Self-Study Modules on Tuberculosis Epidemiology of Tuberculosis Module

Self-Study Modules on Tuberculosis Epidemiology of Tuberculosis Module

Self-Study Modules on Tuberculosis Epidemiology of Tuberculosis Module 2: Objectives At completion of this module, learners will be able to: 1. Describe how the number of TB cases reported in the U.S has changed over the last 60 years 2. List 5 factors that contributed to the increase of TB cases between 1985 and 1992 3. List 3 improvements TB programs made with increased funds that have contributed to a decrease in TB cases since 1993 4. List groups of people who are more likely to be exposed to or infected with M. tuberculosis 5. List groups of people who are more likely to Module 2 Epidemiology of Tuberculosis develop TB

disease once infected with M. 2 Module 2: Overview Introduction to TB Epidemiology People at High Risk for TB Infection and TB Disease Case Studies Module 2 Epidemiology of Tuberculosis 3 Introduction to TB Epidemiology 4

Epidemiology (1) Epidemiology is the study of the distribution and causes of disease and other health problems in groups of people. Module 2 Epidemiology of Tuberculosis 5 Epidemiology (2) Epidemiologists: Determine frequency and pattern of health problems in communities Try to figure out why health problems are occurring Module 2 Epidemiology of Tuberculosis

6 Global Epidemiology of TB TB is one of the leading causes of death due to infectious disease in the world Almost 2 billion people are infected with M. tuberculosis Each year about: 9 million people develop TB disease 1.5 million people die of TB Module 2 Epidemiology of Tuberculosis 7 TB Reporting in U.S. The Report of Verified Case of Tuberculosis (RVCT) is the national TB surveillance data

collection form and is used for reporting all verified TB cases to CDC The 50 states, District of Columbia, New York City, Puerto Rico, and 7 other jurisdictions in the Pacific and Caribbean report TB cases to CDC Health care providers are required by law to report TB cases to state or local health departments Module 2 Epidemiology of Tuberculosis 8 U.S. Epidemiology of TB 1953 - 1986 1953:

More than 84,000 cases of TB 1953-1984: TB cases declined about 6% each year 1985: TB cases reached a low of 22,201 1986: Significant increase in TB cases began Module 2 Epidemiology of Tuberculosis 9 19 8 2 19 8 3 19 8 4 19 8 5

19 8 6 198 7 198 8 19 8 9 199 0 199 1 199 2 199 3 199 4 199

5 199 6 19 9 7 19 9 8 199 9 20 0 0 20 0 1 20 0 2 20 0 3 200 4

20 0 5 20 0 6 20 0 7 20 0 8 20 0 9 20 1 0 20 1 1 201 2 20 1 3 201

4 No. of Cases U.S. TB Resurgence (1) 1986 - 1992 30,000 25,000 20,000 15,000 10,000 5,000

0 Reported TB Cases, U.S., 1982-2014 Module 2 Epidemiology of Tuberculosis 10 U.S. TB Resurgence (2) 1986 - 1992 Contributing factors: Inadequate funding for TB control and other public health efforts HIV epidemic Increased immigration from countries where TB is common Spread of TB in certain settings (e.g., homeless shelters and correctional facilities)

Module 2 Epidemiology of Tuberculosis 11 U.S. TB Control and Prevention (1) 1993 - 2014 1993-2014: Number of TB cases reported annually in U.S. steadily declined Increased federal funds and other resources allowed TB programs to improve control efforts to: Promptly identify persons with TB Start appropriate initial treatment for TB cases Ensure patients complete treatment Conduct contact Module 2 investigations Epidemiology of Tuberculosis

12 19 8 2 19 8 3 19 8 4 19 8 5 19 8 6 198 7 198 8 19 8 9 199

0 199 1 199 2 199 3 199 4 199 5 199 6 19 9 7 19 9 8 199 9

20 0 0 20 0 1 20 0 2 20 0 3 200 4 20 0 5 20 0 6 20 0 7 20 0 8 20 0

9 20 1 0 20 1 1 201 2 20 1 3 201 4 No. of Cases U.S. TB Control and Prevention (2) 1993 - 2014 30,000

