New York City's Experience in Controlling Tuberculosis

Turning the Tide: New York City’s
Experience in Controlling Tuberculosis
Douglas Proops, MD, MPH
Deputy Director of Surveillance and Epidemiology
Bureau of Tuberculosis Control
New York City Department of Health and Mental Hygiene
23 Maart 2012
World TB Day 2012, Rotterdam Edition
Urban Tuberculosis Control
1

Objectives
Background on New York City (NYC)
Review NYC Department of Health
and Mental Hygiene (DOHMH)
Tuberculosis (TB) Control Structure
Recent history of NYC TB Control
• Crisis in the early 1990’s
• Financial and programmatic measures
implemented
• Current situation
2

Nicknames and Motto
The Big Apple
Manhattan on
the Meuse
3

Comparing NYC to Rotterdam
and the Netherlands (2010)
New York Rotterdam Netherlands
Population 8,175,133 603,425 16,574,989
Population Density (per km 2 ) 10,348 2,850 491
% Foreign Born 37 48 19
Largest Group (%) Dominicans (7) Other European (11) German (2)
Next Largest (%) Chinese (5) Surinamese (9) Indonesian (2)
Per Capita Income ($US) $50,285 43,750 (2006) 46,915
% Below Poverty Line 19 17 11 (2005)
4

Medical Care in NYC
Public and private hospitals
• Services at public hospitals are not “free”,, but access
cannot be denied on ability to pay
Few “free” clinics run by DOHMH
• TB Control (BTBC)
• Sexually Transmitted Disease Prevention and Control
• Immunization
Medical insurance
• Government insurance for poor or elderly only for
citizens or permanent “aliens”
• Private insurance typically sponsored/subsidized by
employer
• Self-pay (un-insured)
5

New York City Health
Department
6

Selected Highlights
(Protecting Public Health in NYC: 200 Years of Leadership, NYCDOH, 2005)
1855 - Board of Health established
1870 – Department of Health created
1892 – 1 st municipal laboratory in world
1904 – TB clinics open
1906 – municipal TB sanitorium opens
1926 – chest radiographs @ TB clinic
1985 – free anonymous AIDS tests
1988 – needle exchange program
7

NYC Health Department
Health Department organized into Division
Division of Disease Control includes:
• Bureau of TB Control (BTBC)
• Communicable Disease
• HIV/AIDS Prevention and Control
• Immunization
• Sexually Transmitted Disease Prevention and Control
• Public Health Laboratory
• Viral Hepatitis Coordination
8

BTBC Organization Structure
9

CDC Cooperative Agreement
5-year grant that supports prevention,
control and elimination activities
• no clinical services
Dollar amounts are not cost adjusted
• 1992 - $6 million
• 1993 - $25 million
• 1999 - $25 million
• 2001 - $19 million
• 2005 - $14 million
• 2012 - $9 million
47% CDC cooperative grant
11% city tax levy
42% New York state
10

TB Control in
New York City
Where We Were – 1980’s s and
early 1990’s
11

Tuberculosis Cases and Rates
New York City, 1978 - 1991
4000
Case Rate
60
Number of cases
3500
3000
2500
2000
1500
# Cases
50
40
30
20
Rate/100,000
1000
500
10
0
0
78 79 80 81 82 83 84 85 86 87 88 89 90 91
Year
12

TB Media Coverage in NYC
Early 1990s
13

Causes of Resurgent TB in NYC
HIV/AIDS epidemic
Decline of public health infrastucture
Poor infection control in hospitals and
correctional facilities
Poor treatment practices
Lack of accessible care
Rising rates of poverty, homelessness,
substance abuse, crowding in congregate
settings
Immigration from high incidence countries
14

• 1990
• 1992
• 2010
HIV/AIDS Epidemic
HIV serostatus part of surveillance database
>6000 AIDS deaths
>10,000 new AIDS diagnoses
34% of TB cases co-infected
1700 AIDS deaths
3500 new HIV/AIDS diagnoses
8% of TB cases co-infected
• HIV status ascertained for 83%
• 2011
Sharing of HIV status now permitted from HIV/AIDS
Prevention and Control
15

Decline of Public Health
Infrastructure
• 1988
• 1994
• 2011
140 staff
8 TB clinics (up to 24 previously)
$4 million budget
>600 staff
10 TB clinics
10 fold increase of budget to $40 million
240 staff
5 TB clinics
$19 million budget
16

Poor Infection Control Practices in
Hospitals and Correctional Facilities
• 1991
• 1994
• 2011
MDR-TB outbreaks in hospitals and correctional
facilities with MDR-TB cases in healthcare workers
4% cases felt due to nosocomial transmission
140 room contagious disease unit opens @ Rikers jail
increased use of airborne isolation units in hospitals

• 1991
• 1994
• 2011
Poor Treatment Practices
previously, inconsistent drug susceptibility methods
and patient selection mandatory drug susceptibility
and reporting for all first positive cultures
inadequate treatment regimens and case
management
90% first positive cultures have drug sensitivity
data
IRPE standard empirical treatment and directly
observed therapy (DOT) established as standard of
care
cohort review implemented
90% treatment completion
above measures maintained
90% treatment completion
18

