HomeMy WebLinkAbouttuberculosis-in-alameda-county-2013-archivePage 1Published March 2014
Tuberculosis in Alameda County, 2013
Alameda County Public Health Department
TB Cases and Rates
In this report, data for Alameda County excludes the
City of Berkeley, which is its own health jurisdiction
and reports cases separately. Alameda County’s TB
case rate for 2013 was 7.9 per 100,000 residents, rank-
ing fifth 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 is higher than San Mateo, Contra
Costa and Marin counties (Figure 1).
In 2013, there were 114 cases of TB in Alameda
County, a 16.2% decrease from the previous year.
The number of cases in Alameda County has been
decreasing overall since its most recent peak of 241
cases in 2000 (Figure 2). A lesser decrease in cases was
observed in California. There were 2,170 reported TB
cases in California in 2013, a 0.9% decrease from the
previous year. Alameda, San Francisco, and Marin ju-
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 often affects the lungs,
it can affect 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. TB infection can progress to TB disease when the immune
system cannot fight off the bacteria. TB disease can cause serious illness or death especially if treatment is delayed. Treat-
ment regimens can take at least six to nine months, possibly longer if the strain is drug resistant or if the case is co-infected
with other diseases.
Tuberculosis can infect anyone who lives, works, and breathes in close proximity to active cases, regardless of age, sex, race,
or socioeconomic status. However, it disproportionately affects 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 HIV, diabetes, cancer, or 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 get to medical appointments.
Approximately one-third of the world’s population, or over 2 billion people, are infected with Mycobacterium tuberculosis,
with an estimated 8.6 million new cases of TB and 1.3 million deaths in 2012. Over 90% of TB cases and TB deaths world-
wide are concentrated in resource-poor developing nations where multiple risk factors such as war, poverty, overcrowding,
malnutrition, and insufficient TB control infrastructure make TB endemic. Increased global trade, travel, and population
mobility have contributed to the spread of tuberculosis. Migration from countries with high TB prevalence has led to rising
rates of TB among foreign-born populations in the United States, California, and Alameda County.
Figure 1. TB Case Rates for California
and San Francisco Bay Area Jurisdictions, 2013
5.7 7.9
5.3 5.1
12.9
7.8 9.8
0
4
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16
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CA Alameda
County
Contra
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Marin
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San
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San Mateo
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Santa
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Page 2 Published March 2014
risdictions experienced decreased numbers of cases as well,
while Contra Costa, San Mateo, and Santa Clara reported
increases in TB cases in 2013. The rate in Alameda County
is approximately 40% higher than the California rate of 5.7
per 100,000 residents and has been consistently higher than
state and national rates (Figure 3).
TB Cases by Sex
In 2013, males comprised the majority (64%) of TB cases
(Table 1). The average annual rate among males during
2011-2013 was 10.9 per 100,000, 1.5 times the rate of fe-
males (7.1) (Table 2).
TB Cases by Age Group
In 2013, 92.2% of TB cases occurred among individuals age
25 and over with the greatest proportion of incident tuber-
culosis cases among adults, age 65 years and over (32.5%).
Cases among very young children often indicate recent
transmission of tuberculosis, and thus are of particular
concern. There were two pediatric cases of TB in children
under 15 years during 2013, one of which occurred in a
very young child, 0-4 years old (Table 1).
Individuals ages 65 and over also have the greatest risk of
having TB as they age and their immune systems weaken.
This age group had the highest average case rate of 23.9 per
100,000 during 2011-2013 (Table 2).
Table 2. TB Cases and Average Case Rates 2011-2013,
Alameda County
Number
of Cases
(n=382)
Average Case
Rate per
100,000
Sex Males 228 10.9
Females 154 7.1
Age Group 0-4 yrs 7 n/a
5-14 yrs 10 1.9
15-24 yrs 29 5.5
25-44 yrs 104 8.1
45-64 yrs 115 10.1
65+ yrs 117 23.9
Race/
Ethnicity
Non-Hispanic Black*41 8.1
Asian/PI 267 22.7
Amer Ind/Native AK 1 n/a
Latino 48 4.7
White 25 1.8
Figure 3. Annual TB Case Rates, 1993-2013
Alameda County, California and U.S.
