TUBERCULOSIS CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE
MARCH 19-22, 2019
EPIDEMIOLOGY FOR CASE MANAGEMENT
AND CONTACT INVESTIGATION
LEARNING OBJECTIVES
Upon completion of this session, participants will be able to:
1. Define epidemiology
2. Describe basic epidemiological tools
3. Describe the use of program indicators to improve patient outcomes
4. Describe the use of genotyping data for targeted program interventions
INDEX OF MATERIALS PAGES
1. Epidemiology for case management and contact investigation – slide outline Presented by: Pete Dupree, MPH
17
SUPPLEMENTAL MATERIAL
1. Colorado Tuberculosis Surveillance and Case Management Report TB-18
2. CDC Trends in tuberculosis—United States, 2016. MMWR March 25, 2016
ADDITIONAL REFERENCES
• Centers for Disease Control and Prevention: Reported Tuberculosis in the United States, 2016.
https://www.cdc.gov/tb/statistics/reports/2016/pdfs/2016_Surveillance_FullReport.pdf.
• Ehman M, Shaw T, Cass A, et al. Developing and Using Performance Measures Based on
Surveillance Data for Program Improvement in Tuberculosis Control. J Public Health
Management Practice. 2013, 19(5), E29-E37.
• Ong A, Rudoy I, Gonzalez LC, et al. Tuberculosis in healthcare workers: a molecular epidemiologic
study in San Francisco. Infect Control Hosp Epidemiol. May 2006; 27(5):453-8.
• Sprinson JE, Lawton ES, Porco TC, et al. Assessing the validity of tuberculosis surveillance data in
California. BMC Public Health. Aug 2006; 6:217.
• Controlling Tuberculosis in the United States: Recommendations from the American Thoracic
Society, CDC, and the Infectious Diseases Society of America. MMWR. November 4, 2005; 54
(RR12);1-81. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm.
• National TB Controllers Association/CDC Advisory Group on Tuberculosis Genotyping. Guide to
the Application of Genotyping to Tuberculosis Prevention and Control. Atlanta, GA: US
Department of Health and Human Services, CDC; June 2004.
http://www.cdc.gov/tb/programs/genotyping/images/TBGenotypingGuide_June2004.pdf.
• Geiter LJ. Ending neglect: the elimination of tuberculosis in the United States. Washington D.C.:
National Academy Press; 2000.
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 1
Epidemiology
for CMCI
Pete Dupree, MPH
1
ObjectivesUpon completion of this session participants
will be able to:
➢ Describe basic epidemiology tools
➢ Describe the use of program indicators to
improve patient outcomes
➢ Describe the use of genotyping data for
targeted program interventions
➢ Define epidemiology
2
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 2
What is Epidemiology?
The study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control health problems.
Last. A Dictionary of Epidemiology, 1995
Put more simply…
“Epidemiology is the study of disease and disease characteristics in a (specific) population over time”
3
The Tools of
Epidemiology
4
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 3
Epi Tools – data sources
What information is available to public health agencies?
Surveillance Data: RVCTs , ARPEs (Contact Investigation), and TB-18s
Patient Data: Chart, electronic medical record, TBdb
Lab Data: Genotyping, culture and smear, IGRAs, DST results
Demographic Data: Estimates of those experiencing homelessness, immigration, Refugee status, etc.
Census Data: Population estimates by demographic group
5
Epi Tools – Incidence vs. PrevalenceMaking a clear distinction between disease frequencyand disease burden is vital to “telling a compelling story with your data”
Incidence: Number of new cases during a given time period (usually presented by calendar year)
Prevalence: Total number of new and existing cases during a given time period (often 5,10, or 20 years)
6
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 4
7
Table 2.
Demographic
comparison
of
2017 and 2018
active TB cases
8
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 5
Epi Tools – Measures of MorbidityHow to translate patient data into epi data?
