1

TB Control in New York City: TB Control in New York City: Current status and progress towards Current status and progress towards

eliminationelimination

11

ChrispinChrispin KambiliKambili, MD, MDAssistant Commissioner of HealthAssistant Commissioner of Health

Director, Bureau of TB Control, NYC DOHMHDirector, Bureau of TB Control, NYC DOHMH

World TB Day ConferenceWorld TB Day ConferenceMarch 23, March 23, 20112011

Every 20 Seconds Every 20 Seconds someone somewhere in the world someone somewhere in the world

dies from TB!dies from TB!

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dies from TB!dies from TB!

What constitutes TB control?What constitutes TB control?

Identify prevalent casesIdentify prevalent casesTreat the cases to:Treat the cases to:•• Reduce morbidity & mortalityReduce morbidity & mortality

R d t i iR d t i i

33

•• Reduce transmissionReduce transmission

Mitigate impact of newly transmitted TBMitigate impact of newly transmitted TBAddress other LTBIAddress other LTBI

What’s needed for effective TB control?What’s needed for effective TB control?

Set a legal frameworkSet a legal framework——Defines roles Defines roles of government and providersof government and providers•• Legal framework in NYC is defined by Legal framework in NYC is defined by

State’s Public Health Law and Sanitary State’s Public Health Law and Sanitary

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State s Public Health Law and Sanitary State s Public Health Law and Sanitary Code, and NYC Health CodeCode, and NYC Health Code

Reporting requirementsReporting requirementsDuties, roles and responsibilitiesDuties, roles and responsibilities

Create an infrastructure of carry out Create an infrastructure of carry out the mandatethe mandate

2

Specific StrategiesSpecific Strategies

Accurate and thorough case detectionAccurate and thorough case detection•• DiagnosisDiagnosis•• SurveillanceSurveillance

U i t t d ff ti d i d U i t t d ff ti d i d

55

Uninterrupted, effective and supervised Uninterrupted, effective and supervised treatment, and patient supporttreatment, and patient supportMonitoring and evaluation system and Monitoring and evaluation system and impact measurementimpact measurementAdequate public health infrastructure ($)Adequate public health infrastructure ($)

Main elements of TB Control in USMain elements of TB Control in US

Case findingCase findingpassivepassive -- clinical presentationclinical presentationactiveactive -- contact tracing (source) contact tracing (source)

& screening (migrants)& screening (migrants)

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& screening (migrants)& screening (migrants)•• Treatment of casesTreatment of cases

•• Chemoprophylaxis (for latent TB)Chemoprophylaxis (for latent TB)

•• BCGBCG

Where can we intervene?Where can we intervene?

77

Prophylactictreatment

Preventivetherapy

Chemotherapy

Patient's delay

Doctor's delay

Transmission

8

Subclinicalinfection

Infectioustuberculosis

Non-infectioustuberculosis

BCGvaccination

DeathExposure

After HL Rieder

3

TB in NYC: Where have we TB in NYC: Where have we been and where are we going?been and where are we going?

99

Tuberculosis Cases and Rates Tuberculosis Cases and Rates New York City, 1980 New York City, 1980 –– 2010*2010*

711 Cases in 2010711 Cases in 2010

2,500

3,000

3,500

4,000

40

50

60Case Rate# Cases

51.1

Number of Cases Rate/100,000

1010

500

1,000

1,500

2,000

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10

Year

0

10

20

30

8.5

*Rates since 2000 are based on population estimates.

21.4

US1 and Foreign-Born Tuberculosis Cases and Case Rates2

New York City, 1992 - 2010

1,500

2,000

2,500

3,000

3,500Number of Cases

30.0

40.0

50.0

60.0

70.0Rate/100,000

US-born CasesForeign-born CasesUS-born RateForeign-born Rate

1111

0

500

1,000

1,500

92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10

Year

0.0

10.0

20.0

30.0

1. Puerto Rico and U.S. Virgin Island are included as US-born.2. Rates are based on official Census data and intercensal estimates prior to 2000. Rates since 2000 are based on 2000 Census data.

Top 10 Countries of Birth for Top 10 Countries of Birth for NYC TB ForeignNYC TB Foreign--born TB Patientsborn TB Patients

20102010 NN 20092009 NNChinaChina 103103 ChinaChina 110110EcuadorEcuador 4141 MexicoMexico 4343Dominican RepublicDominican Republic 4141 EcuadorEcuador 4242MexicoMexico 3434 Dominican RepublicDominican Republic 3939

1212

BangladeshBangladesh 3030 IndiaIndia 3232PhilippinesPhilippines 2828 HaitiHaiti 2929IndiaIndia 2626 PhilippinesPhilippines 2525HaitiHaiti 2323 BangladeshBangladesh 2222PakistanPakistan 2020 NepalNepal 1818South KoreaSouth Korea 1717 Guyana & South Guyana & South

