Download Treatment of Migrants with Tuberculosis in an Era of Emerging Drug

•Thank you for viewing this
presentation.
•We would like to remind you that this
material is the property of the author.
It is provided to you by the ERS for your
personal use only, as submitted by the
author.
 2010 by the author
Treatment of Migrants with Tuberculosis in an
Era of Emerging Drug Resistance
European Respiratory Society
Barcelona Congress 2010
20 Sep 10
Timothy R. Aksamit, MD
Associate Professor of Medicine
Consultant
Pulmonary Disease and Critical Care Medicine
Mayo Clinic
Rochester, Minnesota USA
Treatment of Migrants with Tuberculosis in an
Era of Emerging Drug Resistance
DISCLOSURE
Relevant Financial Relationship(s)
None
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
• Epidemiology
• Migrant trends
• Programmatic opportunities
• Summary
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Global TB disease burden
Highly mobile global population
Emergence of drug-resistant TB
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
CDC Plan to Combat Extensively Drug-Resistant TB
• Unless the fundamental causes of MDR TB and
XDR TB are addressed in the United States and
internationally, the United States is likely to
experience a growing number of cases of MDR TB
and XDR TB that will be difficult, if not impossible
to treat or prevent.
MMWR 58: 13 Feb 2009 RR-3
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
• Epidemiology
• Migrant trends
• Programmatic opportunities
• Summary
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
TB Incidence Rates 2008
WHO Global tuberculosis control-a short update to the 2009 report
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology
•
Global TB rates and TB-related mortality are
falling 2008
• 9.4 million incident cases up (9.3 in 2007)
• Population growth
• Incidence 139/ 100k (peak 143/100k in 2004)
•
22 high-burden countries account for 80% of
the global tuberculous burden
•
2 billion with LTBI worldwide
Lancet 375: 1814, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology – MDR new cases
WHO Multidrug and extensively drug-resistant TB (M/XDR-TB) 2010 Global report
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology – MDR previously Rx cases
WHO Multidrug and extensively drug-resistant TB (M/XDR-TB) 2010 Global report
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology - MDR
•
Estimated 440,000 new cases in 2008
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology - MDR
•
Estimated 440,000 new cases in 2008
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology - MDR
•
Estimated 440,000 new cases in 2008
•
•
Only 7% were reported to WHO
•
Cost of Rx (US$) estimated $250,000/case
6000 treated in GLC approved program (16 of 22
high burden countries no MDR in GLCprogrammes)
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology – XDR
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology - XDR
•
58 countries with at least one confirmed case of
XDR
•
8 countries reported XDR-TB in more than 10% of
MDR-TB cases (E Europe, Central Asia)
WHO Multidrug and extensively drug-resistant TB (M/XDR-TB) 2010 Global report
MMWR 58: 13 Feb 2009 RR-3 Chest 136: 333, 2009 NEJM 363: 1050, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology - XDR
•
•
Cost of XDR Rx (US$) estimated $500,000/case
Between 2010-2015 1.3 million cases MDR/XDR
• Cost US$ 16,000,000,000
• Est. budgets combined 2010 - 0.5 billion
• MDR funding 2015 16Xs current 2010 funding
WHO Multidrug and extensively drug-resistant TB (M/XDR-TB) 2010 Global report
MMWR 58: 13 Feb 2009 RR-3 Chest 136: 333, 2009 NEJM 363: 1050, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Epidemiology - XDR
•
Contributing factors drug-resistance:
• funding short fall
• lack of DOT
• infection control nosocomial transmission
• ineffective standardized retreatment regimens