25,000 20,000 15,000 10,000 5,000 0 Reported TB Cases, U.S., 1982-2014 Module 2 Epidemiology of Tuberculosis 13 Continuing Challenges in TB

Control TB is reported in almost every state and is increasing in some areas More than half of all TB cases in the U.S. are among foreign-born persons TB affects racial/ethnic minorities disproportionately MDR TB and extensively drug-resistant TB (XDR TB) remain serious public health concerns Module 2 Epidemiology of Tuberculosis 14 TB Case Rates (1) A case rate is the number of TB cases that occur during a certain time period, divided by size of the population at that time Often expressed in terms of a population size of 100,000 persons

Module 2 Epidemiology of Tuberculosis 15 TB Case Rates (2) Example: In the U.S. in 2014, there were 9,421 new TB cases in a population size of 318,857,056 9,421 x 100,000 = 2.96 318,857,056 In 2014, the U.S. TB case rate was 2.96 TB cases per 100,000 persons (rounded to 3.0) Module 2 Epidemiology of Tuberculosis 16 TB Case Rates by State, 2014

D.C. < 3.0* (2014 national average) *Cases per 100,000 Module 2 Epidemiology of Tuberculosis 17 TB Case Rates (3) Health departments, CDC, and others can compare the occurrence of TB in different places, time periods, and groups of people using case rates Comparisons have shown that rates of TB are higher in certain groups than in others Module 2 Epidemiology of Tuberculosis

18 Epidemiology of TB Study Question 2.1 What happened to the number of TB cases in the United States between 1953 and 1984? From 1953 - 1984, the number of TB cases reported in the U.S. decreased by an average of 6% each year. Module 2 Epidemiology of Tuberculosis 19 Epidemiology of TB Study Question 2.2 What happened to the number of TB cases in the United States between 1985 and 1992?

From 1985 - 1992, the number of new TB cases increased by 20%. Module 2 Epidemiology of Tuberculosis 20 Epidemiology of TB Study Question 2.3 Name 5 factors that may have contributed to the increase in the number of TB cases between 1985 and 1992. Inadequate funding for TB control and other public health efforts HIV epidemic Increased immigration from countries where TB is common Spread of TB in certain settings (e.g., correctional facilities and homeless shelters)

Module 2 Epidemiology of Tuberculosis 21 Epidemiology of TB Study Question 2.4 What happened to the number of TB cases in the United States from 1993 to 2014? From 1993 to 2014, there was a steady decline in the number of TB cases reported annually in the United States. Module 2 Epidemiology of Tuberculosis 22 Epidemiology of TB

Study Question 2.5 Name 3 improvements TB programs were able to make with increased federal, state, and other funds that contributed to the decrease in TB cases since 1993. Promptly identify persons with TB Start appropriate initial treatment for TB cases Ensure patients complete treatment Conduct contact investigations Module 2 Epidemiology of Tuberculosis 23 Race and Ethnicity (1) TB affects certain racial and ethnic minorities disproportionately In 2014, about 85% of TB cases in the U.S. were among racial and ethnic minorities

Percentage of TB cases in racial and ethnic minorities is higher than expected based on percentage of these minorities in the U.S. population Module 2 Epidemiology of Tuberculosis 24 Race and Ethnicity (2) Multiple Race; 2.00% White; 13.29% Black or African American; 21.38% Native Hawaiian or Other Pacific Islander; 0.98%

American Indian or Alaska Native; 1.26% Hispanic or Latino; 29.34% Asian; 31.75% Reported TB cases by race and ethnicity, U.S, 2014* *All races are non-Hispanic. Multiple Race indicates two or more races reported for a person. Does not include persons of Hispanic or Latino origin. Module 2 Epidemiology of Tuberculosis 25 Race and Ethnicity (3) 0.70% 0.20%

4.91% 12.22% 2.10% 16.93% 62.93% Racial and ethnic groups by percentage of U.S. population, 2014 Module 2 Epidemiology of Tuberculosis 26 Race and Ethnicity (4) Disparities may exist due to racial and ethnic minorities having other risk factors for TB, such as:

