The Epidemiology of Tuberculosis in Minnesota, 2013 – 2017

Minnesota Department of Health

Tuberculosis Prevention and Control Program

651- 201-5414 | www.health.state.mn.us/tb

2

TB Morbidity and Mortality, Minnesota, 2013-2017

Year No. of New Cases (Rate)* No. of TB Deaths (% of New Cases)**

2013 151 (2.8) 2 (1%)

2014 147 (2.7) 3 (2%)

2015 150 (2.7) 3 (2%)

2016 168 (3.0) 8 (5%)

2017 178 (3.2) 6 (3%)

* Cases per 100,000 population. Rates calculated using state population estimates from the U.S. Census Bureau.

**Represents only deaths due to TB disease or TB drug-induced toxicity; percentages based on the number of new TB cases

for each year

3

Active TB Cases Reported, Minnesota, 2000-2017

0

50

100

150

200

250

300

No

. of

New

TB

Cas

es

Mean = 185

4

TB Incidence Rates per 100,000 Population,United States and Minnesota, 2000-2017

0

1

2

3

4

5

6

7

Cas

es p

er

10

0,0

00

Year of Diagnosis

United States Minnesota

Healthy People 2010 and 2020 Objective (Rate = 1.0)

5

Percentage of Non U.S.-Born TB Cases, United States and Minnesota, 2008-2017

0

10

20

30

40

50

60

70

80

90

100

% o

f C

ases

Year of Diagnosis

United States Minnesota

MN Mean = 82%

U.S. Mean = 64%

TB Disease by County of Residence, Minnesota, 2017

Total 178

Hennepin County 70

Ramsey County 38

Suburban Metro 22

Greater MN 48

6

TB Disease by County of Residence, Minnesota, 2013-2017

Total 794

Hennepin County 302

Ramsey County 172

Suburban Metro 107

Greater MN 213

7

Number of Cases and Incidence of TB byLocation of Residence, Minnesota, 2013-2017

Location of Residence

2013No. (Rate)*

2014No. (Rate)*

2015No. (Rate)*

2016No. (Rate)*

2017No. (Rate)*

Hennepin County 51 (4.3) 51 (4.3) 57 (4.7) 73 (6.0) 70 (5.7)

Ramsey County 39 (7.5) 26 (4.9) 29 (5.4) 40 (7.4) 38 (7.0)

Suburban Twin Cities Metro†

20 (1.6) 24 (2.0) 25 (2.0) 16 (1.3) 22 (1.7)

Olmsted County 10 (6.8) 16 (10.7) 12 (8.0) 11 (7.3) 12 (7.8)

Greater Minnesota (excluding Olmsted)

31 (1.3) 30 (1.3) 27 (1.2) 28 (1.2) 36 (1.5)

Total 151 (2.8) 147 (2.7) 150 (2.7) 168 (3.0) 178 (3.2)

* Cases per 100,000 population. Rates calculated using state population estimates from the U.S. Census Bureau.† Anoka, Carver, Dakota, Scott, and Washington counties

8

TB Cases by Age Group and Place of Birth,Minnesota, 2013-2017

0

5

10

15

20

25

30

35

40

45

< 5 yrs 5 - 14 yrs 15 - 24 yrs 25 - 44 yrs 45 - 64 yrs >= 65 yrs

% o

f C

ases

Age Category

U.S.-Born Non U.S.-Born

9

TB Cases by Sex at Birth and Place of Birth,Minnesota, 2013-2017

0

10

20

30

40

50

60

Non U.S.-Born U.S.-Born Total

% o

f C

ase

s

Male Female

10

Number of Cases and Incidence of TB by Race*/Ethnicity,Minnesota, 2013-2017

0

5

10

15

20

25

30

2013 2014 2015 2016 2017

Cas

es p

er

10

0,0

00

**

American Indian or Alaska Native Asian or Pacific Islander African/African-American