➢ Percent change in TB cases over time
[(Count at t2 – Count at t1)/Count at t1] x 100
2018 (t2)= 64 cases, 2017 (t1)= 84 cases
[(64-84)/84] x 100 = -0.238 or 23.8% decrease
➢ TB rate per 100,000 population
(CO cases in 2018 / CO population in 2018) x 100,000
(64/5.6 million) x 100,000 = 1.1 TB cases per 100,000 population
➢ Proportion/percentColorado TB patients with diabetes (2018): 0.125 (proportion) or 12.5%[DM cases/total cases] 8/64= 0.125
9
Colorado TB Cases 1999-2018
88
97
138
104
111
127
101
124
111
103
85
71 70
64
74
64
73
64
84
64
50
60
70
80
90
100
110
120
130
140
150
Num
ber
of
case
s
Number of Tuberculosis Cases Linear Trendline (Number of Tuberculosis Cases) 10
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 6
Colorado & U.S. TB Cases Rates 1999-2018
2.1 2.2
3.1
2.32.4
2.7
2.1
2.6
2.32.1
1.7
1.4 1.41.2
1.41.2 1.3 1.2
1.5
1.1
6.3
5.85.6
5.2 5.1 54.8
4.64.4
4.2
3.83.6
3.43.2
3.0 3.0 3.0 2.9 2.8 2.7
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Case
s per
100,0
00
CO rate US rate Linear (CO rate) Linear (US rate) 11
TB Case Rates by Race/Ethnicity: Colorado, 2009-2018
12
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 7
Relative riskRelative risk or risk ratio (RR) is the ratio of the probability of an event occurring (for example, developing a disease, being injured) in an exposed group to the probability of the event occurring in a comparison, non-exposed group.
RR = 20/1001/100
a / (a + b)c / (c + d) = = 20
Develop disease
Do not Develop disease
Exposed a b
Not Exposed c d
Example: smoking and lung cancer Develop disease
Do not develop disease
Exposed 20 (a) 80 (b)
Not Exposed 1 (c) 99 (d)
13
Relative riskScenario:
A clinician contacted your agency with a
concern about TB deaths that had
occurred among the Horn of Africa
(Ethiopia/Eritrea/Somalia/Kenya)
community in her area. She requested
a review of the data for her program.
14
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 8
Year
Total TB casesNon-U.S.-born (NUSB)
excluding HoANUSB from Horn of
Africa Countries
Cases Deaths Cases Deaths Cases Deaths
No. No. (%) No. No. (%) No. No. (%)
2007 39 5 (13) 20 3 (13) 9 1 (11)
2008 47 1 (2) 29 1 (0) 5 0 (0)
2009 44 7 (16) 23 3 (20) 11 1 (9)
2010 42 3 (7) 23 1 (18) 10 2 (20)
2011 29 4 (14) 14 1 (30) 10 3 (30)
2012 34 6 (18) 10 0 (40) 11 4 (36)
2013 38 7 (18) 24 5 (0) 5 0 (0)
2014 30 6 (20) 19 3 (40) 6 2 (33)
2015 38 9 (24) 18 4 (29) 14 4 (29)
2016 30 3 (10) 20 2 (50) 2 1 (50)
Total 371 51 (13.7) 200 23 (11.5) 83 18 (21.7)
TB cases and deaths by select groupsCounty A, 2007-2016
15
TB deaths- County A, 2007-2016
Risk Ratio 21.7/11.5 = 1.9
NUSB from Horn of Africa? TB death
Not a TB death Total
Cumulative Incidence
Yes 18 65 83 18/83 = 21.7%
No 23 177 200 23/200 = 11.5%
Patient age from Horn of Africa cohort: 75 years old (average) vs 70 among NUSB, not from Horn of Africa
Interpretation:In this county during 2007-2016, TB patients who were non-U.S.-born from a HoA country had 1.9 times the risk of dying with TB compared to other non-U.S.-born TB patients
16
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 9
Using Program
Indicator Data
17
Program Indicators
➢ Provide a monitoring system for tracking progress at the program level over time (states report progress each year)
➢ Utilize data already collected by the program for surveillance and case management/contact investigation activities
➢ Use standardized methods for calculating measures so tracking is consistent across sites (i.e. comparisons between states) and over time
We focus on National TB Indicator Project (NTIP) objectives which:
➢ Reflect state & national priorities for TB control and prevention activities
18
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 10
Case Management Indicators
Indicator YearCO
data
5-year trend
NTIP*target (2020)
CO target (2017)
Known HIV status 2017 96% 98% 97%
Completion of Treatment (active) 2017 85% 95% 96%
Tx initiation (+) smear (7 days) 2017 90% 97% 96%
Initiation of a four-drug regimen 2017 79.3% 97% 79.5%
DST for all cases with (+) culture 2017 100% 100% 100%
COT (contacts to (+) smear cases) 2016 93% 81% 82.5%
Sputum culture conversion 2016 83% 73% 73.4%
*NTIP: National TB Indicators Project Improving Worsening No change 19
Sputum Culture Conversion
➢ Indicator: Percent of TB patients with (+) sputum
culture results who have documented conversion to
sputum culture-negative within 60 days of treatment
initiation.