Birth in a country where TB is common HIV infection Low socioeconomic status Exposure to TB in high-risk settings Module 2 Epidemiology of Tuberculosis 27 Relative Risk for TB (1) Relative risk is a comparison of case rates between two groups. Module 2 Epidemiology of Tuberculosis 28 Relative Risk for TB (2) Example:

The case rate for Asians is 17.8 compared to 0.6 for non-Hispanic whites. Therefore, the relative risk for Asians is about 29 times higher than non-Hispanic whites 17.8 (TB case rate for Asians) = 29.6 0.6 (TB case rate for non-Hispanic whites) Module 2 Epidemiology of Tuberculosis 29 Relative Risk for TB (3) Race and Ethnicity, 2014 Race/Ethnicity TB Case Rate Relative Risk

Asians 17.8 29.6 Native Hawaiians or Other Pacific Islanders 16.9 28.1 Blacks or African Americans 5.1

8.5 American Indians or Alaska Natives 5.0 8.3 Hispanics or Latinos 5.0 8.3 Multiple Race 2.8

4.6 Non- Hispanic Whites 0.6 1 Module 2 Epidemiology of Tuberculosis 30 Race and Ethnicity Study Question 2.6 Which racial and ethnic groups are disproportionally affected by TB? Asians, Native Hawaiians or Other Pacific Islanders, non-Hispanic blacks, Hispanics, and American Indians or Alaska Natives are

disproportionately affected by TB. Module 2 Epidemiology of Tuberculosis 31 People at High Risk for TB Infection and TB Disease 32 High-Risk Groups High-risk groups can be divided into two categories: High risk for exposure to or infection with M. tuberculosis High risk for developing TB disease after infection with M. tuberculosis

Module 2 Epidemiology of Tuberculosis 33 People at High Risk for Exposure to or Infection with M. tuberculosis Populations defined locally as having an People who have come to the increased incidence of U.S. within the last 5 years LTBI or TB disease, from areas of the world possibly medically where TB is common underserved, low-income populations, or persons Persons who visit areas with who abuse drugs or

a high prevalence of TB alcohol disease Infants, children, and People who live or work in adolescents exposed to high-risk congregate settings adults who are at increased risk for LTBI or Health care workers who TB disease serve patients at increased risk Module 2 Epidemiology of Tuberculosis 34 Contacts

People at High Risk for Developing TB Disease after Infection with M. tuberculosis (1) People living with HIV Children younger than 5 years of age People infected with M. tuberculosis within past 2 years People with a history of untreated or inadequately treated TB disease People who are receiving immunosuppressive therapy People with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung Module 2 Epidemiology of Tuberculosis 35

People at High Risk for Developing TB Disease after Infection with M. tuberculosis (2) Persons who have had a gastrectomy or jejunoileal bypass Low body weight Cigarette smokers and persons who abuse drugs or alcohol Populations defined locally as having an increased risk Module 2 Epidemiology of Tuberculosis 36 High-Risk Groups for TB Infection (1) Contacts Contacts are persons who have spent time with someone who has

infectious TB disease May include: Family members Coworkers Friends Module 2 Epidemiology of Tuberculosis 37 High-Risk Groups for TB Infection (2) Foreign-Born Persons/Immigrants In the U.S., LTBI and TB disease often occur among people born in areas of the world where TB is common:

Mexico; 22.18% Other Countries; 38.61% Asia Africa Russia Eastern Europe Latin America Philippines; 11.69%

Vietnam; 8.47% Haiti; 2.92% Guatemala; 2.52% China; 5.85% India; 7.76% Module 2 Epidemiology of Tuberculosis 38 High-Risk Groups for TB Infection (3) Foreign-Born Persons/Immigrants Foreign-born Foreign-born 27% 27% U.S.-born

U.S.-born 34% 35% U.S.-born U.S.-born 73% 73% Foreign-born Foreign-born 66% 65% 1992 2014 Cases of TB in foreign-born and U.S.-born,