Table 1. Incident TB Cases
Alameda County, 2013
Number
of Cases
(n=114)Percent
Sex Males 73 64.0
Females 41 36.0
Age Group 0-4 yrs 1 0.9
5-14 yrs 1 0.9
15-24 yrs 7 6.1
25-44 yrs 32 28.1
45-64 yrs 36 31.6
65+ yrs 37 32.5
Race/
Ethnicity
Non-Hispanic Black*11 9.6
Asian/PI 82 71.9
Amer Ind/Native AK 1 0.9
Latino 15 13.2
White 5 4.4
Figure 2. Annual TB Cases, 1993-2013
Alameda County
158
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Alameda County California U.S.
Page 3Published March 2014
TB Cases by Race/Ethnicity
People of color make up an increasing proportion of TB
cases, comprising 95.6% of TB cases in 2013, compared
to 86.1% in 1993. These cases were predominantly among
Asians and Pacific Islanders, who made up 71.9% of new
TB cases in 2013 and who consistently comprise the largest
proportion of TB cases in Alameda County (Figure 4).
Latinos accounted for 13.2% of cases, while Non-Hispanic
Blacks* and Non-Hispanic Whites comprised 9.6% and
4.4% of tuberculosis cases respectively (Table 1).
In the period 2011-2013, Asian/Pacific Islanders had the
highest average annual case rates (22.7 per 100,000), almost
three times the rate among Non-Hispanic Blacks (8.1),
nearly five times that of Latinos (4.7), and twelve times the
rate for Non-Hispanic Whites whose average annual case
rate was 1.8 (Table 2).
The distribution of TB case among racial/ethnic groups
varies by place of birth. In 2013, the majority of the
foreign-born incident cases occurred among Asians/Pacific
Islanders (82.3%) and Latinos (13.5%). By comparison,
Non-Hispanic Blacks made up the largest group of U.S.-
born TB cases (44.4%), followed by Non-Hispanic Whites
(22.2%), U.S.-born Asian/Pacific Islanders (16.7%) and
Latinos (11.1%)(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 2013, 96 of the 114 TB cases
(84.2%) occurred among foreign-born. Individuals most
often came from the Philippines, China, Vietnam, Mexico,
and India (Figure 6).
The average annual case rate in 2011-2013 for foreign-born
individuals in Alameda County was 23.3 per 100,000 resi-
dents, over ten times the rate for individuals with TB who
were born in the United States (2.3).
Other Characteristics of TB Cases
TB bacteria can cause disease in the lungs (pulmonary TB)
or in other parts of the body such as lymph nodes, bones
and joints, and the brain or spinal cord (extra-pulmonary
TB). While the majority (64.9%) of the TB cases reported in
2013 were pulmonary cases, 26.3% were extra-pulmonary,
and 8.8% were both pulmonary and extra-pulmonary. Of
the 84 pulmonary cases, 47 (56.0%) were smear positive and
27 (32.1%) 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, 1993-2013
Figure 5. TB Cases by Place of Birth and Race/Ethnicity,
Alameda County, 2013
Figure 6. Incident TB Cases by Place of Birth
Alameda County, 2013
*For purposes of this report, Non-Hispanic Black refers to both immigrant
Non-Hispanic Africans and Non-Hispanic African Americans.
0%
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Non‐Hispanic White Non‐Hispanic Black
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China
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Mexico
7.0%
Vietnam
6.1%
Other
20.2%
Page 4 Published March 2014
In the 12 months prior to their TB diagnosis, seven (6.1%)
of the 2013 cases had used alcohol excessively, ten(8.8%)
had used non-injection drugs, and no cases reported injec-
tion drug use. Four (3.5%) had been in a long-term care
facility within one year prior to diagnosis, and six (5.3%)
reported having been in correctional facilities. While three
(2.6%) TB cases in 2013 reported being homeless, many
became displaced from their housing as a result of their TB
diagnosis. The TB program assisted in providing housing
for nine individuals in 2013.
