Tuberculosis surveillance: overview, new directions and challenges 1

TB SURVEILLANCE:OVERVIEW, NEW DIRECTIONSAND CHALLENGES

Phil Lowenthal, MPH

Epidemiologist

California Department of Public Health

Curry International Tuberculosis CenterTB Program Manager’s IntensiveNovember 18, 2019

SESSION OUTLINE

Introduction to surveillance

National TB surveillance systems Report of Verified Case of Tuberculosis (RVCT)

California Reportable Disease Information Exchange (CalREDIE)

B-notification & Electronic Disease Notification (EDN)

Uses of surveillance data

National Tuberculosis Indicators Project (NTIP)

Annual Report on TB in California

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Tuberculosis surveillance: overview, new directions and challenges 2

LEARNING OBJECTIVES

Upon completion of this session participants will be able to:

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Describe the pre-immigration screening process for immigrants arriving in the United States

Explain the purpose and the types of indicators that are evaluated by using the national tuberculosis indicators project

Apply the key components of a TB surveillance system to improve program efficiencies

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SURVEILLANCE: WHAT IS IT?

Systematic collection of pertinent information on cases of disease

Dissemination of results to those who use data for TB control activities

Analysis and interpretation of data

Tuberculosis surveillance: overview, new directions and challenges 3

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SURVEILLANCE: WHY DO IT?

Detect trends in disease or health-related behaviors

Identify groups at risk

Identify outbreaks

Direct public health action

Evaluate interventions

Generate hypotheses; stimulate research

Justify funding for continuing surveillance effort

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Deaths in Persons with TBCalifornia, 2007-2016

8.1%8.4%

9.4%

8.4%

9.5%9.8% 10.1%

9.2% 9.1%

11.4%

0.0

2.0

4.0

6.0

8.0

10.0

12.0

0

50

100

150

200

250

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Pe

rce

nt

of

case

s

Nu

mb

er

of

de

ath

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Muerte durante tratamiento Muerte al diagnosis Porcentaje de meurtes con TBDeath during treatment Dead at diagnosis Percent of all TB cases

Tuberculosis surveillance: overview, new directions and challenges 4

REPORTS OF VERIFIED CASE OF TUBERCULOSIS (RVCT)

OBJECTIVES RVCT

- Overview

- When to report a case of TB?

- Data quality control

- How is data used?

CalREDIE- Overview

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Tuberculosis surveillance: overview, new directions and challenges 5

The RVCT consists of three forms:

Report of Verified Case of Tuberculosis Required for all verified, countable TB cases

Recommended for non-countable cases that do not have a CA RVCT number

Submitted within 2 weeks of active TB disease confirmation

Initial Drug Susceptibility Report (Follow-Up 1)Required for culture-positive cases Submitted within 2 months of RVCT, or as soon as

susceptibilities are available

Case Completion Report (Follow-Up 2)Required for cases that were alive at diagnosis Submitted when case completes therapy, transfers out of

jurisdiction, or has another outcome9

COUNTED case:

• Meets the TB case definition

• Has NOT been counted by another reporting area

• >12 months since completing treatment (previous TB)

• Examination and diagnosis occurred in the U.S. (recent arriver)

Submit an RVCT for allcounted cases

NON-COUNTED case:

• Meets the TB case definition

• Counted by another state or country OR <12 months since completing treatment (previous TB)

Submit an RVCT if:

• Patient is treated in your jurisdiction

• Patient does not already have a CA RVCT for this episode

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Tuberculosis surveillance: overview, new directions and challenges 6

QC list sent quarterly as Excel workbookMissing data, unknown data, other data quality issues

Reminders to submit FU1 and FU2

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Year end processYear end training held early December

Case reporting deadline mid-January for provisional count

Final data for publication in annual report finalized April-May

Timely reportingRVCT data is required for CDC to link genotyping data and

generate cluster alerts for early outbreak detection

National and CA-specific TB Indicator Reports

RVCT trainings offered yearly and upon requestWebinar recording also available

Report on TB inCalifornia (CDPH)

Reported TB in the United States (CDC)

