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Quarantine and Border Health Services Branch Division of Global Migration and Quarantine

Tuberculosis (TB) among Travelers Arriving into the United States, 2006-2009. Quarantine and Border Health Services Branch Division of Global Migration and Quarantine 2011 USPHS Scientific and Training Symposium: New Orleans, LA. William L. Jackson, MD, PhD, MSPH, MA

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Quarantine and Border Health Services Branch Division of Global Migration and Quarantine

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  1. Tuberculosis (TB) among Travelers Arriving into the United States, 2006-2009 Quarantine and Border Health Services Branch Division of Global Migration and Quarantine 2011 USPHS Scientific and Training Symposium: New Orleans, LA William L. Jackson, MD, PhD, MSPH, MA CAPT, Commissioned Corps, U.S. Public Health Service National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine

  2. Presentation Overview Outline the distribution of TB in the United States and globally with respect to travelers who are infectious with TB Report on travelers who are infectious with TB as documented using the CDC Quarantine Activity Reporting System (QARS)

  3. Geographic Distribution of Mycobacteriumtuberculosis (MTB)

  4. TB Cases, United States, 1993-2008 Overall TB rate: 4.2 per 100,000 FB 20.6/100K US 2.1/100K Div. TB Elimination (CDC/OID/NCHHSTP) : www.cdc.gov/tb/topic/research/TBESC

  5. TB Case Count and Rate* Among U.S.- and Foreign-born Persons, by Year — United States, 1993–2010 * Per 100,000 population. Data are updated as of Feb 26, 2011 and are provisional.

  6. Foreign-born US Residents Reported with TB in United States -- 2009 Countries of Origin Age Distributions <15 yrs (6%) >65 yrs (20%) 15–24 yrs (11%) 45–64 yrs (30%) 25–44 yrs (34%) Philippines (12%) www.cdc.gov/tb/topic/research/TBESC

  7. Quarantine Activity Reporting System (QARS) • Secure Web-based system used to track diseases of public health interest and activities at CDC Quarantine Stations: • Reports of ill and deceased passengers • Inspections of passengers, cargo, and conveyances • Monitoring shipments of nonhuman primate & drugs • Immigrant and refugee processing • Partnership activities: diseases of public health interest • Other • Administrative log of CDC and partner responses to travel-related events or incidents

  8. CDC Quarantine Stations by Jurisdictions Field offices for responding to and documenting illness in travelers AK ME Minneapolis Seattle Chicago VT NH Anchorage WA Boston MA ND MT Detroit RI NY MN CT CT MI WI New York NJ OR PA ID SD Newark DE WY MD Philadelphia IA OH NE IN No.CA WV IL Washington, D.C. NV VA San Francisco UT KY CO MO KS NC TN Dallas SC So.CA OK AR Atlanta NM AZ Los Angeles AL North TX GA MS San Diego East TX LA West TX El Paso FL Houston Miami Honolulu PR HI GU San Juan CDC Quarantine Stations

  9. QARS Report Types for Diseases of Public Health Interest • Illness reported during travel • Illness reported after travel completed • Death reported during travel • Land border crossing • Other information

  10. Diseases of Public Health Interest • Quarantinable* • Smallpox, Cholera, Plague, Viral Hemorrhagic Fevers, Infectious Tuberculosis, Yellow Fever, Diphtheria, SARS, Novel Influenza Virus (pandemic potential) • Public Health Concern (examples) • Rabies, malaria, dengue, measles, mumps, rubella, varicella, meningococcal, zoonotic poxvirus, polio, legionellosis, pertussis * Executive Order 13375: Revised List of Quarantinable Communicable Diseases, President George W. Bush, April 1, 2005

  11. Objectives • Review of analysis methodology for tuberculosis surveillance • Reports on TB in travelers documented using the CDC Quarantine Activity Reporting System (QARS) • Characteristics and trends of travelers with infectious TB • Baselines and trend changes for TB reporting

  12. METHODOLOGY Tuberculosis Surveillance Definitions in the CDC Quarantine Activity Reporting System (QARS)

  13. Major QARS Report Categories for Travel-Related TB Surveillance Air Sea Land

  14. American Thoracic Society (ATS) CDC TB-Classification System Tuberculosis StatusStage • No TB exposure Class 0† • TB exposure Class 1† • Latent TB infection Class 2† • Active TB disease Class 3‡ • Clinically inactive TB Class 4† • TB suspect Class 5* TB-Class: † No-active (inactive) ‡Active *Temporary(deleted)

  15. QARS Tuberculosis Report Confirmation Clinical criteria Laboratory criteria Confirmation requires direct or indirect evidence of ALL clinical elements in QARS records Clinical (AFB+) specimen MTB complex detection by nucleic acid amplification (NAA) OR culture Acid-fast bacilli (AFB+) sputum smear TB skin test Chest x-ray Culture Nucleic acid amplification Anti-TB therapy Medical exam

  16. Selected Timelines • QARS activated and current CDC Quarantine Station configurations set by end 2005 • Analysis dates 01JAN2006 - 31DEC2009 permit multiple end point analysis • Yearly trends between traveler demographics • Monthly comparisons for TB activity class • Contrast of pre/post-effects and comparisons for 2007 media events on TB(+) traveler(s) • Time segments permit use of USDoT BTS travel statistics to estimate rates (denominators)

  17. TB in Travelers Arriving in US: Analysis Methods 2006-09

  18. RESULTS Tuberculosis Surveillance

  19. Annual Volume of QARS TB Reports comparedwith Traveler Volumes, 2006-2009 (N=873) *Source: Bureau of Travel Statistics (BTS) of the US Department of Transportation

