Tuberculosis in Arizona, 2001 Morbidity There were 15,991 cases of active tuberculosis (TB) reported in the United States (U.S.) in 2001. Of these, 289 occurred in Arizona. While the U.S. has seen nine years of decline in the number of cases and case rates since 1993, this trend is not apparent in Arizona (Table 1 and Figure 1). The mean number of TB cases in Arizona from 1992 to 2001 was 269 with a minimum of 228 cases in 1993 and maximum of 317 cases in 1995. Due to population growth statewide, TB case rates declined from 6.7 in 1992 to 5.1 in 2000. However, in 2001 the TB case rate increased to 5.4. While the Arizona TB rate now approximates the national rate of 5.6 per 100,000 persons, it is higher than the Healthy People 2010 target rate of 1.0 per 100,000 persons (Figure 1). Only three states have met or exceeded the 2010 target goal. Arizona ranked 17 nationwide in TB case rates and 14 in number of cases in 2001. The majority of TB cases in Arizona in 2001 were of Hispanic or Latino ethnicity (45.7%), followed by White, non-Hispanic (25.3%), Native American (15.9%), Asian (8.3%) and Black, non-Hispanic (4.8%). The mean age was 43.9 years, the median age 44 years and 66.4% were male (Table 2). Table 1. Tuberculosis Cases and Case Rates per 100,000 Population, Arizona and United States, 1992 - 2001 Arizona b Year 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Cases 258 228 247 317 282 296 254 262 261 289 Population 3,858,825 3,946,975 4,036,875 4,184,723 4,462,717 4,595,379 4,722,097 4,924,350 5,130,632 5,307,331 c Rate 6.7 5.8 6.1 7.6 6.3 6.4 5.4 5.3 5.1 5.4 a United Statesa Rate Cases 26,673 10.5 25,287 9.8 24,361 9.4 22,860 8.7 21,337 8.0 19,851 7.4 18,361 6.8 17,531 6.4 16,377 5.8 15,989 5.6 Data from U.S. Department of Health and Human Services; Centers for Disease Control and Prevention, available at: www.cdc.gov/nchstp/tb/ b Year reported reflects the year case was verified by Arizona Department of Health Services. c Denominators for computing 2001 rates are from the Arizona Department of Economic Security (http://www.hs.state.az.us/plan/pd01.htm). Year 2000 denominators are from the 2000 U.S. Census. Population projections from Arizona Department of Economic Security are used for years prior to 2000. 1 Figure 1. Tuberculosis Case Rates per 100,000 Population, Arizona and United States, 1992 - 2001 15.0 10.0 5.0 0.0 1992 1993 1994 1995 Arizona 1996 1997 United States 1998 1999 2000 2001 2010 Target (1/100,000) Table 2. Tuberculosis Cases by Ethnicity, Gender and Age Group, Arizona, 2001 Age Group 15-24 25-44 <5 5-14 0 0 0 1 0 1 2 5 7 0 0 0 0 1 1 Male Female Total Native Americand 5 7 12 Male Female Total Asiane Male Female Total Total by Gender Male Female Total by Age Group No. (%) White, Not Hispanic Male Female Total Black, Not Hispanic Male Female Total Hispanic or Latinoc Ratea,b Total by Ethnicity No. (%) Ratea,b 45-64 65+ 7 6 13 19 8 27 20 5 25 49 24 73 (25.3) 2.2 3 1 4 3 2 5 3 0 3 1 0 1 10 4 14 (4.8) 8.5 3 4 7 17 8 25 31 12 43 23 7 30 8 7 15 87 45 132 (45.7) 9.8 2 0 2 0 0 0 0 1 1 12 2 14 7 7 14 11 4 15 32 14 46 (15.9) 17.4 0 0 0 0 0 0 2 1 3 7 6 13 5 2 7 0 1 1 14 10 24 (8.3) 23.4 7 7 4 5 24 16 60 28 57 24 40 17 192 97 (66.4) (33.6) 7.2 3.6 14 (4.8) 3.5 9 (3.1) 1.1 40 (13.8) 5.3 88 (30.4) 5.6 81 (28.0) 7.3 57 (19.7) 8.2 289 a (100.0) 5.4 Rate per 100,000 population. Denominators for computing rates are from the 2000 U.S. Census in order to have population breakdowns by age group and gender. c Persons of Hispanic or Latino origin may be of any race. d Includes American Indians and Native Alaskans. e Includes Native Hawaiians and Other Pacific