Tuberculosis Epidemiology-local, state, national and global Scott Lindquist MD MPH State Epidemiologist Washington State Department of Health

Tuberculosis Epidemiology-local, state, national and global Scott Lindquist MD MPH State Epidemiologist Washington State Department of Health

2014 Global TB Incidence

2014 Global MDR TB rate per 100,000

2014 Global HIV Prevalence in TB Cases

No. of Cases Reported TB Cases United States, 1982 2014* 30,000 25,000 20,000 15,000 10,000 5,000 0 *Updated as of June 5, 2015. Year

333

TB Case Rates,* United States, 2014 D.C. *Cases per 100,000. < 3.0 (2014 national average) >3.0

Map of U.S.-Affiliated Pacific Islands by TB Case Rates, * 2014 Guam Northern Mariana Islands Marshall Islands Palau Federated States of Micronesia American Samoa *Cases per 100,000 9.9 10 49.9 50

TB Case Rates, * U.S.-Affiliated Pacific Islands, 2014 United States overall Hawaii American Samoa Palau Guam Northern Mariana Islands Federated States of Micronesia Marshall Islands 3.0 9.6 1.8 66.1 34.8 44.7 156.1 212.7 0 50 100 150 200 250 *Cases per 100,000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Cases per 100,000 TB Case Rates* by Age Group United States, 1993 2014 20.0 15.0 10.0 5.0 0.0 0-14 15-24 25-44 45-64 65 * Updated as of June 5, 2015.

Cases per 100,000 40.0 TB Case Rates by Race/Ethnicity,* United States, 2003 2014** 30.0 20.0 10.0 0.0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Other Pacific Islander *All races are non-hispanic. **Updated as of June 5, 2015.

No. of Cases 20,000 Number of TB Cases in U.S.-born vs. Foreign-born Persons, United States, 1993 2014* 15,000 10,000 5,000 0 U.S.-born Foreign-born *Updated as of June 5, 2015.

No. of Cases 10000 8000 6000 4000 2000 0 Trends in TB Cases in Foreign-born Persons, United States, 1993 2014* Percentage 70% 60% 50% 40% 30% 20% 10% 0% Number of Cases Percent of Total Cases *Updated as of June 5, 2015.

Countries of Birth of Foreign-born Persons Reported with TB, United States, 2014 Other Countries 39% Mexico (21%) Philippines (12%) Haiti (3%) Guatemala (3%) China (7%) Vietnam (8%) India (8%)

% Resistant 10 Primary Anti-TB Drug Resistance, United States, 1993 2014* 5 0 Isoniazid MDR-TB *Updated as of June 5, 2015. Note: Based on initial isolates from persons with no prior history of TB. Multidrug resistant TB (MDR TB) is defined as resistance to at least isoniazid and rifampin.

Case Count XDR TB Case Count Defined on Initial DST* by Year, 1993 2014** 12 10 8 6 4 2 0 1993199419951996199719981999200020012002200320042005200620072008200920102011201220132014 Year of Diagnosis * Drug susceptibility test. ** Updated as of June 5, 2015. Note: Extensively drug-resistant TB (XDR TB) is defined as resistance to isoniazid and rifampin, plus resistance to any fluoroquinolone and at least one of three injectable second-line anti-tb drugs.

% Coinfection 70 60 50 40 30 20 10 0 Estimated HIV Coinfection in Persons Reported with TB, United States, 1993 2014* All Ages Aged 25-44 *Updated as of June 5, 2015. Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group.

TB Cases by Residence in Correctional Facilities, Age 15, United States, 1993-2014* No. of Cases 1200 Percentage 6.0 1000 5.0 800 4.0 600 3.0 400 2.0 200 1.0 0 0.0 No. of Cases Percent of Total Cases *Updated as of June 5, 2015. Note: Resident of correctional facility at time of TB diagnosis.

No. of Cases 1500 1000 500 0 TB Cases Reported as Homeless in the 12 Months Prior to Diagnosis, Age 15, United States, 1993-2014* Percentage 8.0 6.0 4.0 2.0 0.0 No. of Cases Percent of Total Cases *Updated as of June 5, 2015. Note: Homeless within past 12 months of TB diagnosis.

