Assessing TB Mortality and Related Factors in the State of Maryland Leah Froehle JHSPH PHASE Intern
Background • Each year, around 10 million worldwide people become ill with TB. • Mortality rates are high in those who are not treated. • TB is the leading cause of death from a single infectious agent and one of the top ten overall causes of death worldwide. • In 2018, 1.5 million people died from TB and it remains a public health crisis. Image source: The United States Centers for Disease Control, 2017.
TB in the US and Maryland, 2018 • In the US, there were 9,025 reported incident cases of TB in 2018 for an overall US incidence rate was 2.8 per 100,000 persons per year. • Of the 9,025 reported cases of TB in the US in 2018, 6,276 (69%) of reported cases were observed in non-US born residents of the US. • The US incidence rate of TB among non-US born residents was 14.2 per 100,000 persons per year. • Maryland reported 208 incident cases of TB for an incidence rate of 3.4 per 100,000 persons per year. • The TB incidence rate among non-US-born residents of Maryland was reported as 19.7 per 100,000. • US-born residents in Maryland have a TB incidence rate of 0.7 per 100,000. Image source: The United States Centers for Disease Control, 2018.
TB Mortality Assessment • Although US TB incidence is decreasing overall, the TB mortality rate in the United States has hovered around 0.2/100,000 since 2003. • In many states, TB death and its contributing factors are not yet well- studied. • This project aims to better illustrate the distribution of persons who were diagnosed with TB at death or who died while on treatment, and what factors contribute to this distribution in Maryland. Image source: The United States Centers for Disease Control, 2018.
Why Assess TB Mortality? • Responsible and conscientious public health practice • Allows us to better identify people at highest risk for TB mortality • Regular review of TB deaths at the state-level, even in low incidence areas, provide situational awareness of TB • These systematic reviews can help guide death prevention policy and intervention frameworks Image source: The United States Centers for Disease Control, 2014.
Methods • Using NEDSS, we identified TB patients who were diagnosed with TB after death or died while on treatment from 2015 until 2016. • TB patient records will be reviewed at relevant local health departments, and hospitals if needed, for information regarding severity of disease. • Using the above NEDSS data in conjunction with medical records, the TB death classification tool developed by the California Department of Public Health will be used to determine TB-relatedness of those who died on treatment or who were diagnosed at death.
Basic Demographic Characteristics of Maryland TB Patients 2015-2016, Survivors and Decedents Image source: https://geology.com/county-map/maryland.shtml
Diagnostic Characteristics of Maryland TB Patients 2015- 2016, Survivors and Decedents • Chest x-ray results in 92.3% of decedents were listed as abnormal • Chest x-ray results in 73.3% of survivors were listed as abnormal • 83.3% of chest x-rays among decedents showed no evidence of cavitary disease and 87.5% showed no evidence of miliary disease • This same pattern is observed in CT scan results • This warrants review of medical records
Logistic Regression Results • In this study, the reported OR can approximate RR because the prevalence of death was 6.6%. • Older age, being male, US-born, excess alcohol use, kidney disease, and homelessness were all significantly associated with an increased risk for death from TB. • Being non-US-born appears protective in the univariate for death from TB, but this is not significant in the multi-variate model • This might warrant further investigation.
Limitations and Challenges • This is a retrospective study, so it is subject to selection bias such as misclassification and underreporting. • Cross-sectional studies cannot directly assess causal interactions. • The study population of 26 decedents is relatively small, which limits the conclusions we can make with regard to the analysis. • The study population is specific to Maryland, and these findings may not be generalizable to other US states and territories depending on the underlying demographic structure of each population. • Case reviews are currently incomplete due to COVID-19
Policy and Practice Implications • Risk factors for TB death should not be considered static, but rather constantly evolving as the underlying age structure of a population and its overall demographic profile shift over the years. • A regular review will not only allow TB prevention staff to better understand TB- relatedness of death beyond NEDSS data and beyond the dichotomy of dead at diagnosis or died on treatment. • Gives a better understanding of overall health trends of a state’s population. • Systematic reviews can help guide death prevention policy and intervention frameworks by increasing awareness of those most at risk for TB death. • Within a well-defined framework alongside healthcare providers, epidemiologists, and other TB experts to intervene properly and in a timely manner.
Future Work • Pending COVID-19 status, chart reviews should be completed • Pending completion of medical chart reviews, the CA classification tool should be used to better understand TB-relatedness of death among TB patients
References The U.S. Government and Global Tuberculosis Fact sheet. US Global Health Policy. 2019. [Last accessed on 2019 Nov 20]. Available from: http://www.kff.org/globalhealth/upload/7883-05.pdf The World Health Organization 2019 Global Tuberculosis Report. 2019. [Last accessed on 2019 Nov 2019]. Available from: https://apps.who.int/iris/bitstream/handle/10665/329368/9789241565714-eng.pdf?ua=1 Centers for Disease Control and Prevention (CDC). Reported tuberculosis in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2015. Waitt CJ, Squire SB. A systematic review of risk factors for death in adults during and after tuberculosis treatment. Int J Tuberc Lung Dis. 2011;15:871–85. Anyama N, Bracebridge S, Black C, Niggebrugge A, Griffin SJ. What happens to people diagnosed with tuberculosis? A population-based cohort. Epidemiol Infect. 2007;135:1069–76. Sprinson J, Bahl M, Benjamin R, et al. TB death assessment tool in California: development and pilot test. TB Notes 2008; 4: 9- 13. http://www.cdc.gov/tb/publications/newsletters/notes/TBN_4_08/Highlights.htm#2 Accessed January 2020. Tiemersma EW et al. Natural history of tuberculosis: duration and fatality of untreated pulmonary tuberculosis in HIV- negative patients: A systematic review. PLoS ONE, 2011, 6(4): e17601. Talwar A, Tsang CA, Price SF, et al. Tuberculosis — United States, 2018. MMWR Morb Mortal Wkly Rep 2019;68:257–262. DOI: http://dx.doi.org/10.15585/mmwr.mm6811a2
Acknowledgements I thank Lisa Paulos and Allie Pyan and everyone who welcomed me as a PHASE intern at the Maryland Department of Health Center for TB Control and Prevention. Lisa and Allie’s immense support and leadership throughout the course of this project instilled my passion for disease prevention and public health research. I also thank the Maryland Department of Health for continuing this unique and important partnership with the Bloomberg School of Public Health.
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