Islanders. b 2 The greatest proportion of male (31.3%) and female (28.9%) cases were in the 25-44 year age group (Figure 2), followed by the 45-64 year group (29.7% and 24.7% respectively), greater than 65 years (20.8% and 17.5%), 15-24 years (12.5% and 16.5%), less than 5 years (3.6% and 7.2%) and 5-14 years (2.1% and 5.2%). There were almost twice as many male cases (192) as female cases (97). The mean age of male cases was 45.8 years and the mean age of female cases was 40.2 years. Figure 2. Number of Tuberculosis Cases by Age in Years and Gender, Arizona, 2001 70 60 50 40 30 20 Male 10 Female 0 0-4 5-14 15-24 25-44 45-64 65+ Four of Arizona’s 15 counties, Maricopa, Pima, Yuma and Apache, accounted for 85% of the state’s TB cases. Maricopa County, which includes Phoenix, the sixth largest city and the fourteenth largest metropolitan area in the U.S., led the state with 163 cases (56.4%). Pima County, a U.S.-Mexico border county that includes Arizona’s second largest urban area, Tucson, was second with 45 cases (15.6%). Yuma County, also on the U.S.-Mexico border, had 22 cases (7.6%). Apache County, a largely rural area, had 15 cases (5.2%), three times the 5 cases reported in 2000. Pinal County, which contains Arizona’s two largest state prison facilities, three private prisons, an INS processing center, and a county jail had 11 cases (3.8%); of these, 9 were diagnosed in correctional facilities. Three of the remaining ten counties, Greenlee, La Paz and Yavapai, reported no TB cases in 2001 (Figure 3). 3 Figure 3. Tuberculosis Cases and Case Rates per 100,000 (in parentheses) by County, Arizona, 2001. Yuma County had the highest 5-year median rate (15.6 per 100,000 population) of the 15 counties. Greenlee County was second with a 5-year median rate of 11.3 per 100,000 population. However, this rate is not statistically reliable due to the small number of cases and the small population sizes in Greenlee and other rural counties. In this situation, an increase of only one or two cases will result in a dramatic rate increase. This accounts for some of the rate fluctuations from year to year in counties with small populations. In general, reported rates involving less than 10 cases are not reliable (Figure 4). 4 Figure 4. Five-Year Median Tuberculosis Case Rates per 100,000 by County, Arizona, 1996-2000 Risk Factors Arizona has observed an increasing proportion of cases among the foreign-born, the same trend as seen nationally. In 2000, 56.7% of Arizona cases were born outside the U.S., marking the first year that foreign-born cases outnumbered those born in the U.S. (Table 3). In 2001, almost half (46.0%) of Arizona cases were born outside the U.S. and its territories (Figure 5). The majority (61.73%) of foreignborn persons with TB in Arizona in 2001 were born in Mexico (n=82). Other reported countries of origin 5 include the Philippines, 6.8% (n=9), Vietnam, 4.5% (n=6), India, 3.8% (n=5) and El Salvador, 2.3% (n=3). The remaining 28 cases are from 22 other countries with 2 cases or less per country (Figure 6). Table 3. Tuberculosis Cases by Selected Risk Factors, Arizona, 1996 - 2001 1996 No. (%) 1997 No. (%) 1998 No. (%) 1999 No. (%) 2000 No. (%) 2001 No. (%) Correctional Facility Worker 0 (0.0) 0 (0.0) 1 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) Health Care Worker 2 (0.7) 3 (1.0) 3 (1.2) 1 (0.4) 6 (2.3) 5 (1.7) Migrant Farm Worker 9 (3.2) 2 (0.7) 5 (2.0) 6 (2.3) 9 (3.4) 6 (2.1) Occupation Reported Behaviors Injecting Drug Usea 12 (4.3) 11 (3.7) 6 (2.4) 10 (3.8) 11 (4.2) 11 (3.8) Non-injecting Drug Usea 13 (4.6) 15 (5.1) 10 (3.9) 20 (7.6) 20 (7.7) 22 (7.6) Excess Alcohol Usea 37 (13.1) 48 (16.2) 39 (15.4) 55 (21.0) 46 (17.6) 60 (20.8) Type of Residence Long Term Care Facilityb 14 (5.0) 12 (4.1) 4 (1.6) 7 (2.7) 7 (2.7) 12 (4.2) Correctional Facilityb 18 (6.4) 23 (7.8) 14 (5.5) 18 (6.9) 21 (8.0) 16 (5.5) a 35 (12.4) 29 (9.8) 29 (11.4) 36 (13.7) 38 (14.6) 45 (15.6) Homeless Country of Birth Foreign Bornc Underlying Disease HIV infection, All Agesd HIV infection, 25-44 Years Oldd Total Cases 108 (38.3) 111 (37.5) 102 (40.2) 111 (42.4) 148 (56.7) 133 (46.0) 15 (5.3) 12 (4.1) 14 (5.5) 16 (6.1) 18 (6.9) 12 (4.2) 11 (12.9) 10 (10.4) 11 (15.9) 10 (10.1) 13 (14.3) 8 (9.1) 282 296 254 262 261 289 a Within one year prior to diagnosis of tuberculosis. Residence at time of diagnosis. c Includes persons born outside the United States and its territories. d Tuberculosis cases with a reported positive HIV test result. The percent positive represents HIV co-infection among all verified TB cases, including those not tested for HIV infection. b Figure 6. Reported Country of Birth, Arizona TB Cases, 2001 Figure 5. Foreign-Born TB Cases, Arizona, 1992 - 2001 100% Mexico 61% 80% 60% U.S. 40% Foreign Philippines Vietnam India 20% 0% 19 9 19 2 9 19 3 9 19 4 9 19 5 9 19 6 9 19 7 9 19 8 9 20 9 0 20 0 01 Other 6 El Salvador Excess alcohol use has been increasingly reported among TB cases in Arizona, up from 13.1% in 1996 to 20.8% in 2001. In 2000, excess alcohol use was reported in 17.6% of Arizona cases, slightly higher than the national average of 15% for that year. Homelessness is another important risk factor for TB in Arizona with the proportion of TB cases among homeless persons in 2000 2.4 times higher than the national average of 6.1%. The proportion of TB cases among homeless persons in Arizona increased in 2001 to 15.6%. In 2001, the proportion of TB cases diagnosed in Arizona correctional facilities was 5.5% (n=16), down slightly from 8.0% (n=21) of reported cases in 2000. In contrast, only 3.6% of TB cases nationally were reported as diagnosed in correctional facilities in 2000. The greatest challenge among the correctional facility cases in Arizona has been in providing adequate treatment for Immigration and Naturalization Service (INS) detainees diagnosed with TB while in custody (n=11 in 2001 versus n=15 in 2000). Most detainees are deported prior to completion of treatment and may even be deported prior to culture results. In these cases, the detainee is unaware of their diagnosis of TB. In 2000, Arizona’s TB Control Program began actively enrolling every TB suspect who is in INS custody in the bi-national TB referral program, CURE-TB, offered by the San Diego TB Control Program. This enables detainees and their providers access to their medical information following deportation. Nationally, the proportion of TB cases known to be co-infected with HIV has been declining, from 15% in 1993 to 10% in 1999, while remaining approximately stable in Arizona at 7% in 1993 and 6% in 1999. During these years, the proportion of TB cases for which HIV results are known has increased much more in Arizona (from 18% to 60%) than nationally (30% to 48%). In 2001, HIV test results are known for 64% of TB cases in Arizona among all age groups and for 82% of those in the 25-44 year age group, considered to be at highest risk for HIV co-infection (Table 4). The proportion of TB cases known to be co-infected with HIV in Arizona decreased from 7% in 2000 to 4% in 2001 (Figure 7). 