HomeMy WebLinkAbouttuberculosis-in-alameda-county-2012-archivePage 1Published March 2013.
Tuberculosis in Alameda County, 2012
Alameda County Public Health Department
In this report, data for Alameda County excludes the
City of Berkeley which is its own health jurisdiction
and reports independently. Alameda County’s TB
case rate for 2012 was 9.5 per 100,000 residents, 1.6
times the California rate of 5.8, ranking fourth among
all jurisdictions in the state. Compared to other Bay
Area jurisdictions, the rate in Alameda County ranks
lower than San Francisco and Santa Clara counties, but
higher than Contra Costa, San Mateo and Marin coun-
ties, and the City of Berkeley (Figure 1).
Tuberculosis Overview
Tuberculosis (TB) is a preventable and curable disease that remains one of the leading causes of death worldwide. TB is a
communicable disease caused by the bacteria Mycobacterium tuberculosis and spreads from person-to-person when the
bacteria is released into the air by a person with active TB disease. Transmission can occur when others breathe in the
bacteria while in close and prolonged contact with a person with infectious TB. Although TB most oft en aff ects the lungs, it
can aff ect any part of the body.
Once TB bacteria have been inhaled, that person may become infected with TB. In most cases, the body is able to keep the
bacteria from growing, but will still show evidence of exposure or infection. In persons with latent TB infection (LTBI),
the TB bacteria in the body remain alive but inactive, and cannot be spread to others. Individuals with latent TB infection
have a 5-10% chance of developing TB disease over their lifetime. For some, TB infection can progress to TB disease when
the immune system cannot fi ght off the bacteria. Both LTBI and TB disease are medically treatable, but can cause serious
illness or death if TB disease goes untreated. Th e treatment regimens can take at least six to nine months, possibly longer if
the strain is drug resistant or if the individual is co-infected with other diseases.
Tuberculosis can infect anyone who lives, works, and breathes in proximity to active cases – regardless of age, sex, race, or
socioeconomic status. However, it disproportionately aff ects the poor, homeless, and other socially marginalized groups
who live in overcrowded conditions and/or lack access to healthcare. Poor nutrition, substance abuse, and co-infection
with diabetes, cancer, HIV and other conditions that weaken the immune system can increase the risk of developing TB
disease. Poverty can limit access to TB health services and essential supports that promote treatment adherence, like having
family support in taking medication or transportation to medical appointments.
Approximately one-third of the world’s population, or over 2 billion people, are infected with TB, with an estimated 8.7
million new cases of TB and 1.4 million deaths in 2011. Over 90% of TB cases and TB deaths worldwide are concentrated
in resource-poor developing nations where multiple risk factors such as war, poverty, overcrowding, malnutrition, and
insuffi cient TB control infrastructure make TB endemic. Increased global trade, travel, and population mobility have con-
tributed to the spread of tuberculosis. Migration from countries with high TB prevalence has led to high rates of TB among
foreign-born populations in the United States, California, and Alameda County.
Alameda County TB Cases and Rates
Figure 1. TB Case Rates for California
and San Francisco Bay Area Jurisdictions, 2012
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Page 2 Published March 2013.
In 2012, there were 136 tuberculosis cases in Alameda
County, a 3.0% increase from the previous year (Figure 2).
Th ere were 2,189 TB cases in California, a 5.8% decrease in
cases across the state from the previous year. Four Bay Area
jurisdictions – Alameda, San Francisco, Marin, and the
City of Berkeley - experienced increased numbers of cases,
while Contra Costa, San Mateo, and Santa Clara reported
decreases in TB cases in 2012. Th e rate in Alameda County
is consistently higher than TB rates for California and the
U.S. (Figure 3).
TB Cases by Sex
In 2012, males comprised 54.4% of TB cases while females
made up 45.6% (Table 1). Th e average annual rate among
males during 2010-2012 was 12.7 per 100,000, 1.5 times the
rate of females (8.5) (Table 2).
TB Cases by Age Group
In 2012, the greatest proportion of incident tuberculosis
cases occurred among adults, age 45-64 years (30.9%), with
87% of TB cases among individuals 25 years and older. Ad-
ditionally, individuals ages 65 years and older had the great-
est risk of having TB with a 2010-2012 average case rate of
26.2 per 100,000 (Table 2).
