Quarantine and Border Health Services Branch

Division of Global Migration and Quarantine2011 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 DiseasesDivision of Global Migration and Quarantine

Tuberculosis (TB) among Travelers Arriving into

the United States, 2006-2009

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)

Geographic Distribution of Mycobacterium tuberculosis (MTB)

TB Cases, United States, 1993-2008

Overall TB rate:4.2 per 100,000

FB 20.6/100KUS 2.1/100K

Div. TB Elimination (CDC/OID/NCHHSTP) : www.cdc.gov/tb/topic/research/TBESC

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

02468

10121416182022

0

5

10

15

20

25

30

35

40

45 No. of TB cases among U.S.-born persons No. of TB cases among foreign-born persons TB rate among U.S.-born persons TB rate among foreign-born persons

Year

Num

ber (

in th

ousa

nds)

Rate

* Per 100,000 population. Data are updated as of Feb 26, 2011 and are provisional.

TB Case Count and Rate* Among U.S.- and Foreign-born Persons, by Year — United States, 1993–2010

Age Distributions

Foreign-born US Residents Reported with TB in United States -- 2009

Countries of Origin

www.cdc.gov/tb/topic/research/TBESC

Philippines(12%)

<15 yrs(6%)15–24

yrs(11%)

25–44 yrs (34%)

45–64 yrs (30%)

>65 yrs (20%)

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

San Diego

VT

ME

MANY

PA

NH

WVVA

MD

NJ

RICT

AZ

IN

WI

KY

MI

OHIA

MN

MO

ILNE

KS

SD

ND

AL

TN

GA

SC

NC

AR

LA

MS

OKAtlanta

ChicagoSeattle

WYID

WA

AK

OR

MT

NVUT

NM

CO

East TX

Miami

FL

No.CA

So.CA

Los Angeles

San Francisco

HI

Honolulu

Washington, D.C.

El PasoHouston

NewarkNew York

Boston

GU

San Juan

Minneapolis

DetroitAnchorage

West TX

PR

Philadelphia

Dallas

North TX

CT

DE

CDC Quarantine Stations by Jurisdictions

Field offices for responding to and documenting illness in travelers

CDC Quarantine Stations

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

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

• 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

Objectives

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

METHODOLOGY

Major QARS Report Categories for Travel-

Related TB Surveillance

After TravelIllness reported after person reached final destination

Before Travel

Illness reported prior to initiation of transit

Sea Air

Land

During Travel

Illness/death reported while person in transit

American Thoracic Society (ATS) CDC TB-Classification System

Tuberculosis Status Stage• 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)

Clinical criteria = all below Lab criteria = any below

Clinical criteria Laboratory criteria

QARS Tuberculosis Report Confirmation

Chest x-ray

TB skin test

Medical exam

Anti-TB therapy

Culture

Acid-fast bacilli

(AFB+) sputum

smear

Nucleic acid amplification

Clinical (AFB+) specimen MTB complex detection by nucleic acid amplification

(NAA) OR culture

Confirmation requires direct or indirect evidence of ALL clinical elements in

QARS records

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)

Categorize

• 949 reports met TB case definition after medical officer review• SAS text-search with Medical Officer duplicate checks

Classify

• 873 TB-cases met American Thoracic Society definitions• Medical Officer consultation with Q-Stations or health departments

Analyze

• Confirmation reviews for report case definition assignment• Epi-info 3.5 analysis and evaluations

552,759QARS Entries

104,530 Illness Reports

6,596 TB-related Reports

Record extraction from QARS

Record rev iew

TB in Travelers Arriving in US: Analysis Methods

2006-09

Tuberculosis Surveillance

RESULTS

2006 2007 2008 20090

50

100

150

200

250

300

0

10

20

30

40

50

60

70

80

Active No-Active US-Inbound Traveler Vol.

Years

Case

Rep

orts

Trav

eler

Vol

ume

x 10

6

*

*Source: Bureau of Travel Statistics (BTS) of the US Department of Transportation

Annual Volume of QARS TB Reports compared with Traveler Volumes,

2006-2009 (N=873)

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

Before Travel During Travel After Travel0

50

100

150

200

250

300

350

400

2006 2007 2008 2009

Years

TB-C

ase

Repo

rts

Time PeriodsBefore TravelDuring TravelAfter Travel

Federal US Customs* Travel industry Health Dept. Care Provider International Other

Agency Sources for TB Reporting to CDC Quarantine Stations, 2006-2009 (N=949)

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

Comparison: TB and Other Illness Reports, 2006-2009

0

100

200

300

400

500

600

700

800

0

5

10

15

20

25

30

35

40

45

50

QARS

Illn

ess R

epor

ts

TB-R

epor

ts

Month

No-Active TB Active TB (Class 3) QARS Illness Reports

TB(+) Traveler Media Event

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

Novel H1N1

Passport Proportions by country of origin travelers with TB recorded in QARS: 2006-2009

Countries of Origin for Persons Reported with TB in United States

Philippines(10%)