➢ Data Sources: RVCT fields: Month-Year Counted, Status at Diagnosis of TB, Sputum Culture, Date Therapy Started, Date Therapy Stopped, Reason Therapy Stopped, Sputum Culture Conversion Documented.
➢ Cohort: TB patients with positive sputum culture results alive at diagnosis and have initiated treatment, counted in the performance year. Patients who died within 60 days of initiating treatment are excluded.
20
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 11
Sputum Culture Conversion
Calculation:[Number of TB patients with positive sputum culture results who have documented conversion to sputum culture - negative within 60 days of treatment initiation] / Cohort
X 100
21
Sputum Culture Conversion
Next Steps:
Identify areas were improvements can be made or where further investigation may be warranted:➢ 6 of 36 (16.6%) of 2017 CO cases did not have
conversion documented within 60-days➢ Possible cause for delayed conversions of (+) culture
cases:➢ Delayed collection of sputum➢ Inadequate treatment regimen or drug resistance➢ Laboratory delays in reporting results➢ Anything else come to mind?
➢ We can use such metrics to identify patterns over time.22
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 12
Cascade of Care for High Risk
Individuals (Contacts and Class B TB):
Colorado 2017
572
442(77%)
123(28%) 93
(21%) 65(15%)
49(11%)
0
672
Individuals Evaluated Diagnosed with TBinfection
Recommended toInitiate Treatment
InitiatedTreatment
CompletedTreatment
23
Genotyping Data
➢ Brief overview of genotyping program in Colorado
➢ Example of genotype cluster surveillance
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 13
National TB Genotyping Service
➢Goal: Genotype all culture-confirmed TB cases in the U.S.
➢Michigan state public health lab contracted by the CDC
➢Genotype results provided to agencies via secure online database (TB GIMS)
➢ 100% of CO culture confirmed TB cases genotyped in 2017 (NTIP target (2020)/CO 2017 target= 100%)
25
Surveillance methods
➢Uses algorithm to detect:
➢Growing clusters within a (short) period of time
➢Clusters localized down to a county-level
➢New clusters
➢ Review clusters with high LLR scores
➢High LLR = unexpected geospatial concentration
➢Assess and prioritize flagged clusters using surveillance data
➢Notify agencies of concerning clusters26
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 14
Example of a Concerning TB Genotype Cluster
➢ Are there any links among these cases that could suggest recent transmission?
Case #
Report date County
Country Birth Major Site
Sputum Smear
Sputum Culture Cavitary
RVCT Risk Factors DST
4 Oct 2010 A Malawi Pleural Negative Negative NoImmune
suppression S
3 Oct 2010 A Malawi Pulmonary Positive Positive Yes None S
2 Sep 2010 A Mexico Pulmonary Positive Positive No None S
1 Apr 2008 A Zimbabwe Pulmonary Positive Positive No Alcohol S
27
Initial review by the local health department
➢ 2 Malawian brothers in household
➢ No known epi links to the other 2 clustered cases (from Zimbabwe and Mexico)
➢ Important worksites: College campus, law office
➢ Potential next steps:
➢ More chart review, patient re-interviews
➢ Teleconference with case managers
28
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 15
Summary
➢ Genotyping can help with outbreak case finding by:
➢ Identifying outbreak cases and transmission sites
not detected by traditional epidemiologic
investigations
29
Next Steps
➢ The LPHA can aggressively pursue contact evaluation and treatment for latent TB infection at campus and law office:
➢ LPHA can f/u with contacts in next 2 years
➢ LPHA can routinely review data of contacts associated with this outbreak at case management meetings/cohort reviews
➢ Monitor for new cases with the same genotype moving forward
30
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 16
Additional Resources
CDC Surveillance Reportshttp://www.cdc.gov/tb/statistics/default.htm
Program Evaluation and NTIPhttp://www.cdc.gov/tb/programs/Evaluation/Default.htm
Genotyping http://www.cdc.gov/tb/programs/genotyping/default.htm
TB Outbreak Response Team Fact Sheethttps://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/TBCB-MDR-Fact-Sheet.pdf
U.S. Census Bureauhttp://www.census.gov
World Health Organization – Global TB Reporthttp://www.who.int/tb/publications/global_report/en/index.html
Mapping Americahttp://projects.nytimes.com/census/2010/explorer?view=raceethnicit
&lat=37.75&lng=-122.45&l=12
31
CDPHE TB ContactsPete Dupree, MPH, TB Program Manager and Public Health
Epidemiologist
303-692-2677
Juli Bettridge, TB Data Coordinator
303-692-2675
32
Epidemiology for Case Management and Contact InvestigationPete Dupree, MPHColorado Department of Public Health and Environment
TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 17
Thanks!