Six (5.3%) of the 114 cases in 2013 were known to be
co-infected with HIV/AIDS. HIV is the most important
risk factor 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 shown to improve TB treatment
completion rates and to reduce the development of drug
resistance and treatment relapse. In 2013, 70 (61.4%) cases
received DOT for all or some portion of their treatment.
For many other TB patients, therapy is self-administered
throughout the course of treatment.
Residents of Oakland comprised 30.1% of TB cases in 2013.
In the southern portion of the county, the cities of Fremont
and Hayward reported the greatest proportion of cases,
with 22%, and 15% respectively. Dublin, Pleasanton, and
Livermore in the eastern portion of the county collectively
comprised 9.6% of TB cases. The areas in the county with
the highest rates 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 was inadequately or inappro-
priately 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.
Twelve (10.5%) of the 114 TB cases in 2013 were resistant to
at least one of the anti-tuberculosis medications, of which
eight (7.0%) were resistant to Isoniazid (INH) (Figure 8).
Multi-drug resistant (MDR) TB is a strain of TB resistant
to at least Isoniazid and Rifampin, the two most potent
anti-TB medications. There were no MDR cases in Alameda
County in 2013, but there has been a total of 34 MDR cases
since 1993. Of these MDR cases, 94% occurred among
foreign-born individuals.
Figure 7. Alameda County TB Rates by Zip, 2009-2013
Page 5Published March 2014
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 pre-departure tuberculosis screening
in accordance with the Centers for Disease Control and
Prevention (CDC) 2007 Technical Instructions, a policy
supported by the Alameda County Public Health Depart-
ment. The state or local health jurisdiction is notified of the
arrival of each immigrant or refugee classified overseas with
a TB condition requiring follow-up TB evaluation upon
arrival in the U.S., and the individual is advised to report to
his/her local health department.
In 2013, 401 new arrivers requiring TB evaluation were re-
ported to Alameda County by the CDC’s Division of Global
Migration and Quarantine (Figure 9). Alameda County
comprises 4% of the state’s population, but received 7% of
California’s new arrivers in 2013 who required follow-up TB
evaluation. Alameda County differs from the state, with a
smaller proportion of individuals arriving from Mexico and
a larger proportion arriving from China (Figure 10).
TB Control Program in Action
In its efforts 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
confirmed 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
improve outcomes in terms of TB disease, 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
adherence, such as medical insurance, food, housing,
and transportation;
• Forging partnerships with community service providers
to make sure clients, upon treatment completion, are
Figure 9. New Arrivers Requiring TB Evaluation
Alameda County, 2001-2013
Figure 8. Percent TB Cases Resistant to any TB Meds,
INH Resistance and MDR Resistance,
Alameda County, 1993-2013
Figure 10. New Arrivers Requiring TB Evaluation by
Country of Origin, 2013
220 269 220
294 281 326 298
391 438
513
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Philippines
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India
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Mexico
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Alameda
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Vietnam
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China
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India
3.0%
Mexico
13.0%
Other
14.0%
California
Page 6 Published March 2014
Acknowledgments
This brief was produced by the Alameda County
Public Health Department (ACPHD)
Muntu Davis, MD, MPH
Health Officer and Director, ACPHD
Erica Pan, MD, MPH
Deputy Health Officer 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
1000 Broadway, 5th Floor
Oakland, California 94607
(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/
TuberculosisDiseaseData.aspx
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, those 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 five
key areas, including: 1) economics, 2) education, 3) housing,
4) criminal justice, and 5) land use and transportation.
Specifically supporting tuberculosis control:
• The PM Economics workgroup is working with com-
munity partners to develop a proposal for Alameda
County to support the creation of an affordable small
lending program to help low-income families stabilize
their finances and build positive credit and financial
skills. By helping to protect income and build wealth
at individual and community levels, this policy would
address poverty, a TB risk factor.
• The 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. Resulting im-
provements 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.