7 Figure 7. HIV Coinfection in Persons Reported with TB, U.S. and Arizona, 1993-2001 Percent 20 15 10 5 0 1993 1995 1997 United States 1999 2001 Arizona Note: Based on reported HIV status among all TB cases, including those not tested. Table 4. Proportion of Reported Tuberculosis Cases with HIV Test Results and HIV Coinfection by Age Group, U.S. and Arizona, 1993-2001. 25-44 Years Old HIV Test HIV Positiveb Results Knowna U.S. AZ U.S. AZ HIV Test Results Knowna U.S. AZ U.S. AZ (%) (%) (%) (%) (%) (%) (%) (%) 1993 (46) (38) (29) (19) (30) (18) (15) (7) 1994 (49) (28) (29) (15) (33) (16) (15) (6) 1995 (52) (53) (26) (19) (36) (33) (13) (8) 1996 (57) (65) (25) (13) (41) (44) (12) (5) 1997 (60) (69) (21) (10) (44) (45) (11) (4) 1998 (61) (77) (20) (16) (45) (47) (10) (6) 1999 (62) (84) (19) (10) (48) (60) (10) (6) Year All Ages HIV Positiveb 2000 (74) (14) (62) (7) 2001 (82) (9) (64) (4) a Rhode Island reported HIV test results in 1998 and 1999. California reporting of HIV status is incomplete and only includes persons also reported with AIDS. Includes cases with positive, negative and indeterminate HIV test results. b Based on reported HIV positive status among all reported tuberculosis cases, including those not tested. 8 Drug susceptibility Initial drug susceptibility testing was obtained on 98% (224/228) of culture-proven TB cases in Arizona in 2001. Overall, drug resistance patterns have not changed significantly in recent years. All multi-drug resistant cases since 1998 have occurred among foreign-born persons (Table 5). Table 5. Drug Resistance Among U.S.-born and Foreign-born Tuberculosis Cases, Arizona, 19962001 INH Resistancea,b Multi-Drug Resistanta,c Year U.S.-born Foreignborn Totale U.S.-born Foreignborn Totale 1996 1997 1998 1999 2000 2001 No. (%) 1 (1) 8 (6) 6 (5) 2 (2) 2 (2) 4 (3) No. (%) 5 (6) 10 (12) 4 (5) 4 (4) 13 (10) 5 (5) No. (%) 6 (3) 18 (8) 10 (5) 6 (3) 15 (7) 9 (4) No. (%) 2 (1) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) No. (%) 5 (6) 1 (1) 1 (1) 2 (2) 2 (2) 3 (3) No. (%) 7 (3) 2 (1) 1 (0) 2 (1) 2 (1) 3 (1) Other Drug Resistancea,d U.S.-born Foreignborn Totale No. 19 17 10 18 10 9 No. (%) 4 (5) 5 (6) 4 (5) 9 (9) 9 (7) 10 (10) No. (%) 23 (10) 22 (10) 14 (7) 27 (12) 19 (9) 19 (8) (%) (13) (12) (8) (14) (11) (8) a More than 95% of isolates had susceptibility testing performed. Resistance to at least isoniazid without rifampin resistance. c Resistance to at least isoniazid and rifampin (multi-drug resistance). d Other drug resistance without isoniazid resistance. e Includes persons of unknown country of birth. b Completion of Tuberculosis Therapy While completion of therapy data is not available for 2000 and 2001, there has been a consistent trend of increasing rates of therapy completion in Arizona from 1994 to 1999. In cases diagnosed in 1994, 83% completed therapy and in cases diagnosed in 1998, 95% completed therapy. Nationally, the overall completion of therapy rate was 90% in 1998 (the last year for which national data is available). In 1999, Arizona had a 95% overall completion of therapy rate. In Arizona, rates for completing therapy within one year increased from 67% in 1994 to 82% in 1999, still short of the national objective of 90% (Figure 8). In 1998, 84% of Arizona cases completed therapy within one year versus 79% nationally. 