1992 and 2014 Module 2 Epidemiology of Tuberculosis 39 High-Risk Groups for TB Infection (4) Foreign-Born Persons/Immigrants To address high rates of TB in foreign-born persons, CDC and other public health organizations are working to: Improve the overseas and domestic screening process for immigrants and refugees Strengthen the notification system that alerts health departments about the arrival of immigrants and refugees with suspected TB disease Test recent arrivals from countries where TB is common for TB infection and ensure completion of treatment Module 2 Epidemiology of Tuberculosis

40 High-Risk Groups for TB Infection (5) Foreign-Born Persons/Immigrants Individuals applying for immigration and refugee status from overseas: Must be screened for TB by panel physicians before entering the U.S. Must have completed treatment before entering the U.S. if diagnosed with TB disease Module 2 Epidemiology of Tuberculosis 41 High-Risk Groups for TB Infection (6) Foreign-Born Persons/Immigrants Immigrants living in the U.S. who apply for

permanent residence or citizenship: Must be tested for TB infection and evaluated for TB disease by U.S.- based civil surgeons Module 2 Epidemiology of Tuberculosis 42 High-Risk Groups for TB Infection (7) Congregate Settings In certain congregate settings, the risk of being exposed to TB is higher than other places. This may include: Correctional facilities Homeless shelters Nursing homes Health care facilities Module 2 Epidemiology of Tuberculosis

43 High-Risk Groups for TB Infection (8) Congregate Settings Risk of exposure to TB is higher than in other settings Risk is higher if facility is crowded Module 2 Epidemiology of Tuberculosis 44 Correctional Facilities Higher risk in correctional facilities may be due to: Incarcerated population includes a high proportion of people at greater risk for TB than overall population (risk factors may include HIV-infection

and a history of homelessness or drug use) Physical structure of correctional facilities (e.g., close living quarters, overcrowding, potential for inadequate ventilation) Movement of inmates into and out of facilities can lead to interruption of therapy Module 2 Epidemiology of Tuberculosis 45 High-Risk Groups for TB Infection (10) Health Care Workers Might be exposed to TB at work Risk depends on: Number of persons with TB in facility Job duties Infection control

procedures Module 2 Epidemiology of Tuberculosis 46 High-Risk Groups for TB Infection (11) Populations Defined Locally Populations that may have an increased risk include Persons experiencing homelssness Medically underserved populations Low-income groups Persons who abuse drugs or alcohol Module 2 Epidemiology of Tuberculosis 47

High-Risk Groups for TB Infection (12) Populations Defined Locally Low-income is linked to higher risk of TB exposure Possible reasons include factors associated with low-income: Inadequate living conditions Crowding Malnutrition Poor access to health care TB rates are 10 times higher for people experiencing homelessness Module 2 Epidemiology of Tuberculosis 48 High-Risk Groups for TB Infection (13) Children and Adolescents

High risk if exposed to adults in high-risk groups If a child has TB infection or disease, it suggests that: TB was transmitted relatively recently Person who transmitted TB to child may still be infectious Others may have been Module 2 Epidemiology of Tuberculosis exposed 49 High-Risk Groups for TB Disease (1) Infants and Children Younger than 5 Years High risk for rapidly developing TB disease due to underdeveloped immune system

Module 2 Epidemiology of Tuberculosis 50 High-Risk Groups for TB Disease (2) People Living with HIV HIV is the strongest known risk factor for developing TB disease TB is the leading cause of death for people with HIV/AIDS Risk of developing TB disease is 7% - 10% each year for people who are infected with both TB and HIV (if the HIV is not treated) Module 2 Epidemiology of Tuberculosis 51

High-Risk Groups for TB Infection Study Question 2.7 Name 7 groups of people who are more likely to be exposed or infected with M. tuberculosis. Contacts of people known or suspected to have TB People who have come to the U.S. within last 5 years from countries where TB is common Persons who visit areas with a high prevalence of TB disease People who live or work in high-risk congregate settings Health care workers who serve high-risk groups Populations defined locally as having an increased incidence of LTBI or TB disease, possibly medically underserved, low-income populations, or persons who abuse drugs or alcohol Module 2 Epidemiology of Tuberculosis 52 High-Risk Groups for TB Infection Study Question 2.8