• lack of DST and laboratory services
• lack of reliable second-line drugs
• lack of new drugs
• lack of comprehensive provider buy-in
WHO Multidrug and extensively drug-resistant TB (M/XDR-TB) 2010 Global report
MMWR 58: 13 Feb 2009 RR-3 Chest 136: 333, 2009 NEJM 363: 1050, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
• Epidemiology
• Migrant trends
• Programmatic opportunities
• Summary
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Migrant trends
•
Global estimates
•
214 million international migrants
worldwide
•
3.1% world population are migrants
United Nations’ Trends in Total Migrant Stock: The 2008 Revision http://esa.un.org/migration
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Migrant trends
•
Global trends
•
Total number of international migrants has
increased : 150 to 214 million from 2000 –
2008 (up 43%)
•
Migration distributed widely across more
countries – Top 10 countries of destination
(2008) receive a smaller share of all
migrants than in 2000
United Nations’ Trends in Total Migrant Stock: The 2008 Revision http://esa.un.org/migration
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
• Epidemiology
• Migrant trends
• Programmatic opportunities
• Summary
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
TB Sceening new immigrants: systematic review and
meta-analysis Arshad, et al
•
Assessment of yield of active screening for TB
among new immigrants at point of entry
•
Migrants to Western Europe, Kuwait, Australia,
New Zealand, & USA (low prevalence, 1980-2006)
Eur Respir J 35: 1336, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
TB Sceening new immigrants: systematic review and
meta-analysis Arshad, et al
•
•
•
Overall, 3.5 cases / 1000 screened (*)
Refugees 11.9*, asylees 2.8*, and reg immigr 2.7*
Prevalence ratio immigrants-autochthonous 48.2
Eur Respir J 35: 1336, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
TB Sceening new immigrants: US immigrants and
refugees Liu et al
•
1999 – 2005: 2,714,223 U.S. bound screened
• c. 400k immigrants, 50-75k refugees /yr
•
TB rates (U.S.):
• foreign born 11 times U.S. born (2009)
•
Refugees: 10.4/ 1000 Immigrants 9.6 / 1000
NEJM 360: 2406, 2009
MMWR 59: 289, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
TB Sceening new immigrants: US immigrants and
refugees Liu et al
•
Top 5 birth countries of immigrants with
overseas dignosis of TB:
• Phillipines, Vietnam, China, Mexico, India
•
Top 5 birth countries of refugees with overseas
diagnosis of TB:
• Ukraine, Vietnam, Somalia, Bosnia/
Herzegovina, Sudan
NEJM 360: 2406, 2009
MMWR 59: 289, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
TB Sceening new immigrants: US 2007 Technical
Instructions
•
Improvements in overseas screening
• Mycobacterial cultures
• Drug susceptibility testing
• Directly observed therapy
• TST for children 2 – 14 years
• Shorter interval between screening and
departure for the U.S.
NEJM 360: 2406, 2009
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
TB Sceening new immigrants: US 2007 Technical
Instructions
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Programmatic Opportunities - Epidemiology U.S.
•
•
•
U.S. TB case rate 3.8 / 100,000 in 2009
11.4% decrease from 2008 (4.2)
“ The 2009 rate showed the greatest single-year
decrease ever recorded and was the lowest
recorded rate since national TB surveillance
began in 1953.”
MMWR 59: 289, 2010
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Programmatic Opportunities - Epidemiology U.S.
•
? New technical instructions for preimmigration TB screening
•
? Other: improved TB control, populationdemographic shifts, under-reporting/diagnosis,
reductions in immigration / return home
(Mexico), census adjustment
MMWR 59: 289, 2010
Estimated Migrants “Entering” U.S.
Visitors without visas
~ 30,000,000
Non-immigrant visas
27,907,139
Immigrants and refugees
411,266
Undocumented migrants
~ 275,000 ????
