Mexican and Central American TB cases in California 2001-2010 Neha Shah, MD MPH Division of Tuberculosis Elimination Centers for Disease Control and Prevention California Department of Health Tuberculosis Control Branch California TB Controllers Association Annual Meeting May 15, 2011 Los Angeles, CA
BACKGROUND
US TB cases among Mexican-born individuals Approximately 1 million persons cross the U.S.-Mexico border daily Among foreign-born TB cases in the US in 2011, 37% were from Mexico 1 Ways TB is transmitted across the border into the US Individuals with active TB migrate to the US Individuals with latent TB infection reactivate after arrival Most Mexican Born (MB) TB cases in US reported by the four border states: TX, NM, AZ and CA 2 1. Trends in Tuberculosis United States, 2011 Centers for Disease Control and Prevention, 2011. MMWR March 23, 2012 2. Tuberculosis along the US Mexico Border Work Group, Centers for Disease Control and Prevention, 2001. Preventing and controlling tuberculosis in the US Mexico border. MMWR Recomm Rep 50: 1 27
California MB TB Cases In 2011, 78% of California TB cases were foreign-born (n=1783) Mexican-born accounted for the largest proportion of foreign-born cases (28%, n=495) Philippines (21%, n=374) Vietnam (13%, n=239) China (7%, n=121) India (5%, n=89)
Unique Challenges with MB TB Cases Frequent border crossings complicate case management and continuity of care Potential differences in treatment regimens Movement within the US Difficulty in locating cases Potential for creating MDR and XDR TB due to treatment interruptions
CALIFORNIA TB CASES AMONG MEXICAN AND CENTRAL AMERICAN BORN INDIVIDUALS
TB Cases in California 2001-2010 28601 reported California TB cases 165 missing data on FB status 21866 (77%) TB cases among foreign born individuals 8092 (37%) MB/CAB TB cases 13774 (63%) all other FB TB cases
60 Reported TB Cases in California by Country of Birth, 1993-2011 CA/MB Other FB US Born 50 40 Percent 30 20 10 0 Year Counted
Demographic characteristics of CAB/MB and all other FB TB cases in California, 2001-2010 MB/CAB All other FB n % n % RR (95% CI) Sex (Male) n = 8090 n = 13773 5336 65.94 7664 55.64 1.19 (1.16, 1.21) Age n = 8090 n = 13774 0 14 279 3.45 212 1.54 2.24 (1.88, 2.67) 15 44 4320 53.40 5138 37.30 1.43 (1.39, 1.47) 45 64 2172 26.85 4321 31.37 0.86 (0.82, 0.90) 65+ 1319 16.30 4103 29.79 0.55 (0.52, 0.58) Median Age 41 52 T test <.0001 Time in US n = 7787 n = 13237 Less than 6 months 868 10.73 2054 14.91 0.72 (0.67, 0.77) 6mos 1 year 349 4.31 460 3.34 1.29 (1.13, 1.28) 1 5 years 1454 17.97 2042 14.83 1.21 (1.14, 1.29) 5+ years 5116 63.22 8681 63.02 1.00 (0.98, 1.02)* Median Time in US 11.1 10.4 T test <.0001 Migrant worker n = 7084 n = 13272 486 6.02 26 0.019 31.78 (21.44, 47.11) * RR not significant at 95%
TB risk factors of CAB/MB and all other FB TB cases in California, 2001-2010 MB/CAB All other FB RR (95% CI) n % n % Homeless n= 8005 n = 13714 534 6.67 176 1.28 5.20 (4.39, 6.15) Corrections n= 8074 n = 13757 404 5.00 81 0.58 8.60 (6.78, 10.92) Long term care facility n= 8077 n = 13755 82 1.02 230 1.66 0.61 (0.47, 0.78) Any substance abuse n= 7848 n = 13521 1422 18.12 547 4.05 4.48 (4.07, 4.92)
