TB Trends in Arizona Arizona Department of Health Services Bureau of Epidemiology and Disease Control Tuberculosis Control Section May 2004 ARIZONA • Sixth largest state • Phoenix is the sixth largest city in U.S. • Population 5.6 million: 64% non-Hispanic White, 25% Hispanic, 5% Native American, 3% Black, 2% Asian • Shares 360 miles of border with Sonora, Mexico (19% of the US-Mexico border) Tuberculosis Case Rates per 100,000, Arizona, 1923 - 2003 Cases per 100,000 600 500 400 300 200 100 0 19 19 19 19 19 19 19 19 19 19 19 20 23 30 37 44 51 58 65 72 79 86 93 00 Number of Cases Reported TB Cases United States, 1981-2003 28000 26000 24000 22000 20000 18000 16000 14000 12000 10000 80 982 984 986 988 990 992 994 996 998 000 002 9 1 1 1 1 1 1 1 1 1 1 2 2 What Happened in Mid 1980s? • HIV epidemic • Deterioration of Public Health infrastructure for TB services • Homelessness • Drug and alcohol abuse • Immigration from high incidence countries Tuberculosis Case Rates/100,000 Arizona and United States, 1992 - 2003 10 8 6 4 2 0 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 Cases per 100,000 12 Arizona United States 2010 Target (1/100,000) 350 300 250 200 150 100 50 0 295 258 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 Number of Cases Reported TB Cases Arizona, 1992 - 2003 Number of Cases Tuberculosis Cases by County, Arizona, 2003 250 195 200 150 100 24 30 25 50 2 3 2 2 5 4 3 0 Yum a ai Yav ap C ruz Sant a Pinal Pim a o N avaj ve M oha opa M aric z La Pa Gila e Apac h 70 60 50 40 30 30 25 24.5 20 12.4 6.5 20 10 0 15 10 5.1 1.7 5 0 Asian Black Hispanic Percentage Native American Rate White Cases per 100,000 Percentage Case Rates and Percentage of Tuberculosis Cases by Race/Ethnicity, Arizona, 2003 Tuberculosis Cases by Age Group and Race/Ethnicity, Arizona, 2003 Number of Cases 70 60 50 40 30 20 10 0 0-4 Asian 5-14 Black 15-24 Hispanic 25-44 45-64 Native American White 65+ Tuberculosis Cases by Age Group and Gender, Arizona, 2003 Number of Cases 70 60 50 40 30 20 10 0 0-4 5-14 15-24 Female 25-44 Male 45-64 65+ Percentage of TB Cases Occurring in Foreign-born Persons, Arizona and United States, 1993 - 2003 70 Percentage 60 50 40 30 20 10 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Arizona United States Country of Origin for Foreign-born TB Cases, Arizona, 2003 Honduras Guatemala Philippines Mexico 68% South Korea India Vietnam Other Cases per 100,000 TB Case Rates in U.S.-born vs. Foreign-born Persons, United States, 1992-2002 40 30 20 10 0 1992 1994 1996 U.S. Overall 1998 U.S.-born 2000 Foreign-born 2002 Risk Factors for TB Cases, Arizona and U.S. AZ (2003) Category U.S. (2002) No. % % Excess Alcohol 55 18.6 14.5 Correctional Facility 39 13.2 3.1 Homeless 35 11.9 6.0 Non-injecting Drug Use 23 7.8 7.0 HIV Positive 16 5.4 8.0 (2001) Injecting Drug Use 5 1.7 2.2 Long-term Care Facility 5 1.7 2.6 Clinical Characteristics of TB Cases, Arizona,1999-2003 • 55% of pulmonary cases >14 years are sputum smear positive • 32% of pulmonary cases >14 years have a cavitary CXR at diagnosis • 69% of TB/HIV patients were 25-44 yrs; BUT 25 co-infected persons were not in this age range, 4 were younger, 3 were in their 70’s (test everyone)! 16 70 14 60 12 50 10 40 8 30 6 4 20 2 10 0 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 HIV positive, US % tested, US HIV positive, AZ % tested, AZ % of all TB cases HIV tested % of all TB cases HIV positive HIV Co-infection of TB Cases, Arizona and US, 1993-2003 Percentage Proportion of Total TB Cases Occurring in Homeless Persons, Arizona and United States, 1993 - 2003 18 16 14 12 10 8 6 4 2 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Arizona United States Completion of TB Therapy Among Homeless Persons, Arizona, 1993 - 2001 100 Percentage 55 60 40 70 72 80 62 59 81 72 63 89 88 73 73 72 83 62 49 35 35 20 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 % Complete within 1 Year Overall Completion 14 45 12 40 35 10 30 8 25 6 20 15 4 10 2 5 0 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 % AZ Cases % US Cases Number of AZ Cases In 2002, AZ had the highest percentage (7.3%) of TB cases diagnosed in a correctional facility in the US Number of Cases Percentage Tuberculosis in Residents of Correctional Facilities, Arizona and U.S., 1993 - 2003 Completion of TB Therapy Within 12 Months by Residence: Correctional Facility vs Non-CF, Arizona, 1993-2001 Percentage 100 60 68 56 55 40 40 20 76 72 80 38 84 87 77 50 84 81 61 47 50 35 17 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 Non-correctional Correctional National Goal: 90% to complete therapy within 12 months Primary Resistance to Anti-TB Drugs, Arizona, 1999 - 2003 10 Percentage 8 Mean INH 5.6% 6 4 2 0 1999 2000 Total INH 2001 2002 INH & RIF (MDR) 2003 Mean INH Use of Directly Observed Therapy, Arizona, 1998 - 2002 100% 80% 60% 40% 20% 0% 1998 1999 DOT only 2000 DOT + SA 2001 2002* SA only *data for 2002 are preliminary Directly observed therapy (DOT); Self-administered therapy (SA) Completion of Tuberculosis Therapy, Arizona, 1993 - 2001 Percentage 100 80 80 60 83 67 81 70 81 73 88 76 95 84 95 82 89 78 92 82 55 40 20 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 Complete Within 1 Year Overall Completion National Goal: 90% to complete therapy within 12 months Median rate 3.5 cases / 100,000 Number Rate per 100,000 persons Note: 77% of 2003 pediatric cases were Hispanic in 2003 8 7 6 5 4 3 2 1 0 Cases per 100,000 35 30 25 20 15 10 5 0 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 Number of Cases Pediatric (<5 years) TB Cases, Arizona, 1993 - 2003 Conclusion • Arizona moved up from #18 in 2002 to #11 in 2003 for the number of TB cases in the U.S. • Funds for targeted testing are drying up – the focus for decreasing new cases is to quickly identity and treat persons with active disease • Improve case finding among Hispanics and other high risk groups to decrease transmission and reduce pediatric cases • THINK TB!