N= ~ 59,000,000
Status adjusters in U.S.:
679,305
Source: U.S. Department of Homeland Security, 2003 (2002 data)
Refugee Arrivals to Minnesota by
Region of World, 1979-2007
8000
Number of arrivals
7000
6000
5000
4000
3000
2000
Southeast Asia
Sub-Saharan Africa
Refugee
Health
Program,
Minnesota
Department
of Healthof
Refugee
Health
Program,
Minnesota
Department
Health
Eastern Europe
FSU
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
0
1979
1000
Other
*First resettled in Minnesota
Tuberculosis Incidence Rates per 100,000
Population, United States and Minnesota, 19922008
United States
12
Minnesota
Healthy People 2000
Objective*
Healthy People 2010
Objective
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
20
04
20
05
20
06
20
07
20
08
Cases per 100,000
10
Year of Diagnosis
Number of Cases
Number of Tuberculosis Cases by Place
of Birth, Minnesota, 1999-2008
240
220
200
180
160
140
120
100
80
60
40
20
0
Total
Foreign-Born
U.S.-Born
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year of Diagnosis
Tuberculosis Cases by Drug Susceptibility
Patterns and Place of Birth,
Minnesota, 2004-2008
Place of Birth
Cases With Any Drug
INH‡
†
**
MDR-TB
Susceptibility Resistance Resistant
No. (%)
Results*
No. (%)
No. (%)
Foreign-Born Cases
U.S.-Born Cases
660
132
97 (15)
12 ( 9)
75 (11)
8 ( 6)
12 ( 2)
4 ( 3)
Total
792
109 (14)
83 (10)
16 ( 2)
§
* Culture-confirmed cases with drug susceptibility results available
† Resistance to at least one first-line anti-TB drug [i.e., isoniazid (INH), rifampin, pyrazinamide (PZA), or ethambutol]
** INH-resistant cases (also may have resistance to other drugs)
‡ Multi-drug resistant TB, with resistance to at least INH and rifampin
§ Two
of these cases were resistant to INH, rifampin, PZA, and ethambutol.
Percentage of Cases
Tuberculosis Cases by Site of Disease and
Place of Birth, Minnesota, 2004-2008
100
90
80
70
60
50
40
30
20
10
0
(63%)
(47%)
(53%)
(37%)
Foreign-Born
Pulmonary
U.S.-Born
Extrapulmonary*
* Includes cases with both extrapulmonary and pulmonary sites of disease
Foreign-Born Tuberculosis Cases by Interval
Between Arrival in U.S. and Diagnosis of
Tuberculosis, Minnesota, 2003-2007
Interval (years)
Cases
No. ( %)
<1
1-2
3-5
>5
Unknown
Total
247 (28)
170 (19)
165 (19)
296 (33)
9 ( 1)
887 (100)
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
• Epidemiology
• Migrant trends
• Programmatic opportunities
• Summary
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
CDC Plan to Combat Extensively Drug-Resistant TB
• Unless the fundamental causes of MDR TB and
XDR TB are addressed in the United States and
internationally, the United States is likely to
experience a growing number of cases of MDR TB
and XDR TB that will be difficult, if not impossible
to treat or prevent.
MMWR 58: 13 Feb 2009 RR-3
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
2006 WHO Stop TB Strategy
1. Pursue high-quality DOTS expansion
•
•
•
•
•
Political commitment with increased and sustained funding
Case detection rate through quality-assured bacteriology
Standardized treatment, with supervision and patient support
An effective drug supply and management system
Monitoring and assessment system, and impact measurement
2. Address TB/HIV, MDR-TB, and other challenges
•
•
•
Implement TB/HIV collaborative activities
Prevent and control MDR-TB
Address prisoners, refugees, and other high-risk groups, and
special situations
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Summary
•
World population is increasing and more mobile
•
Drug-resistance is man-made
•
Increased screening in conjunction with
international initiatives (STOP-TB, GLC, GLIEXPAND TB) is critical
Treatment of Migrants with Tuberculosis in
an Era of Emerging Drug Resistance
Summary
•
World population is increasing and more mobile
•
Drug-resistance is man-made
•
Increased screening in conjunction with
international initiatives (STOP-TB, GLC, GLIEXPAND TB) is critical