Lack of Accessible Health Care
• 1991
Combined public health and chest clinics in
municipal and voluntary hospitals disbanded
Public hospitals and clinics (Health and
Hospitals Corporation or HHC)
• not free
• financial assistance and charity care are available
without regard to immigration status
• $15 per visit for family of four with income
between $58,000 and $69,000
• 2011
HHC
• 11 hospitals, 4 skilled nursing, 6 diagnostic
centers, 70 community based clinics
• 1.3 million patients, 475,000 uninsured
19

Poverty, Homelessness, Crowding in
Congregate Settings, Substance Abuse
• 1985
• 1991
homelessness included in surveillance
database
TB screening implemented by Department
of Homeless Services
housing opportunities expanded for HIV
infected individuals and family members
through city housing services without
regard to immigration status
large city shelters or single-room
occupancy hotels begin to be closed or
downsized
20

March 1992

Immigration from High
Incidence Countries
•Foreign-born now constitute 80% of all TB
cases
•CDC has implemented TB screening as a
requirement for permanent visa applicants from
high TB incidence countries upon arrival,
immigrants referred to TB clinics for further
evaluation and treatment
•BTBC launched the “Foreign-born Initiative” in
2010 to identify needs and resource gaps
among two foreign-born groups of particular
concern (Tibetan and Mexicans)
22

Case Managment
23

Cohort Review
Bureau director reviews all cases in a
particular borough that were diagnosed
from 3-63
6 months previously on a quarterly
basis
Formalized case presentations provided by
case manager (non-clinician)
Aspects of treatment, and contact
investigation reviewed
Identified issues are reviewed for
resolution at subsequent cohort
24

NYC Health Code
Establishes legal authority of Health Department
to obtain medical records of TB suspects, cases,
and contacts
Reporting - both providers and laboratories
(clinical and pathology) required to report (now
electronic)
Mandatory conduct of and reporting of drug
susceptibility (1991)
Mandatory genotyping (2001)

Genotyping
Early 1990’s – isolates from MDR-TB or those
associated with outbreaks genotyped
(spoligotype and IS6110
RFLP)
2001 – mandatory genotyping of culture + cases
Spoligotype + RFLP used to cluster cases
MIRU/VTNR also used (CDC funds nationwide)
Investigation tool for possible false positive
cultures (about 3% of cases)
Outbreak detection method
Establish epidemiological links independent of
contact investigation through cluster
investigation
26

Other BTBC Measures
Regulatory Affairs
• Bureau staff may obtain Commissioner of Health
“order” for non-adherent patients
• Various “orders” can be for: examination, DOT,
or detention
• Detained patients are kept in a locked hospital
ward until either cure is documented or the
patient deemed no longer a public health threat

Engaging Partners
• Initiated active surveillance and screening
for high-risk populations (especially
homeless) served by other NYC agencies
• Issued clinical guidelines and protocols,
strengthened outreach to healthcare
providers and community-based
organizations
• Collaborated with other public and/or
private organizations for programmatic
support and/or research
28

New York City
1992 to Current
TB Case Rates Decline!
29

Tuberculosis Cases and Rates
New York City, 1980 – 2011*
689 Cases in 2011
Number of Cases
4,000
Case Rate
3,500
# Cases 51.1
3,000
2,500
2,000 21.4
1,500
1,000
500
80
81828384858687888990919293949596979899000102030405060708091011
Year
Rate/100,000
60
50
40
30
8.5 20
10
0
*Rates since 2000 are based on population estimates and 2010 Census data.

U.S.* and Foreign-Born Cases and Case Rates †
New York City, 1992 - 2011
31

Selected Data
New York (2011) Netherlands (2010)
Incidence (per 100,000) 8.5 6.5
% Foreign-born 80 74
% Any Pulmonary 75 55
Sputum smear positive rate 2.8 1.2
% Culture Positive (all) 71 73
% HIV Co-infected 8 4
% HIV Status Ascertained 78 34
% Treatment Completion 90* 83
% INH-resistant # 8 5
% MDR #

The Netherlands vs. New York City
2010 TB incidence per 100,000 population
The
Netherlands
New York City

Selected Bibliography
Munsiff, SS, et. al. . Ensuring accountability: the contribution of the
cohort review method to TB control in NYC. IJTLD 2006;
10(10): 1133-1139.
1139.
Frieden, TR. Lessons from TB control for public health. IJTLD
2009;13(4):421-428.
428.
Frieden TR, et al. . Tuberculosis in New York City—turning turning the tide. N
Engl J Med 1995; 333: 229–233.
233.
Gasner, MR, et al. . The use of legal action in NYC to ensure
treatment of TB. NEJM 1999; 340 (5): 359-66.
Perri, BR, Proops D, et al. M. tb Cluster with Developing Drug
Resistance, New York, NY, USA, 2003-2009. 2009. EID 2011 Mar; 17 (3):
372-8.
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Many Thanks!
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