  20. Active-TB Case Reports in relation to Travel, 2006-2009 (N=949)

  21. *US Customs = CBP of US DHS, Federal = all US Government agencies excluding CBP

  22. Novel H1N1 TB(+) Traveler Media Event TB infected travelers recorded in QARS Illness Reports 01JAN2006-31DEC2009

  23. Countries of Origin for Persons Reported with TB in United States Passport Proportions by country of origin travelers with TB recorded in QARS: 2006-2009 Mexico (13%) Philippines (10%) Other Countries (58%) India (8%) China (4%) Vietnam (3%) (1.5%) Ethiopia/Kenya Pakistan Korea (2%)

  24. TB infected travelers recorded in QARS Illness Reports 01JAN2006-31DEC2009

  25. Countries of Origin for Persons Reported with TB in United States Foreign-born US Residents 2009 Travelers recorded in QARS 2006-09 Mexico (13%) Philippines (10%) Other Countries (58%) India (8%) China (4%) Philippines (12%) Vietnam (3%) Korea (2%) (1.5%) Ethiopia/Kenya/Pakistan www.cdc.gov/tb/topic/research/TBESC

  26. QARS TB Reports, by Age: 2006-09 Foreign-born US Residents 2009 Travelers recorded in QARS 2006-09 <15 yrs (3%) <15 yrs (6%) >65 yrs (16%) 15–24 yrs (16%) >65 yrs (20%) 15–24 yrs (11%) 45–64 yrs (25%) 45–64 yrs (30%) 25–44 yrs (34%) 25–44 yrs (40%) http://www.cdc.gov/tb/topic/research/TBESC

  27. Monthly TB Report Trends for Active v. Non-active Cases, Adjusted for Travel Volume Active Slope1 p < 0.10 Non-Active Slope2 p < 0.01 TB(+) Traveler Media Event 2006 2007 2008 2009

  28. Summary • Countries of citizenship for travelers with TB reported in QARS consistent with • WHO estimates of TB incidence by country • TB in foreign-born US residents • TB-reporting to CDC Quarantine Stations increased significantly after high-profile media events in May 2007 • Sustained for Active TB disease > inactive disease • Difference persisted into 2009

  29. Limitations • QARS functions as a passive surveillance system for communicable diseases • Reliant on reportage of partners outside of CDC • Reflects only fractions of actual infected travelers • Passports act as surrogates to traveler countries-of-origin • Unable to precisely discern microbial origins • Unable to discern any episodes of microbial transmission

  30. Conclusions • Majority of TB cases reported in QARS were active pulmonary disease • Majority of all TB cases reports came from state or local public health partners after travel completed • Increased TB-reporting rates after 2007 may reflect enhanced Federal, State and local public health surveillance partnerships for infectious TB in travelers • Sustained growth in pre-travel reports from public health partners (2008-09) likely reflect the institution of a public health “Do Not Board” program by CDC

  31. Next Steps • Conduct further evaluation to characterize high-risk travelers who are not included in current pre-travel screening systems (e.g. , students, temporary workers) • Additional analyses will establish baseline TB report rates and inform strategies to control TB in travelers and prevent spread to US communities

  32. Acknowledgments Division of Global Migration and Quarantine and Quarantine Station Officers Daniel Fishbein Nina Marano Brian Miars An Nguyen LaTonia Richardson Chris Schembri Ciji Adams Francisco Alvarado-Ramy Kirsten Buckley Peter Houck Tonyka Jackson Curi Kim Laura Leidel Brian Schmidt Paige Szymanowski

  33. Questions? William L. Jackson, MD, PhD, MSPH, MA CAPT, U.S. Public Health Service Commissioned Corps National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine

  34. International Health Regulations (June,2007) • Global agreements about procedures to protect public health • Adopted at the World Health Assembly & binding on all WHO’s Member States (unless they reject or reserve) • Legal language in a document containing 66 articles and 9 annexes • Supported by technical (compliance) guidelines www.who.int/ihr/en/

  35. Illness Reports in QARS, 2010 (N=2,003)

  36. TB Cases reported in QARS, by age, 2006-2009 F-statistic = 3.2291: T-Statistic = 1.7970 (GENDER) = 6.3370 (df 1) p<0. 0728

  37. Major QARS Report Categories for TB Surveillance • Illness Reported During Travel • Ill individual reported before s/he reached final destination • Individuals who are currently on a conveyance (airplane, cruise ship, etc) at a port or otherwise in transit • Illness Reported After Travel Completed • Death Reported During Travel • Land Border Crossing • Other Information

  38. Major QARS Report Categories for TB Surveillance • Illness Reported During Travel • Illness Reported After Travel Completed • Ill individual reported after s/he reached his/her final destination for a leg of a trip • Frequently but not always a residence • Death Reported During Travel • Land Border Crossing • Other Information

  39. Major QARS Report Categories for TB Surveillance • Illness Reported During Travel • Illness Reported After Travel Completed • Death Reported During Travel • Land Border Crossing • Other Information • Captures activities or events that do not fit prior report types • Examples: Before Travel Illness, public health Do Not Board and Lookout Lists, Foreign Notification of Case/Contact, Human Remains

  40. Modi, et al; Clin. Inf. Dis. 2009:49 885 1 June 2006 – 31 May2008

  41. TB Reports by Quarantine Station, 2006-09 2006 mean

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