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Tuberculosis surveillance: overview, new directions and challenges 7

CA TB Indicator ReportsNational TB Indicators Project Reports (NTIP)

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RVCT variables are used to determine, in part, funding level from CDC to California and from California to local health jurisdictions:

Place of birth

Race and ethnicity

Sputum smear positivity

HIV co-infection

Alcohol or drug abuse

Homelessness

Multidrug resistance

Drug susceptibility tests completed

Treatment completion14

Tuberculosis surveillance: overview, new directions and challenges 8

CALIFORNIA REPORTABLE DISEASE INFORMATION EXCHANGE

CALREDIE OVERVIEW

Centralized web-based reporting and surveillance system

Public health staff can securely collect data, investigate cases/contacts and manage outbreaks

Designed for reporting data for all communicable diseasesReporting a case of TB in CalREDIE requires a TB

incident and a complete RVCT

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Tuberculosis surveillance: overview, new directions and challenges 9

Provider Portal - Health care providers can submit confidential morbidity reports (CMRs) via CalREDIE

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Electronic Lab Reporting - Laboratories can electronically send lab results via HL7 messaging into CalREDIE

Data Distribution Portal – State and local public health staff can extract data entered in CalREDIEusing the portal

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RVCT:Maria CarterSurveillance AssociateE-mail: Maria.Carter@cdph.ca.gov or TBregistry@cdph.ca.govPhone: (510) 620-3026

CalREDIE:Varsha HampoleSurveillance & Informatics CoordinatorE-mail: Varsha.Hampole@cdph.ca.govPhone: (510) 620-3994

Contact

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B-notification and the Electronic Disease Notification System

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OUTLINE

Origin of non-US-born TB cases in CA

Strategies in place to prevent importation of infectious TB to the U.S.

Process for overseas TB screening of immigrants and refugees

Electronic Disease Notification (EDN)

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Tuberculosis surveillance: overview, new directions and challenges 11

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STRATEGIES TO PREVENT IMPORTATION OF INFECTIOUS TB TO THE U.S.

1) Overseas screening: persons screened for TB prior to U.S. arrival using CDC’s pre-immigration screening and treatment algorithm

2) Domestic follow-up evaluation: state and local health departments are notified by CDC of persons at risk of developing TB

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Tuberculosis surveillance: overview, new directions and challenges 12

Class A: applicant with active TB disease who was granted a waiver

Class B0, Pulmonary: applicant who completed directly observed therapy (DOT) for TB disease at a panel site prior to immigration. Travel clearance valid for 3 months

Class B1, Pulmonary: medical history, physical exam, or CXR findings suggestive of TB but applicant has negative sputum smears and cultures. Travel clearance valid for 3 months

Class B1, Extrapulmonary: applicant diagnosed with EPTB with normal CXR, negative sputum smears and cultures. Travel clearance valid for 3 months

Class B2 (LTBI): applicants with positive IGRA, otherwise negative evaluation for TB. Travel clearance valid for 6 months

Class B3 (Contact): recent contact to a known TB case. Information about source case (contact info, drug resistance) must be documented. Travel clearance is for 6 months

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2018 Technical Instructions for TB Screening and Treatment for Panel Physicians

https://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/tuberculosis-panel-technical-instructions.html

Tuberculosis surveillance: overview, new directions and challenges 13

Overseas TB Screening of Immigrants and RefugeesPersons > 15 years old

IGRA positive

If medical history, physical exam, or CXR suggestive ofTB or HIV, AFB sputum smears (3) and cultures (3)

Persons 2-14 years old

Infectious TB: Class ADST on positive culture andDOT until therapy complete,

reclassify as B0

Noninfectious TB: Class B1

All (-)(at least one + smear or culture)

Medical history, physical examand IGRA

CXR negative:2-14 y/o: B2 (LTBI)≥15 y/o: No B class

CXRKey

Revisions(2018 TI)

