Tuberculosis Update for Indiana Sang Thao, MPH, TB Epidemiologist TB/Refugee Health Epidemiology Resource Center March 25, 2019

Reported Tuberculosis (TB) Cases and Rates United States, 1993-2017 National data Decline in the U.S. *Prelim: 2018 data from CDC, 9029 cases in 2018. Decrease from 9094 cases in 2017. IR = 2.76. Lowest case counts in the U.S. Ever recorded. CDC Reported Tuberculosis in the United States, 2017

Number of Tuberculosis Cases Indiana, 2009-2018 Stagnant trend within 10 years. 116 cases reported in 2018. 16% increase from 2017. Incidence rate of 1.7 per 100,000 persons in 2018. This is an increase from 1.5 in 2017. Unfortunately, This increase was 2nd highest in the nation behind Ohio (15.5% increase). Rank 32nd in 2017. Below nat’l avg

Indiana TB cases County numbers Marion County: 38 cases 5 38 16 Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vander burgh Verm. Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur DeKalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St Joseph Indiana TB cases County numbers Marion County: 38 cases St Joseph County: 16 cases Allen County: 8 cases Lake County: 8 cases Tippecanoe County: 8 cases Total counties reported cases Increases in counties of 3+ cases

TB Cases and Incidence Rates 84 11 7 19 5 39 14 31 22 10 20 8 60 18 9 408 46 26 17 Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vander burgh Verm. Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur DeKalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St Joseph TB Cases and Incidence Rates 10-year Period of 2009-2018 10 yr trends Marion County: 408 cases Allen County: 84 cases Lake County: 60 cases St Joseph County: 46 cases Elkhart County: 39 cases IR and case counts in 10 yrs

TB Cases by Site of Disease, Indiana, 2018 Extrapulmonary sites Lymphatic Pleura Meningeal Peritoneal Genitourinary Ocular Pulmonary is most common reported site of disease Proportion of pulmonary cases remain steady from 2017 to 2018, 72% reported in both years. Extrapulmonary cases increased slightly from 14% to 16% in 2018

TB Case Rates by Age Group Indiana, 2014-2018 Compare trends Proportion of cases in older individuals IR highest in older

Number of Pediatric TB Cases by Age Group, Indiana, 2014-2018 Talk trend Indicative of recent transmission Demographics of children cases

TB Cases by Hispanic Ethnicity and Non-Hispanic Race, Indiana, 2018 The incidence rate of tb in Asians remain highest in Indiana. 2.3% of the population but make up 28.4% of total tb cases. IR of Asians are 19.8 per 100,000 people IR in Ha/PI = 76.8 per 100,000 population (1 case) IR in Black = 5.4 per 100,000 population IR in White = .7 per 100,000 population Hispainc latino 3.7% of IN population, account for 15.5% of TB cases. IR Hispanic = 3.7 per 100,000 population IR Non-Hispanic = 1.6 per 100,000 population

Number of TB Cases by Place of Birth, Indiana, 2014-2018 IR 5 year trend: 18.9 per 100,000 compared to .8 per 100,000 persons in 2018 56.9% of cases occurred in those born outside of U.S.. Only make up 5% of IN total pop. Top 5 Countries: Burma India Mexico Nigeria Malawi

Percentage of TB Cases with HIV Comorbidity, Indiana, 2009-2018 HIV comorbidity importance (increased risk of progression) Talk trend Proportion of cases with HIV test results known

Most Common Risk Factors Indiana, 2018 Percent Diabetes 15.5% Contact to infectious TB case 10.3% Alcohol use 9.5% Non injection drug user 8.6% Immunosuppression (not HIV/AIDS)

Percentage of TB Cases by Drug Resistance, Indiana, 2014-2018 Trend 97.7% of culture positive gets DST. Above nat’l average of 90.6%. Continues to be in high 90’s

TB Treatment Indicators Indiana, 2017-2018 Percent of Cases National Average Program Goal Initiate RIPE (2018) 91.1% 92.4% 96.0% Culture Conversion <60 Days (2017) 71.1% 62.9% 72.0% Completion of Therapy <1 year (2017) 96.4% 80.5% 95.0% Completed ever 97.6 Colored base on meeting program goal. Red=Not Met. Green=Met.

Number of TB Deaths Indiana, 2014-2018

TB Mortality, Indiana, 2018 Average age in years Alive: 42 years Died from TB: 60 years Average length of treatment Alive and completed: 210 days Died from TB: 18 days

Percentage of Cases by Site of Disease and Mortality Status, Indiana, 2018 Sites include Lymph nodes, meningeal, spleen, rectum, small intestine

Percentage of TB Cases by Hispanic Ethnicity/Non-Hispanic Race and Mortality Status, Indiana, 2018

Percentage of TB Cases by Place of Birth and Mortality Status, Indiana, 2018

Genotyping Indiana, 2018 97.7% of culture positive cases were genotyped 52.4% of genotyped cases were identified as part of a cluster Six cases were identified and confirmed as part of recent transmission Three cases were linked to a case with last exposure >3 years This does not include clinical cases where we could not use dna data to match cases

Genotype Lineage Indiana, 2018  Number of Cases EuroAmerican  40 East Asian  12 IndoOceanic 9 East African Indian 4 Bovis (not BCG) 2 Africanum 1 Lineage Unknown 16

Contact Investigation, Indiana, 2017 AFB + Sputum (387 Contacts) Program Goal AFB – Sputum, Culture + (128 Contacts) Contacts Elicited 100.0% 92.0% Contacts Evaluated 83.5% 75.0% 85.2% LTBI Treatment Initiated 90.0% 93.0% 87.5% LTBI Treatment Completed 87.3% 65.0% Indiana continues to excel in CI 387 evaluated 70 with LTBI (3 ATB) Cx + 128 contacts evaluated 8 LTBI Colored base on meeting program goal. Red=Not Met. Green=Met.

LTBI, Indiana, 2018 Preliminary data 73/92 counties reported a case of LTBI 41 of those counties had 5 or more 2,048 LTBI reported Marion, Tippecanoe, Allen, Elkhart and St. Joseph reported most LTBI Marion County accounts for approximately 58% of all reported LTBI cases Increase focus on LTBI surveillance nationally

Summary Indiana TB burden increased in 2018 Second highest incident rate increase nationally TB mortality has increased over past five years Proportion of U.S.-born cases increased This trend matches national data Continued success in TB treatment and case management indicators HIV testing Contact investigations Completion of treatment

Questions? sthao@isdh.in.gov 317.233.7841 Sang Thao, MPH TB Epidemiologist sthao@isdh.in.gov 317.233.7841