In 2012, there were six pediatric TB cases (children under
15 years), of which three cases occurred in very young
children 0-4 years old (Table 1). Cases among very young
children oft en indicate recent local transmission of tubercu-
losis, and thus are of particular concern.Table 2. TB Cases and Average Case Rates
2010-2012, Alameda County
Number
of Cases
(n=346)
Average Case
Rate per
100,00
Sex Males 263 12.7
Females 183 8.5
Age Group 0-4 yrs 9 n/a
5-14 yrs 13 2.4
15-24 yrs 41 7.8
25-44 yrs 127 10.0
45-64 yrs 132 11.5
65+ yrs 124 26.2
Race/
Ethnicity
Non-Hispanic
Black*
52 10.1
Asian/PI 294 24.8
Amer Ind/Native AK 0 n/a
Latino 65 6.4
White 35 2.6
Figure 3. Annual TB Case Rates, 1993-2012
Alameda County, California and U.S.
Table 1. Incident TB Cases, 2012 Alameda County
Number
of Cases
(n=136) Percent
Sex Males 74 54.4
Females 62 45.6
Age Group 0-4 yrs 3 2.2
5-14 yrs 3 2.2
15-24 yrs 12 8.8
25-44 yrs 39 28.7
45-64 yrs 42 30.9
65+ yrs 37 27.2
Race/
Ethnicity
Non-Hispanic
Black*
17 12.5
Asian/PI 90 66.2
Amer Ind/Native AK 0 0.0
Latino 18 13.2
White 11 8.1
0
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15
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Alameda Co California U.S.
Figure 2. Annual TB Cases, 1993-2012
Alameda County
200
238 234
192
223 224 241
196 199
178
250
300
158 143 154 141 149 134
156
132 136
0
50
100
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Page 3Published March 2013.
Tuberculosis Cases by Race/Ethnicity
In 2012, people of color comprised 91.9% of TB cases
countywide compared to 86.1% in 1993. Of the TB cases in
2012, 66.2% were among Asians/Pacifi c Islanders (Figure
4). Latinos accounted for 13.2% of cases in 2012, while
Non-Hispanic Blacks* and Non-Hispanic Whites comprised
12.5% and 8.1% of tuberculosis cases respectively (Table 1).
In the period 2010-2012, Asian/Pacifi c Islanders had the
highest average annual case rate (24.8 per 100,000), more
than double the rate among Non-Hispanic Blacks (10.1),
nearly four times that of Latinos (6.4), and nine times the
rate for Non-Hispanic Whites whose average annual case
rate was 2.6 (Table 2).
In 2012, the majority of the foreign-born incident cases
occurred among Asian/Pacifi c Islanders (78.4%) and Lati-
nos (11.7%). Among U.S.-born cases, the largest number
occurred in Non-Hispanic Blacks (40.0%), followed by
Non-Hispanic Whites (28.0%), U.S.-born Latinos (20.0%),
and Asian/Pacifi c Islanders (12.0%) (Figure 5).
TB Cases by Place of Birth
Foreign-born residents account for an increasing propor-
tion of annual TB cases in Alameda County. In the early
1990s, TB cases were almost evenly split between foreign-
and U.S.-born persons. By 2012, 82% of TB cases occurred
among the foreign-born. Th e most frequently reported
countries of birth were the Philippines, China, India, Viet-
nam, and Mexico (Figure 6).
Th e average annual case rate in 2010-2012 for foreign-born
individuals in Alameda County was 26.8 per 100,000 resi-
dents, over eight times the rate for individuals born in the
United States (3.1).
Other Characteristics of TB Cases
TB bacteria can cause disease in the lungs (pulmonary TB)
or in other parts of the body (extra-pulmonary TB) such as
lymph nodes, bones and joints, and the brain or spinal cord.
While the majority (61.8%) of the TB cases reported in 2012
were pulmonary cases, 31.6% were extra-pulmonary, and
5.9% were both pulmonary and extra-pulmonary. Of the
92 pulmonary cases, 45 (48.9%) were smear-positive and
32 (34.8%) had evidence of cavitary disease, both of which
indicate a high level of infectiousness.
Figure 4. Annual Percent of TB Cases by Race/Ethnicity,
Alameda County, 1993-2012
Figure 5. TB Cases by Place of Birth and Race/Ethnicity,
Alameda County, 2012
Figure 6. Incident TB Cases by Place of Birth
Alameda County, 2012
US
18%Other
26%
Philippines
16%
China
15%
India
13%Mexico
6%
Vietnam
6%
50%
60%
70%
80%
al
T
B
C
a
s
e
s
Non-Hispanic White Non-Hispanic Black
Hispanic Asian/PI
0%
10%
20%
30%
40%
19
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%
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28%
40%
20%
12%
U.S.Ͳborn
NonͲHispanicWhite NonͲHispanicBlack Latino/
Hispanic
Asian/PI
4%6%
12%
78%
ForeignͲborn
*For purposes of this report, Non-Hispanic Black refers to both immigrant
Non-Hispanic Africans and Non-Hispanic African Americans.
