EPIDEMIOLOGY FOR CASE MANAGEMENT AND CONTACT … · EPIDEMIOLOGY FOR CASE MANAGEMENT AND CONTACT INVESTIGATION LEARNING OBJECTIVES Upon completion of this session, participants will

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.

https://www.cdc.gov/tb/statistics/reports/2016/pdfs/2016_Surveillance_FullReport.pdf

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm

http://www.cdc.gov/tb/programs/genotyping/images/TBGenotypingGuide_June2004.pdf

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



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



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



7

Table 2.

Demographic

comparison

of

2017 and 2018

active TB cases

8



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



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



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



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



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



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




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


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



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



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



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



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



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

[email protected]

303-692-2677

Juli Bettridge, TB Data Coordinator

[email protected]

303-692-2675

32

http://www.cdc.gov/tb/statistics/default.htm

http://www.cdc.gov/tb/programs/Evaluation/Default.htm

http://www.cdc.gov/tb/programs/genotyping/default.htm

https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH Document Library/TBCB-MDR-Fact-Sheet.pdf

http://www.census.gov/

http://www.who.int/tb/publications/global_report/en/index.html

mailto:[email protected]

mailto:[email protected]



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

( )

Email

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.

http://www.cdc.gov/mmwr/cme/conted_info.html#weekly

http://www.cdc.gov/tb/worldtbday

Documents

EPIDEMIOLOGY FOR CASE MANAGEMENT AND CONTACT … · EPIDEMIOLOGY FOR CASE MANAGEMENT AND CONTACT INVESTIGATION LEARNING OBJECTIVES Upon completion of this session, participants will