KoreaKorea1313

4

2010 NYC TB cases by country of birth

1313

No 2010 cases born in this country

One or more 2010 cases born in this country

Top 20 2010 country of birth

Tuberculosis Cases by Borough Tuberculosis Cases by Borough New York City, 2009 and 2010New York City, 2009 and 2010

276

205

257232

200

250

300

Cas

es

2009 2010

1414

120 137

18

88116

130

50

100

150

Manhattan(5.4*)

Queens(11.1*)

Brooklyn (9.0*) Bronx (8.3*) Staten Island(2.6*)

* Rate per 100,000 based on 2009 population estimates

Num

ber o

f C

West Queens

Flushing - Clearview

Fordham - Bronx Park

TB cases counted in New York City by UHF neighborhood, 2010

Number of TB cases0

1 - 9

10 - 24

25 - 49

50 - 96

1515

Borough Park

Sunset Park

East Flatbush - Flatbush

Bedford Stuyvesant - Crown Heights

West Queens

Flushing - Clearview

Fresh MeadowsLong Island City - Astoria

Fordham - Bronx Park

Crotona - Tremont

Williamsburg - Bushwick

High Bridge - Morrisania

Central Harlem - Morningside Heights

TB rates in New York City by UHF neighborhood, 2010

TB case rate0.0

0.1 - 3.8

3.9 - 9.1

9.2 - 22.5

1616

Rates are based on 2009 population estimates.

Borough Park

Sunset Park

Bensonhurst - Bay Ridge

Bedford Stuyvesant - Crown Heights

Williamsburg Bushwick

5

Top 10 Medical Facilities First Evaluating Top 10 Medical Facilities First Evaluating Patients for TBPatients for TB

New York City, 2010New York City, 2010

Facility NameFacility Name # of Cases# of Cases % of all % of all CasesCases

1. Elmhurst Hospital Center1. Elmhurst Hospital Center 6464 992. Bellevue Hospital Center2. Bellevue Hospital Center 4848 773. Mount Sinai Hospital3. Mount Sinai Hospital 2929 44

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4. Kings County4. Kings County 2424 335. New York Hospital Medical Center of Queens5. New York Hospital Medical Center of Queens 2323 336. Fort Greene Chest Center6. Fort Greene Chest Center 2222 337. Beth Israel Medical Center, Maimonides Medical Center 7. Beth Israel Medical Center, Maimonides Medical Center 2121 338. Queens Hospital Center 8. Queens Hospital Center 1919 339. Corona Chest Center, Jacobi Medical Center, 9. Corona Chest Center, Jacobi Medical Center, WoodhullWoodhull 1616 2210. Lutheran Hospital, Washington Heights Chest Center10. Lutheran Hospital, Washington Heights Chest Center 1515 22

Tuberculosis Cases by Site of DiseaseTuberculosis Cases by Site of DiseaseNew York City, 2010New York City, 2010

BOTH PULMONARY AND

EXTRAPULMONARY DISEASE 75 (11%)

ONLY EXTRAPULMONARY DISEASE 155 (22%)

ONLY PULMONARY DISEASE 481 (68%)

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Note: Denominator = All confirmed cases in 2010 (n=711)

Extrapulmonary Sites among TB Cases Extrapulmonary Sites among TB Cases New York City, 2010New York City, 2010

Sites*Sites* % of Total Extra% of Total Extra--pulmonary pulmonary SitesSites

LymphaticLymphatic 4242PleuralPleural 2626

1919

Other Other 1313Bone/JointBone/Joint 99PeritonealPeritoneal 88GenitourinaryGenitourinary 77MeningealMeningeal 55

*Categories are not mutually exclusive

Trend in HIVTrend in HIV--Infection and TBInfection and TBNew York City, 1992New York City, 1992--20102010

34 33 34 3331

1,000

1,200

1,400

40

50

% TB/HIV+# TB/HIV+

% of TB/HIV Infected CasesNumber of Cases

2020

2622 22

1815

1816 16 15

13 1311

97

200

400

600

800

92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10Year

0

10

20

30

6

MDRMDR--TB in NYC,1992TB in NYC,1992--20102010441

296

250

300

350

400

450

500

2121

176

10984

53 38 31 25 24 27 21 18 24 219 11 9 11

0

50

100

150

200

250

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Those who do not learn from history Those who do not learn from history are doomed to repeat it!are doomed to repeat it!

6000

7000

8000

9000

10000

f cas

es

Actual Cases Projected Cases

2222

0

1000

2000

3000

4000

5000

1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Years

Num

ber

of

Think TB!Think TB!

2323

New York City Department of Health New York City Department of Health and Mental Hygieneand Mental Hygiene

Bureau of TB ControlBureau of TB Control

http://www nyc gov/health/tbhttp://www nyc gov/health/tb

2424

http://www.nyc.gov/health/tbhttp://www.nyc.gov/health/tb

Tel: 311 or Tel: 311 or 212212--788788--4162 (TB Provider Hotline)4162 (TB Provider Hotline)