Global Tuberculosis Control Report 2011; Global TB/HIV 1.1M (13%) incident TB cases among HIV+ 82% of TB/HIV in Africa TB is cause of death in 25% 34% of TB patients tested for HIV 46% of TB/HIV patients on ART 7% of HIV+ tested for TB Africa: Estimated TB incidence All TB TB/HIV+

28 Number receiving ART low/middle-income countries, WHO/UNAIDS Towards Universal Access, Progress Report 2010

29 TB/HIV: 3 Is and ART Intensified case finding Infection control INH preventive therapy ART Reduces TB incidence 50-90% Reduces TB mortality by 54 95% WHO/UNAIDS Towards Universal Access, Progress Report 2010

30 AIDS and TB Cases, California,

31 TB/HIV in California, Time Period Total TB cases HIV/TB Cases N (%) TB rate among HIV+ (per 100,000) Case Fatality (%) (Overall) (pre-haart) (post-haart) 57, (6.8) 14, (9.2) , (5.3)

32 HIV/TB Changes Post-HAART, California Age > % 20.6% Age > % 20.6% Female 11% 17% Female 11% 17% Race/ethnicity White 25% 13% Black 33% 21% Hispanic 38% 57% Asian 4% 8% Race/ethnicity White 25% 13% Black 33% 21% Hispanic 38% 57% Asian 4% 8% Foreign-born 37% 63% Foreign-born 37% 63% 32

33 TB Epidemiology: Diabetes

34 Diabetes 366 million in million by 2030 Number increasing in every country 80% live in low- and middle-income countries 183 million (50%) undiagnosed

35 2008 Age-standardized diabetes prevalence Adults 25+ years by World Bank income group

36 Diabetes and TB Comorbidity by Nativity, California 2010 (Aged 18) Nativity % total TB cases TB rate per 100,000 CA pop 1 % TB DM cases Diabetes and TB Co-Morbidity TB Rate per 100,000 CA diabetes pop U.S. Born 21% % 4.2 Foreign Born 77% % 44.2 Foreign-born DM have a RR 24.6 compared with US-born nondm Among foreign-born TB-DM patients, 75% were diagnosed with TB after residing in the U.S. for more than 10 years (compared with 54% among foreign-born TB patients without DM) 1 CA Department of Finance Population Estimate,

37 TB Epidemiology: Tobacco

38 TB and Tobacco 1.3 Billion people smoke (29%; 48% of men) Tobacco increases risk of infection; Progression; Death 20% of global TB attributable to smoking

39 Drug Resistant TB

40 Global MDR Burden Surveillance varies by country and region Resistance surveys vs continuous surveillance National vs subnational 2010: Data from 59% of countries since Estimate: 440,000 incident cases Half from China + India 2010 Estimate: 650,000 prevalent cases WHO Global Tuberculosis Control Report 2011 WHO. M/XDR TB: 2010 Global Report on Surveillance and Response

41 Estimated Absolute Number of Incident MDR TB Cases 2009 WHO Global Tuberculosis Control Report

42 Detecting and Treating MDR TB <2% of new and <6% of retreatment TB cases tested for MDR Among 27 high MDR burden countries <7% of estimated cases diagnosed WHO Global Tuberculosis Control Report 2011

43 % MDR-TB cases MDR-TB in 9 Asian countries, 2010 vs. 158,050 7,126 (4.5%) 5, targets 2,000* Estimated Notified Enrolled Successfully treated Slide courtesy Sarah Royce Global Plan 2015 targets *estimated using 2008 cohort

44 XDR TB 69 countries have reported at least 1 case Estimated 25,000 new cases each year TDR reports from Iran and India

45 # of Cases % of TB Cases MDR Tuberculosis Cases with MDR-TB California,

46 MDR TB in California: % Foreign-born by year 100% 80% 60% 40% 20% 0% 94% 93% 90% 97% 92%

47 % MDR TB among U.S.-born vs. Foreignborn Persons, California, % 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% U.S.-born Foreign-born Note: MDR TB defined as resistance to at least isoniazid and a rifamycin.

48 % % MDR TB by History of Prior TB, California, % 8% 6% 4% 2% 0% Prior TB No Prior TB Note: MDR TB defined as resistance to at least isoniazid and a rifamycin.

49 China s Success WHO: China has dramatically reduced the burden of disease caused by TB Incidence Mortality

50 Acknowledgments Lisa Pascopella Allison Kelley Ellen Demlow Phil Lowenthal Sarah Royce Janice Westenhouse Melissa Ehman Jennifer Flood Deb Lee CDPH TB Control Branch 50