TB In Philadelphia: Current Trends, Changing Demographics Barry Dickman, MPA Director Philadelphia TB Control Program M. Christina Dogbey, MPH Philadelphia TB Control Program Epidemiologist Overview • Philadelphia TB Program Overview • Philadelphia TB Epidemiology • Disease Burden • Risk factors • Drug resistance 1
Percentage of TB Program Budget By Source 18% City State Federal 57% 25% Total funding for FY 2011: $1,524,260 Source: TB Cooperative Agreement, State TB Grant, Philadelphia City Budget TB Case Management Model Disease Surveillance Investigator (DSI) Involvement Compliance Home/ Clinic Agreement and Directly Observed Legal Process Therapy Active Social Monthly Physician TB Patient Worker Visits in clinic Involvement Regular Review of Enablers for Clinic Therapy Regimens by Visits (e.g. subway Medical Director tokens) 2
TB Epidemiology • Disease Burden • Risk Factors – Foreign born – Substance Abuse – HIV status – Other TB Cases in Commonwealth of Pennsylvania: 2007-2011 • Average Philadelphia Case Rate: 7.7 cases per 100,000 population • Average Pennsylvania Case Rate: 42% 1.3 cases per 100,000 population 58% Philadelphia Cases Pennsylvania Cases (excluding Phila) Total Number of cases for the time period: 1397 Source: Pennsylvania National Electronic Disease Surveillance System (PA-NEDSS) 3
Philadelphia TB Cases 1947 to Present 3000 2500 2000 Cases 1500 1000 500 0 1947 1950 1953 1956 1959 1962 1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 Years Source: PA-NEDSS, Philadelphia TB Control Archives Philadelphia TB Cases: 2001-2011 180 162 160 149 147 144 133 140 129 Number of Cases 120 116 120 101 98 96 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Calendar Year Source: PA-NEDSS 4
Lawrence J. Flick Memorial Clinic Patient Visits 4500 4000 Number of Visits 3500 3000 2500 2000 1500 1000 500 0 2007 2008 2009 2010 2011 Year Source: Philadelphia TB Control Program Source: PA-NEDSS 5
Tuberculosis Case Rates 2001-2010: Philadelphia Compared with Other Large Cities 25 cases per 100,000 20 NYC LA population 15 CHI HOUS 10 PHNX PHIL 5 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Source: PA-NEDSS, CDC DTBE Reported Tuberculosis in the United States 2010 Philadelphia TB Cases by Race and Ethnicity: 2005-2011 70 60 Percent of Cases 50 White Non Hispanic 40 Black, Non Hispanic All races, Hispanic 30 Asian/Pacific Islander 20 10 0 2005 2006 2007 2008 2009 2010 2011 Count Year Source: PA-NEDSS 6
Number of Foreign vs. U.S. Born Cases of TB in Philadelphia 140 120 Number of Cases 100 80 60 40 20 0 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 9 9 9 0 0 0 0 0 0 0 0 0 0 1 1 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 Calendar Year Source: PA-NEDSS U.S. Born Foreign Born Philadelphia TB Foreign Born Patients Representing World Health Organization Regions 2007-2011 Western Pacific 4% 5% African 15% 36% The Americas (not US) S.E. Asia European 21% 19% Eastern Mediterranean Source: PA-NEDSS 7
Culture Positive vs Clinical Cases 180 160 Number of Cases 140 120 100 80 60 40 20 0 1 2 3 4 5 6 7 8 9 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 Calendar Year Culture Positive Clinically Confirmed Source: PA-NEDSS Risk Factors Associated with TB Disease in Philadelphia Cases: 2005-2010 60 50 Percent of Cases 40 30 20 10 0 HIV Positive Substance Born outside Other* Status Abuse of the U.S. Risk Factor *homelessness, residence in a long term care facility or being incarcerated at the time of TB diagnosis Source: PA-NEDSS 8
Philadelphia TB Epidemiology: Risk Factors • HIV positive serostatus – 11% of Philadelphia TB cases were HIV positive 3 , compared with 1.2% of the general Philadelphia population 1 and 8.6%* of all TB cases in the nation (all ages) 4 * Reporting areas missing HIV data include: California, Georgia, Hawaii, Massachusetts, Vermont, Federated States of Micronesia and U.S. Virgin Islands • Substance Abuse (injecting drug use, non injecting drug use and alcohol abuse) – 24% of Philadelphia TB cases were using injecting, non injecting illicit drugs and/or abusing alcohol at time of diagnosis 3 – Nationally, 12.5% of TB cases were using injecting, non injecting illicit drugs and/or abusing alcohol 4 Philadelphia TB Epidemiology: Risk Factors (2) • Homelessness – 5% of cases were homeless at the time of diagnosis or had a history of homelessness 3 , compared with 1.2% of the Philadelphia population 2 – Nationally, 5.5% of TB cases were or had a history of homelessness 4 • Residence in Correctional Facilities – 1.7% of Philadelphia TB cases either were a resident in a correctional facility 3 , or had a history of incarceration compared with 0.5% of the Philadelphia population 2 – The national rate among TB cases is 4.1% 4 • Residence in Long-term Care Facilities – 3% of Philadelphia TB cases were either residing in or had a history of residence in long term care facilities (i.e. nursing homes, drug treatment facilities) 3 compared with 0.5% of the Philadelphia population 2 – The national rate among TB cases is 2.6% 4 9
Proportion of Drug Resistance in Positive Culture U.S. and Foreign Born Cases with Drug Sensitivity Testing: 2004-2011 25 20 15 Percent INH Resistance (U.S. Born) 10 INH Resistance (Foreign Born) Multi-drug Resistance (U.S. Born) 5 Multi-drug Resistance (Foreign Born) Rifampin Resistance 0 (U.S Born) 2004 2005 2006 2007 2008 2009 2010 2011 Rifampin Resistance (Foreign Born) Calendar Year Source: PA-NEDSS Conclusion • The demographics of TB in Philadelphia have changed considerably in the past few years • While the number of TB cases has dropped over the past few years, the proportion of cases that are foreign born continues to rise • Drug resistance is emerging as a challenge in managing TB in Philadelphia • We expect both of these trends to continue 10
References 1. AIDS Activities Coordinating Office: Philadelphia Department of Public Health. 2010 Epidemiological Annual Report . Retrieved from: http://www.phila.gov/health/pdfs/2010SurveillanceReportFinal.pdf 2. Census.gov. Commonwealth of Pennsylvania and Philadelphia County. Retrieved from: http://2010.census.gov/2010census/popmap/ipmtext.php?fl=42:42 001:42101 3. The Pennsylvania Version of the National Electronic Disease Surveillance System (PA-NEDSS) 4. CDC. Reported Tuberculosis in the United States 2010. Atlanta, GA: U.S. Department of Health and Human Services, CDC, October 2011. 11
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