Any Questions?
33
4300 Cherry Creek Drive South
DCEED-TB-A3
Denver, Colorado 80246-1530
TBdb# (303) 692-2638 Phone (303) 759-5538 Fax
Last Name MI Current Home Address
/ /
Male City
Female
Race American Indian/
Alaska Native Not Hispanic/Latino Other Address Specify Type
Asian Hispanic/Latino
African-American/
Black Country United States City
Native Hawaiian/ of Birth Mexico
Pacific Islander ( )
White Home Phone Other Phone Specify Type
Unknown
( )
Date Arrived in US Date Arrived in CO Work Phone
Preferred Language
Country of Birth of Parents/Guardians
(Under 18 y/o) Interpreter Needed Yes No
Occupation
Health care worker
Corrections employee Retired Insurance
Migrant/seasonal worker Unknown (Medicaid, Medicare, private (name), none)
Unemployed past 12 months Other
Not seeking employment
Specify other Date Patient Reported to LPHA / /
Employer
Administrative Known active Targeted testing- pregnancy
Class B TB notification Health care worker Targeted testing- specific project
Incidental lab result Suspect case Transfer case/suspect
Employment Symptomatic Contact investigation*
Immigration medical exam Targeted testing- individual Source case investigation*
Abnormal CXR * Index case TBdb#
Current / / / / mm Previous / / mm
Induration Induration
TST conversion in last 2 years
ATTACH ALL LAB RESULTS TO THIS DOCUMENT
/ / Type of IGRA Quantiferon (Qiagen)
T-Spot (Oxford Immunotec)
Other
IGRA Positive Indeterminate
Results Negative Unknown (If other, list test type)
Imaging ATTACH ALL IMAGING RESULTS TO THIS DOCUMENT
X-Ray Previous Imaging
CT / / Yes Name of Facility
MRI Date Taken Name of Facility No / /
Unknown Date Taken
TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT TB-18
DEMOGRAPHICS LOCATING and ADDITIONAL INFORMATION
First Name Apt #
Date of Birth Gender State Zip Code County
Ethnicity
State Zip Code County
( )
Specify other
/ /
Month/Year Month/Year
REASON FOR EVALUATION
TST AND IGRA
TST Date Placed Date Read TST Date
IGRAs
Collection Date Testing Laboratory
IMAGING
Last Name First Name DOB / /
Symptoms Weight Height Smoker
None Yes
Cough Previous TB Diagnosis Current
Hemoptysis Yes Past
Chest pain TB Infection Date quit / /
Weight loss TB disease
Night sweats Completed Treatment for TBI or TBD No
Urinary Documented
Fever Verbal
Other (specify) No None
Unknown Homeless
Medical History Refugee camp
None BCG Vaccine Yes No Patient lived/traveled outside ofGI / / US for >1 month List countries
Gastrectomy Vaccine date
Jejunoileal bypass
GU problems Drug Allergies Resident of
Weight loss > 10 lbs correctional facility
GI issues Medications Yes* No
Immunosuppression Facility name, type, & location
Diabetes mellitus *List recent/current meds and/or previous TB
Renal failure meds below including birth control Resident of long
HIV Medication Dose term care facility
Immunosuppressive therapy
Chest Facility name, type, & locationChest injuryHeart disease HIV Test HIV Test Date
Lung PostiveSilicosis Negative / /Lung disease Not done Date in last year
Liver (specify type) UnknownHepatitisLiver disease Alcohol Yes
Use No Drinks per week
Transfusion UnknownSurgeriesCancer InjectingOther Use Noninjecting
No
Special Conditions Unknown
Pregnant EDD / /Postpartum breast feeding
( )
Local Health Agency (LHA) PCP/Clinic Name
( ) ( ) ( )
PCP/Clinic Address
Nurse Case Manager PCP City PCP State PCP Zip Code
/ /
Person Completing Form (Signature) Person Completing Form (Print) Date Interview Completed
*Updated 6/2017
Additional Comments or Notes
MEDICAL HISTORY