Page 4 Published March 2013.
In the 12 months prior to their TB diagnosis, fi ve (3.7%) of
the 2012 cases had used alcohol excessively, four (2.9%) had
used non-injection drugs, and two (1.5%) reported injection
drug use. Th ree (2.2%) had been in a long-term care facility
within one year prior to diagnosis, and two (1.5%) reported
having been in correctional facilities. While three (2.2%) TB
cases in 2012 had been homeless in the year prior to their
TB diagnosis, others became displaced from their housing
as a result of their diagnosis, and the TB program assisted in
providing housing for a dozen individuals in 2012.
Seven (5.1%) of the 136 cases were known to be co-infected
with with HIV/AIDS. HIV is the most important risk fac-
tor for progression from latent TB infection to TB disease,
and TB is the leading cause of death among HIV-infected
individuals.
Directly observed therapy (DOT) is a strategy where a
trained healthcare worker or other designated individual
watches the ingestion of every prescribed dose of medica-
tion. Patients who are highly infectious or at risk for drug
resistance or failure to adhere to treatment are assigned an
outreach worker who observes them ingest each dose of
medication. DOT has been proven to reduce the numbers
of new TB infections each year and has been associated with
the decreased development of drug resistant strains of TB.
In 2012, 78 (57.4%) of cases received DOT for all or some
portion of their treatment. For many other TB patients,
therapy is self-administered throughout the course of treat-
ment.
More than one-third of 2012 TB cases were among Oakland
residents. In the south county, the cities of Fremont and
Hayward reported the greatest proportion of cases, with
15.4%, and 14.0% respectively. Th e east county (Dublin,
Pleasanton, and Livermore) comprised 8.1% collectively.
Th e areas in the county with the highest average annual
rates for 2008-2012 are in Oakland’s downtown, Fruitvale,
and San Antonio neighborhoods (Figure 7).
TB Drug Resistance
Drug resistance can occur when the bacteria become
resistant in a person whose TB disease was inadequately or
inappropriately treated, or can be acquired directly from
someone with a drug resistant strain of TB. Individuals with
drug resistant TB undergo longer and more complicated
courses of treatment. Th irteen (9.6%) of the 136 TB cases in
2012 were resistant to at least one of the anti-tuberculosis
medications (Figure 8). Multi-drug resistant (MDR) TB
is resistant to at least Isoniazid (INH) and Rifampin, the
two most potent anti-TB medications. One MDR TB case
was identifi ed in 2012, and 34 MDR TB cases have been
reported in Alameda County since 1993. Of these, 94% oc-
curred among foreign-born individuals.
Figure 7. Alameda County TB Rates by ZIP, 2008-2012
Page 5Published March 2013.
New Immigrants to Alameda County
Before obtaining a visa to enter the United States, docu-
mented immigrants and refugees from countries with high
rates of TB undergo a pre-departure tuberculosis screening
in accordance with the Centers for Disease Control and
Prevention (CDC) 2007 Technical Instructions, a policy
supported by Alameda County Public Health Department.
Th e state or local health jurisdiction is notifi ed of the arrival
of each immigrant or refugee classifi ed overseas with a TB
condition requiring follow-up TB evaluation upon arrival in
the U.S., and the individual is advised to report to their local
health department.
In 2012, 470 new arrivers requiring TB evaluation were
reported to Alameda County by the CDC’s Division of
Global Migration and Quarantine (Figure 9). Alameda
County comprised 4% of the state’s population, but received
approximately 7% of California’s new arrivers in 2012 who
required follow-up TB evaluation. Alameda County diff ers
from the state with a smaller proportion of individuals
coming from Mexico, and a larger proportion arriving from
China (Figure 10).
TB Control Program in Action
In its eff orts to prevent and reduce TB transmission
throughout the county, the Alameda County TB Control
Program prioritizes work in three core areas:
1) Identifying persons who have active TB and ensuring
treatment completion, with the provision of DOT for
higher-risk subgroups such as the highly infectious, multi-
drug resistant, HIV co-infected, or homeless;
2) Finding, testing and evaluating persons who might have
been exposed to active TB cases to identify secondary cases,
then facilitating and linking to care those persons with
confi rmed latent or active TB; and
3) Conducting targeted testing among other subgroups who
are especially vulnerable to TB (e.g., newly arrived immi-
grants from countries with high TB rates).