What are public health agencies doing to address the high rate of TB in foreign born persons? Improve the overseas and domestic screening process for immigrants and refugees Strengthen the notification system that alerts health departments about the arrival of immigrants and refugees with suspected TB disease Test recent arrivals from countries where TB is common for TB infection and ensure completion of treatment Module 2 Epidemiology of Tuberculosis 53 High-Risk Groups for TB Infection Study Question 2.9 Why is the risk of being exposed to TB

higher in certain settings, such as nursing homes or correctional facilities? Many people in these facilities are at risk for TB disease Risk of exposure is higher if facility is crowded Module 2 Epidemiology of Tuberculosis 54 High-Risk Groups for TB Infection Study Question 2.10 What are some reasons why rates of TB disease are higher in correctional facilities? The incarcerated population contains a higher proportion of people at greater risk for TB than the general population An increasing number of inmates are infected with HIV,

which means that they are more likely to develop TB disease if they become infected with M. tuberculosis Some correctional facilities are crowded and may have inadequate ventilation, which promotes the spread of TB Therapy can be interrupted when inmates are moved into and outModule of facilities 2 Epidemiology of Tuberculosis 55 High-Risk Groups for TB Infection Study Question 2.11 When a child has TB infection or disease, what does it tell us about the spread of TB in the childs home or community? Name 3 things. TB was transmitted relatively recently

The person who transmitted TB to the child may still be infectious Other adults and children in the home or community have probably been exposed to TB Module 2 Epidemiology of Tuberculosis 56 High-Risk Groups for TB Disease Study Question 2.12 Name 8 groups of people who are more likely to develop TB disease once infected. People living with HIV Children younger than 5 years of age People infected with M. tuberculosis within the past 2 years People with a history of

untreated or inadequately treated TB disease People receiving immunosuppressive therapy People with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung Persons who have had a gastrectomy or jejunoileal bypass Low body weight Cigarette smokers and person who abuse drugs or alcohol Populations defined locally as having an increased incidence of disease due to

M. tuberculosis Module 2 Epidemiology of Tuberculosis 57 High-Risk Groups for TB Disease Study Question 2.13 What is the strongest known risk factor for the development of TB disease? HIV infection is the strongest known risk factor for developing TB disease. HIV infection weakens the bodys immune system, making it more likely for a person who has TB infection to develop TB disease. Module 2 Epidemiology of Tuberculosis

58 High-Risk Groups for TB Disease Study Question 2.14 If a person is infected with both M. tuberculosis and HIV, what are his or her chances of developing TB disease? How does this compare to the risk for people who are infected only with M. tuberculosis? Risk is 7% to 10% each year if person is infected with both M. tuberculosis and HIV and the HIV is not treated Risk is 10% over a lifetime if person is only infected with M. tuberculosis Module 2 Epidemiology of Tuberculosis 59 Case Studies

60 Module 2: Case Study 2.1 For each of the following people, choose the factor(s) known to increase the risk of being exposed to or infected with TB Person Factors a) Mr. Petrov ___ Works at a nursing home ___ Rides the subway every day ___ Emigrated from Russia b) Ms. Montoya

___ Was born in Latin America ___ Has a father who had pulmonary TB disease ___ Volunteers in the emergency room of an inner-city hospital ___ Works in a day care center ___ Was released from prison last year ___ Sleeps in a homeless shelter c) Ms. Parker d) Mr. Dudley Module 2 Epidemiology of Tuberculosis 61 Module 2: Case Study 2.2 For each of the following people, indicate the factor(s) known to

increase the risk of developing TB disease once infected Person Factors a) Mr. Sims ___ Injects heroin ___ Has HIV b) Mr. Allen ___ Has diabetes ___ Has high blood pressure c) Ms. Li ___ Has chest x-ray findings suggestive of

previous TB disease ___ Has heart problems d) Mr. Vinson ___ Is overweight ___ Became infected with M. tuberculosis 6 months ago Module 2 Epidemiology of Tuberculosis 62

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