Percentage** Mode of Treatment Administration in Persons Reported with TB, United States, 1993 2012* 100% 80% 60% 40% 20% 0% DOT only DOT + SA SA only *Updated as of June 5, 2015. Data available through 2012 only. **Percentage of total cases in persons alive at diagnosis, with an initial regimen of one or more drugs prescribed, and excluding cases with unknown mode of treatment administration. Directly observed therapy (DOT); Self-administered therapy (SA).

Cumulative Case Counts WA

Comparative Incidence US and WA

Proportional Disease Burden by Origin 1 WA 1 U.S. territories include: American Samoa, Fed. States of Micronesia, Guam, Marshall Islands, Midway Island, Northern Mariana Islands, Puerto Rico, Palau, U.S. Virgin Islands, and U.S. Minor and Outlying Pacific Islands.

Proportional Disease Burden by Race/Ethnicity 1 WA 1 AIAN - American Indian or Alaskan Native; NHOPI - Native Hawaiian or Other Pacific Islander.

Proportional Disease Burden by Race/Ethnicity WA Foreign-born 1 Cases 1 Foreign-born defined as country of birth other than U.S. proper or any U.S. territory irrespective of citizenship.

Select Medical Risk Factors 1,2,3 WA Cases, 2009-2015 1 Medical risks recorded at diagnosis, as documented in medical record or otherwise reported by healthcare provider. 2 Frequencies represent medical risks as reported alone or along with other risk factors. 3 Immunosuppressing conditions include: TNF alpha-antagonist therapy, post-organ transplantation, end-stage renal disease, and other immunosuppression.

Select Classes of Drug-resistance 1 Annual Case Counts and Period Totals WA 1 1 st -line poly-resistant: Isolate resistance to two or more 1 st -line drugs (not MDR); MDR: Isolate resistance to Isoniazid and Rifampin; Pre-XDR: Isolate resistance to Isoniazid, Rifampin, and 2 nd -line injectable agent OR a fluoroquinolone.

Arrival to TB Diagnosis WA Foreign-born Cases, 2009-2015 1,2 1 Foreign-born defined as country of birth other than U.S. proper or any U.S. territory irrespective of citizenship. 2 Date of TB diagnosis defined as earliest collection among positive clinical specimen(s) supporting final case verification else case report date if verified as provider diagnosed.

Respiratory Culture (+) Clinical Specimens Collection to Arrival at Lab Within 2 Days Eligible cases: Case specimens culture (+) from sputum and/or respiratory, tracheal or bronchial fluids. Excludes: Incarcerated at Fed or state correctional, or ICE facility at diagnosis. Notes: 1. Eligible specimen sources consistent with definition of respiratory specimens as per CDC NTIP methods in the evaluation of lab turnaround times. 2. Evaluation based on shortest time from collection to arrival at lab among all eligible case specimen(s) on record.

Treatment Start Within 7 Days Of Sputum AFB Smear (+) Specimen Collection Eligible cases: Alive at diagnosis, AFB (+) on initial sputum smear results. Excludes: Treatment start > 14 days prior to specimen collection date; specimen collection date is < 7 days from date of data analyses; incarcerated at Fed or state correctional, or ICE facility at diagnosis.

Treatment Completion Within 12 Months Eligible cases: Alive at diagnosis; initiating treatment with >=1 TB drug. Excludes: Rifampin resistance; meningeal TB; TB in bone and/or joint; TB in central nervous system; <=14 y.o. with disseminated disease; death within 12 months of Tx start; move out of U.S. within 12 months of Tx start; Tx start < 366 days prior to date of data analyses with disposition pending; Tx stop date prior to Tx start date; Not TB ; incarcerated at Fed or state correctional, or ICE facility at diagnosis.

Minimum 90% Treatment Weeks on DOT Sputum AFB Smear (+) Cases Eligible cases: AFB (+) on initial sputum smear, with treatment completed. Program measure defined as: At least 90% of total weeks in completed treatment regimen were administered by directly-observed therapy (DOT). Weeks counted as DOT are those in which > 5 of given week s daily doses are administered under DOT.

Immigrant and Refugee Follow-up Process Outcomes by Year of Arrival Notes: 1. Records evaluated include all persons entering the U.S. under an immigrant, refugee, or asylee visa, assigned a TB notification classification of B1 or B2 (1991 or 2007 Technical Instructions). 2. Treatment starts evaluated among arrivals completing medical evaluation who are diagnosed with latent infection and recommended for treatment. 3. Treatment completions are evaluated among arrivals initiating treatment => 180 days prior to date of data analyses.