Mexico(13%)

India(8%)

China(4%)

Vietnam(3%)

Korea(2%)

Other Countries(58%)

(1.5%)Ethiopia/KenyaPakistan

Countries of citizenship for non US-citizens with TB reported in QARS, 2006-2009

0

10

20

30

40

50

60

70

80

Active

Non-Active

CASES

COUNTRIES

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

Travelers recorded in QARS 2006-09

Countries of Origin for Persons Reported with TB in United States

Foreign-born US Residents 2009

www.cdc.gov/tb/topic/research/TBESC

Philippines(10%)

Mexico(13%)

India(8%)

China(4%)Vietnam(3%)

Korea(2%)

Other Countries(58%)

Philippines(12%)

(1.5%)Ethiopia/Kenya/Pakistan

QARS TB Reports, by Age: 2006-09

Foreign-born US Residents 2009

Travelers recorded in QARS 2006-09

http://www.cdc.gov/tb/topic/research/TBESC

<15 yrs(6%)15–24

yrs(11%)

25–44 yrs (34%)

45–64 yrs (30%)

>65 yrs (20%)

>65 yrs (16%)

<15 yrs(3%)

15–24 yrs(16%)

25–44 yrs (40%)

45–64 yrs (25%)

Ratios and Rates of Total TB Reporting to CDC Quarantine Stations, 2006-2009

Monthly 2006 2007 2008 2009

TB Reports per 10 0 QARS Illness Reports

6.67 [3.31]

13.74 [7.44]

15.44 [5.67]

8.97 [5.73]

TB Reports per Million Air Travelers

1.17 [0.47]

2.51 [1.56]

3.17 [0.99]

*3.22 [0.63]

M ean [Std. D eviation] *p < 0.001 (F-test)

Rates of Total TB Reporting to CDC Quarantine Stations, 2006-2009

Monthly Jan 06-May 07 Jun 07-Dec 09

TB Reports per 10 0 QARS Illness Reports 5.4 [2.6] *9.3 [4.7]

TB Reports per MillionAir Travele rs 1.18 [0.45] **3.18 [0.78]

M ean [Std. D eviation] *p < 0.001 **p < 0.001 (F-test)

Monthly TB Report Trends for Active v. Non-active Cases, Adjusted for Travel

Volume

0 10 20 30 40 50 600

0.5

1

1.5

2

2.5

3

Rate-ActiveRate-Non

MONTHS

Case

s pe

r Tr

avel

er x

106

Slope2 p < 0.01

Slope1 p < 0.10

TB(+) Traveler Media Event2006 2007 2008 2009

Active

Non-Active

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

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

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

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

Acknowledgments

Daniel FishbeinNina MaranoBrian MiarsAn NguyenLaTonia RichardsonChris Schembri

Ciji AdamsFrancisco Alvarado-RamyKirsten BuckleyPeter HouckTonyka JacksonCuri KimLaura LeidelBrian SchmidtPaige Szymanowski

Division of Global Migration and Quarantine and Quarantine Station

Officers

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Questions?

National Center for Emerging and Zoonotic Infectious DiseasesDivision of Global Migration and Quarantine

William L. Jackson, MD, PhD, MSPH, MA

CAPT, U.S. Public Health Service Commissioned Corps

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/

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

Illness Frequency (%)

H1N1/ILI 252 (31)Varicella 195 (24)

Tuberculosis 171 (21)Mumps 31 (4)Measles 30 (4)Malaria 27 (3)

Pertussis 22 (3)Dengue fever 18 (2)Typhoid fever 16 (2)

Cholera 12 (1)Meningococcal 12 (1)

Hepatitis 16 (1)Legionnaires’

disease9 (1)

YEAR FemaleActive

TB

FemaleInactive

TB

MaleActive

TB

MaleInactive

TB

TOTALS (Pct. Male)

N=873

2006 27 8 44 1897

(63.9%)

2007 47 31 99 49226

(65.5%)

2008 102 34 99 49284

(52.1%)

2009 79 29 105 53266

(59.4%)Pct(+)TB

MeanAge[StdDev]

29.2%40.9

[19.3]

11.7%40.7

[20.7]

39.7%43.6

[18.2]

19.3%41.2

[18.0]

100%42.1

[18.7]Chi-square: GENDER=6.3370(df 3 )p<0.0963; F-statistic=3.229: T-Statistic=1.797(df 1) p<0. 0728

MTB -Disease

ObservedCases

Mean Age

Std Dev

FemaleActive 241 40.9 19.3 MaleActive 380 43.6 18.2 FemaleNon-Active 94 40.7 20.7 MaleNon-Active 165 41.2 18.0

F-statistic = 3.2291: T-Statistic = 1.7970 (GENDER) = 6.3370 (df 1) p<0. 0728

TB Cases reported in QARS, by age, 2006-2009

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

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

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

Modi, et al; Clin. Inf. Dis. 2009:49 885

1 June 2006 – 31 May2008

TB Reports by Quarantine Station, 2006-09

2006 mean