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IGRA

reclassify as B0

Medical history, physical exam

Moving Surveillance into the 21st Century:Electronic Disease Notification System

Tuberculosis surveillance: overview, new directions and challenges 14

AIS - Alien Information System

IMP - Information on Migrant Populations

EDN - Electronic Disease Notification

*limited medical data collected

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AIS*

1995 20102000 2005

IMP* EDN200719991995

2008—100% centralization

DGMQ Quarantine Stations mail to state/LHJs (paper)

Electronic no�fica�on CDC → State/LHJs

2015 2020

eMedical & EDN2019

Electronic notification overseas → US

EDN - OVERVIEW

Electronically notify refugee programs and health departments of all newly arriving refugees and immigrants

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Provide access to scanned overseas medical evaluation forms for refugees with/without B class and immigrants with B class

Inform EDN system users of alien arriver’s secondary migration

Provide useful database functions for arrivers including batch print, data download and report generation

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EDN - DATA FLOW

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Scan Forms

Enter Data

Data Entry CenterCDC HQ - Atlanta

Data Entry Web

State / Local Refugee And Health Departments

New Alien Notification

OverseasScreening

OverseasForms

Overseas

View Overseas

Data

Perform Domestic

Evaluation (WS)SubsequentMigration

Notification

Reports

Downloads

EDN System

U.S.

eMedical

Outcome of Domestic Evaluation of California B-notification Arrivers

Tuberculosis surveillance: overview, new directions and challenges 16

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TB Cases Reported among Class B1 Arrivers*California 2009-2018

*Reported with active TB <6 months after US arrival

1.6%

0.7%

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

0

1000

2000

3000

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5000

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2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Perc

ent

of

B1

s re

po

rted

wit

h a

ctiv

e TB

Cla

ss B

1 a

rriv

ers

Year

NEXT STEPS

eMedical

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TB care directory (DGMQ pilot)

Expand pre-departure screening to other legal entrants (e.g. students, workers)?

Tuberculosis surveillance: overview, new directions and challenges 17

CONTACT

Varsha Hampole

Surveillance & Informatics Coordinator

Phone: (510) 620-3994

Varsha.Hampole@cdph.ca.gov

Phil Lowenthal

Epidemiologist

Phone: (510) 620-3051

Phil.Lowenthal@cdph.ca.gov

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NATIONAL TUBERCULOSIS INDICATORS PROJECT

Tuberculosis surveillance: overview, new directions and challenges 18

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NTIP OVERVIEW

Purpose: Strengthen the capacity of state and local health departments to improve TB program performance

Participation: 14 local health jurisdictions that report an average of ≥55 TB cases per year (contributes ~89% of CA TB morbidity)

NTIP - INDICATORS

Identification and Reporting

TB Case Rate

Timely Reporting

Complete Reporting

Culture Identification

Completion of Therapy

Recommended Initial Therapy

Timely Treatment

Culture Conversion

Appropriate DOT

Inappropriate SAT

Timely Completion of Therapy

Not Defaulting from Treatment

Contact Investigation

Contact Identification

Contact Evaluation

Contact LTBI Treatment Initiation

Contact LTBI Treatment Completion

Sentinel Events

Pediatric TB Cases

TB Deaths

Infrastructure

Program Capacity (self-assessment)

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Tuberculosis surveillance: overview, new directions and challenges 19

Source: National TB Indicators Project (NTIP)37

SPUTUM CULTURE CONVERSION

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Tuberculosis surveillance: overview, new directions and challenges 20

SPUTUM CULTURE CONVERSIONNext Steps:

Identify areas were improvements can be made

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7.5% of cases don’t have conversion documented

Possible cause for delayed conversions of culture-positive cases (22.1%)

Delayed collection of sputum Inadequate treatment regimen or drug resistance Laboratory delays in reporting results

What patterns do you see over time?

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NTIP PROCESS

Initial assessment Complete Infrastructure Self-Assessment Review indicator data

Analyze and plan (select indicator to target) Verify problem Determine reasons for problem

Develop interventions (action plan)

Implement interventions

Evaluate and reassess

Tuberculosis surveillance: overview, new directions and challenges 21

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National TB Indicators Project (NTIP)

Centers for Disease Control and PreventionDivision of TB EliminationDTBESupport@cdc.gov

Thank you!

Questions?