9 Figure 10. Completion of Tuberculosis Therapy, Arizona, 1994 - 1999 100 83 Percent 80 81 67 70 81 95 88 76 73 95 84 82 60 40 20 0 1994 1995 1996 Overall Completion 1997 1998 1999 % Complete within 1 Year Note: Completed in one year or less excludes persons resistant to RIF and children <15 years with meningeal, bone or joint or miliary disease Contacts Provisionally, contacts were reported for 55% (134/244) of pulmonary TB cases in Arizona in 2001 (Figure 9). The decrease in reported contacts of pulmonary TB cases in 2000 may in part be related to the introduction of new reporting forms and categories by the Centers for Disease Control and Prevention (CDC) to reporting sources. In addition, a new computerized TB Prevention Registry that utilized the new reporting format was introduced to local health departments in 2000. Figure 9. Proportion of Counted Pulmonary TB Cases with Contacts Identified, Arizona, 1998 - 2001 Percentage 100 80 60 40 20 0 1998 1999 2000 Calendar Year 10 2001 In 2001, the average number of contacts identified per pulmonary TB case in Arizona was 4.0 (964/244). This is an increase from an average of 2.4 (556/236) contacts per pulmonary TB case in 2000 (Figure 10). Figure 10. Average Number of Contacts Identified per Pulmonary TB Case, Arizona, 1998 - 2001 Number 10 8 6 4 2 0 1998 1999 2000 2001 Calendar Year Nineteen percent (154/813) of contacts who were evaluated were found to have newly recognized latent TB infections and 0.2 percent (2/813) were found to have newly recognized active TB disease. Eightyfour percent (813/964) of contacts completed the evaluation process, a decrease from 88% (491/556) in 2000 (Figure 11). Figure 11. Proportion of Contacts to Pulmonary TB Cases that Were Evaluated, Arizona, 1998 - 2001 Percentage 100 80 60 40 20 0 1998 1999 2000 Calendar Year Completion of Therapy for Latent TB Infection 11 2001 In 1999, the last year for which Arizona data is complete, 62% (114/185) of contacts to TB cases and 61% (1694/2793) of others (who were not contacts to TB cases) with positive skin tests who started therapy for latent TB infection completed therapy (Figure 12). Both are below the National Goals (85% and 75%, respectively). Figure 12. Completion of Therapy for Latent TB Infection, Arizona, 1998 -1999 Percent 100 1998 1999 80 60 40 20 0 Contacts Others Category TB Skin Testing in Children Provisionally, completed skin tests were reported for 2,718 children (under 18 years of age) in Arizona in 2001. Forty-five percent (1211/2718) were tested as part of local health department skin test screening activities; 17% (470/2718) as part of immigration evaluation; and 16% (425/2718) as part of contact investigations. Data show peaks in skin testing at age 4 years (n=243) and age 17 years (n=235) (Figure 13). It is unclear why there are a greater number of completed skin tests at these ages; it may be due to school entry and volunteer or work requirements. 12 Number 300 Figure 13. Number of Children with Completed TB Skin Tests Reported, Arizona, 2001 250 200 150 100 50 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Age in Years Overall, 26% (716/2718) of children who completed skin testing had positive TB skin tests reported. Of children who completed testing as part of local health department screening activities, 32% (384/1211) had positive TB skin tests. Of children who completed testing during immigration evaluation, 23% (108/470) had positive TB skin tests. Of children who completed testing as part of a contact investigation, 11% (48/425) had positive TB skin tests. Skin tests were more likely to have positive results among children age 9 years or older versus children age 8 years or less (Figure 14). Figure 14. Proportion of Children With Positive TB Skin Tests by Age, Arizona, 2001 Percentage 100 80 60 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Age in Years The Tuberculosis Surveillance Report is published annually by the Arizona Department of Health Services, TB Control Section. All data are provisional. Report finalized 4/18/2002 based on available data as of 3/11/2002. 13