In addition to these core areas, the TB Control Program is
working at individual, community, and policy levels to im-
prove outcomes in terms of tuberculosis and overall health
and health equity by:
Reaching out to healthcare providers, hospitals, schools,
correctional facilities, and various local organizations to
educate the community about tuberculosis;
Working with vulnerable clients to ensure they are
linked to essential resources that support treatment
•
•
Figure 9. New Arrivers Requiring TB Evaluation
Alameda County, 2001-2012
Figure 8. Percent TB Cases Resistant to any TB Meds, INH,
and MDR Resistance, Alameda County, 1993-2012
Figure 10. New Arrivers Requiring TB Evaluation
by Country of Origin, 2012
269 2 4 326 298
391 438
520
432 470
400
500
600
equ
i
r
i
n
g
TB
io
n
220 220
0
100
200
300
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
#of
Ar
r
i
v
e
r
s
R
Ev
a
l
u
a
t
Philippines
47%
Vietnam
13%
China
18%
India
4%
Mexico
3%Other
15%
Alameda
Philippines
48%
Vietnam
11%
China
11%
India
2%
Mexico
16%
Other
12%
California
0
5
10
15
20
25
19
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3
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9
4
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5
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9
6
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7
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1
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Pe
r
c
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n
t
Resistant to any TB Meds INH Resistant MDR
Page 6 Published March 2013.
Acknowledgments
Th is brief was produced by the Alameda County
Public Health Department (ACPHD)
Muntu Davis, MD, MPH
Health Offi cer and Director, ACPHD
Erica Pan, MD, MPH
Deputy Health Offi cer and Director, Division of Communicable
Disease Control and Prevention, ACPHD
Sandra Huang, MD
TB Controller and Communicable Disease Controller, ACPHD
Susan Sawley, RN, BSN
TB Program Manager, ACPHD
Alex Briscoe
Director, Health Care Services Agency
Comments and questions can be directed to:
TB Control Program
Alameda County Public Health Department
Eastmont Town Center
7200 Bancroft Way, #202
Oakland, California 94605
(510) 577-7000
www.acphd.org
This report was prepared by
Elaine Bautista, MPH
CAPE Unit, ACPHD
Data Sources
For information on TB in California
http://www.cdph.ca.gov/data/statistics/Pages/TuberculosisDis-
easeData.aspx
adherence, such as medical insurance, food, housing,
and transportation;
Forging partnerships with community service providers
to make sure clients, upon treatment completion, are
transitioned into necessary ongoing support, such as a
permanent medical home, housing assistance, or drug
rehabilitation;
Collaborating with HIV care providers to appropriately
manage patients co-infected with HIV by connecting
them to critical services like Medi-Cal or housing as-
sistance;
Finding permanent medical homes for patients with
co-morbidities, in need of preventative services, or for
patients who request assistance.
Beyond the TB Control Program, the Alameda County
Public Health Department (ACPHD) is taking action to
address economic and social conditions that are root causes
of TB and overall health inequities. ACPHD is involved
in a national Place Matters (PM) initiative, working col-
laboratively with multiple sectors to advance health equity
through community-centered local policy focused in fi ve
key areas, including: 1) economics, 2) education, 3) hous-
ing, 4) criminal justice, and 5) land use and transportation.
Specifi cally supporting tuberculosis control:
Th e PM Economics workgroup is continuing to develop
a County banking policy that will expand access to
•
•
•
•
non-predatory fi nancial services in underserved
neighborhoods and ensure that the bank that Alameda
County does business with gives back to underinvested
communities. Alameda County helped the City of Oak-
land update its Linked Banking Ordinance to include
requirements that banks disclose detailed lending data,
including any ties to predatory fi nancial services located
in Oakland. By helping to protect income and build
wealth at individual and community levels, this policy
would address poverty – a major TB risk factor that
drives up rates of infection and progression to disease
Th e PM Housing workgroup is helping the City of
Oakland to transform code enforcement services to
proactively address substandard housing conditions
that threaten public health and safety. Alameda County
researched new models of code enforcement that are
more focused on preventing conditions that harm
health and presented fi ndings to Oakland City staff and
a Building Services Improvement Taskforce. On Sep-
tember 29, 2012 the Oakland City Council’s Commu-
nity and Economic Development Committee approved
the Task Force’s recommendations to move forward
with piloting this model. Resulting improvements in
housing conditions could help to reduce vulnerability
to major public health problems – like TB, asthma,
and lead poisoning – and support better treatment
adherence among vulnerable subgroups in unstable,
unhealthy housing situations.
•