TB Clinical Characteristics of CAB/MB and all other FB TB cases in California, 2001-2010 MB/CAB All other FB n % n % RR (95% CI) Previous TB Diagnosis n= 8014 n = 13619 343 4.24 1080 7.84 0.54 (0.48, 0.61) HIV/AIDS match n= 8089 n = 13659 692 8.55 224 1.64 5.22 (4.50, 6.05) Site of Disease n= 8086 n = 13768 Pulmonary 5588 69.11 9814 71.28 0.97 (0.95, 0.99) Extrapulmonary 1717 21.22 3035 22.04 0.96 (0.91, 1.02)* Both 781 9.66 919 6.67 1.45 (1.32, 1.59) Sputum Smear Positive n= 6118 n = 10260 3605 58.92 4655 45.37 1.30 (1.26, 1.34) Cavity n= 5638 n = 9399 1621 28.75 1965 20.91 1.38 (1.30, 1.46) * RR not significant at 95%
TB Outcomes of CAB/MB and all other FB TB cases in California, 2001-2009₁ MB/CAB All other FB RR (95% CI) n % n % Start 4 drug Tx n = 7349 n = 12421 6423 87.40 11036 89.19 0.98 (0.97, 0.99) Outcome n = 7236 n = 12229 Completed (ever) 6122 84.60 10725 87.70 0.96 (0.95, 0.98) <366 days 5255 76.62 9198 75.21 0.97 (0.95, 0.98) Moved 386 5.33 438 3.58 1.49 (1.30, 1.70) Lost 227 3.14 129 1.05 2.97 (2.40, 3.68) Uncooperative/ Refused 27 0.37 70 0.57 0.65 (0.42, 1.02)* Died 419 5.79 801 6.55 0.88 (0.79, 0.99) ₁ Most recent complete follow-up 2 data * RR not significant at 95%
RESULTS NEW 2010 RVCT VARIABLES
MB/CAB compared to all other FB using New 2010 Variables Reason for evaluation Immigration medical exam (MB/CAB: 1.1%, FB: 6.0%, p<.0001) Targeted testing (MB/CAB: 3.0%, FB: 0.6%, p<.0001) Immigration Status at First Entry Other: (MB/CAB: 32.3%, FB: 7.8%, p<.0001) Unknown: (MB/CAB: 38.98%, FB: 22.3%, p<.0001) Immigrant visa (MB/CAB: 22.5%, FB: 50.38%, p<.0001) Diabetes (MB/CAB: 24.4%, FB: 22.5%, p<.3582)
2010 US Born Pediatric Cases Cohort: US born cases aged < 15 whose guardians are foreign-born (N = 65) MB/CAB: 47 (72%) Other FB: 18 (28%) Extrapulmonary disease: MB/CAB: 18 (38%) Other FB: 2 (11%) PZA mono-resistance MB/CAB: 12 (80% of 15 culture positive cases with susceptibility) Other FB: 0 (of 6 culture positive cases with susceptibility) Outcomes 1 child of MB/CAB guardians was dead at diagnosis 1 child of MB/CAB guardians was lost prior to completion All other cases completed treatment or are still on treatment
CONCLUSIONS
Conclusion Mexican/Central American-born TB cases have higher likelihood of: Being younger and migrant workers Higher proportion of pediatric cases among MB/CAB than other FB Having risk factors of homeless, corrections, substance abuse or living with HIV Having smear positivity or cavitary disease by the time they are diagnosed Moving or being lost prior to completion of therapy
Discussion MB/CAB TB cases may disproportionately influence funding formula in future Completion of therapy Higher proportion lost or moved Less likely to complete within 12 months Case management Sputum conversion Need strong, stable binational programs Increased collaboration with our Mexico partners with protocol development on how to share data across the border
Acknowledgements Katherine Robsky Janice Westenhouse Saul Kanowitz Tambi Shaw Martin Clinis Pennan Barry Jenny Flood Phil Lowenthal Melissa Ehman Kathy Moser
THANK YOU QUESTIONS? Neha.shah@cdph.ca.gov 510.620.3056 The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.