Symptom Length
PROVIDER INFORMATION
Packs per day
Exposure Risks
Start
Purpose Date
Drug
PCP Phone Number
PHN Direct Line LHA Fax Number PCP Fax Number
SIGNATURE
Leveling of Tuberculosis Incidence — United States, 2013–2015
Jorge L. Salinas, MD1,2; Godwin Mindra, MBChB1,2; Maryam B. Haddad, MSN2; Robert Pratt2; Sandy F. Price2; Adam J. Langer, DVM2
After 2 decades of progress toward tuberculosis (TB) elimina-tion with annual decreases of ≥0.2 cases per 100,000 persons (1), TB incidence in the United States remained approximately 3.0 cases per 100,000 persons during 2013–2015. Preliminary data reported to the National Tuberculosis Surveillance System indicate that TB incidence among foreign-born persons in the United States (15.1 cases per 100,000) has remained approximately 13 times the incidence among U.S.-born per-sons (1.2 cases per 100,000). Resuming progress toward TB elimination in the United States will require intensification of efforts both in the United States and globally, including increasing U.S. efforts to detect and treat latent TB infection,
Continuing Education examination available at http://www.cdc.gov/mmwr/cme/conted_info.html#weekly.
U.S. Department of Health and Human ServicesCenters for Disease Control and Prevention
Morbidity and Mortality Weekly ReportWeekly / Vol. 65 / No. 11 March 25, 2016
INSIDE279 Tuberculosis Among Temporary Visa Holders
Working in the Tourism Industry — United States, 2012–2014
282 Photokeratitis Linked to Metal Halide Bulbs in Two Gymnasiums — Philadelphia, Pennsylvania, 2011 and 2013
286 Travel-Associated Zika Virus Disease Cases Among U.S. Residents — United States, January 2015–February 2016
290 Preventing Transmission of Zika Virus in Labor and Delivery Settings Through Implementation of Standard Precautions — United States, 2016
293 Notes from the Field: Injuries Associated with Bison Encounters — Yellowstone National Park, 2015
296 QuickStats
World TB Day — March 24, 2016
World TB Day is recognized each year on March 24, which commemorates the date in 1882 when Dr. Robert Koch announced his discovery of Mycobacterium tuberculosis, the bacillus that causes tuberculosis (TB). World TB Day is an opportunity to raise awareness about TB and support worldwide TB prevention and control efforts. The U.S. theme for World TB Day, “Unite to End TB,” highlights how much more needs to be done to eliminate TB in the United States.
After 2 decades of annual declines, TB incidence in the United States has leveled at approximately 3.0 new cases per 100,000 persons. (1,2). The determinants of this leveling in TB incidence are not yet clear; further evaluation of available data is required to understand the causes of this trend.
CDC is committed to eliminating TB in the United States. Staying on the path toward TB elimination will require more intensive efforts, both in the United States and globally. These efforts will not only focus on strengthening existing systems for interrupting TB transmission, but also on increasing testing and treat-ment of persons with latent TB infection. Additional information about World TB Day and CDC’s TB elimination activities is available on CDC’s website (http://www.cdc.gov/tb/worldtbday).
References
1. Salinas JL, Mindra G, Haddad MB, Pratt R, Price SF, Langer AJ. Leveling of tuberculosis incidence—United States, 2013–2015. MMWR Morb Mortal Wkly Rep 2016;65:273–8.
2. CDC. Reported tuberculosis in the United States, 2014. Atlanta, GA: US Department of Health and Human Services, CDC; 2015.