White Hispanic/Latino (any race) All race/ethnic groups

*Race categories do not include persons of Hispanic/Latino ethnicity

**Rate per 100,000 population. Calculated using population estimates from the U.S. Census Bureau. 11

TB Cases by Race*/Ethnicity and Place of Birth,Minnesota, 2013-2017

Race / Ethnicity* Non U.S.-Born Cases No. (%)

U.S.-Born CasesNo. (%)

White 19 (3) 46 (34)

Black 352 (53) 36 (27)

Asian 240 (36) 11 (8)

American Indian / Alaska Native 0 19 (14)

Native Hawaiian / Pacific Islander 2 (<1) 0

Multi-racial 0 1 (<1)

Hispanic/Latino 47 (7) 21 (16)

Total 660 (100) 134 (100)

*Race categories do not include persons of Hispanic/Latino ethnicity

12

Non U.S.-Born TB Cases by Country of Birth,Minnesota, 2013-2017

Country of Birth No. of Cases (%)

Somalia 174 (26)

Ethiopia 89 (13)

Laos 64 (10)

India 42 (6)

Viet Nam 38 (6)

Kenya 29 (4)

Mexico 27 (4)

Other 197 (30)

Total 660 (100)

13

African/African-American TB Cases by Place of Birth,Minnesota, 2013-2017

Somalia45%

Ethiopia23%

US9%

Kenya7%

Liberia6%

Other10%

N = 38814

Asian/Asian-American TB Cases by Place of Birth,Minnesota, 2013-2017

Laos25%

India17%

Viet Nam15%

Philippines8%

Cambodia7%

Burma6%

China6%

US4%

Other12%

N = 25115

Non U.S.-Born TB Cases by Region of Birth and Year of Diagnosis, Minnesota, 2013-2017

0

10

20

30

40

50

60

70

80

90

2013 2014 2015 2016 2017

Nu

mb

er o

f ca

ses

Sub- Saharan Africa South/ Southeast Asia East Asia/ Pacific Latin America/ Caribbean Other*

* “Other” includes: Eastern Europe, North Africa/Middle East, and Western Europe16

Non U.S.-Born TB Cases byVisa Status Upon Arrival in the U.S., Minnesota, 2013-2017

Refugee45%

Immigrant30%

Other*19%

Unknown6%

* “Other” includes visitors, tourists, students, and those arriving on employment visas 17

N = 660

Non U.S.-Born TB Cases by Interval Between Arrival in U.S. and Diagnosis of TB, Minnesota, 2013-2017

< 1 year19%

1-2 years15%

3-5 years14%6-9 years

11%

10+ years41%

Unknown<1%

18

N = 660

“TB Class” Notifications* Among Refugees/Immigrants Diagnosed with TB within One Year After Arrival to U.S., MN, 2013-2017

No TB Class24%

Class B127%Class B2

6%

Unknown43%

* Per results of pre-immigration screening performed overseas 19

N = 90

TB Cases by Method of Case Identification,Minnesota, 2013-2017

Method of Identification No. of Cases (%)

TB symptoms 641 (81)

TB contact investigations 50 (6)

Overseas TB Class follow-up 25 (3)

Domestic refugee health exam 14 (2)

Other immigration exams 9 (1)

Other targeted testing 23 (3)

Employment screening (including health care workers)

11 (1)

Incidental chest X-ray or lab result 21 (3)

Total 794 (100)

20

21

TB Cases by Type(s) of Provider*, Minnesota, 2013-2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2013 2014 2015 2016 2017

% o

f C

ases

Public health Both public and private/other Private/other

* Some patients are managed by multiple providers throughout disease course

TB Cases by Risk Category* and Place of Birth,Minnesota, 2013-2017

0 5 10 15 20 25 30

Incarcerated

Long-term care resident

Homeless

Healthcare worker

Substance abuse†

Other medical risk factor**

HIV-infected

Travel to TB endemic area

Recent TB contact

% of Cases

All

U.S.-born

Non U.S.-born

*Risk categories are not mutually exclusive

**Conditions or therapies risk for progression to active TB disease, not including HIV/AIDS

†Excess alcohol use and/or injection or non-injection drug use 22

TB Cases With Other Medical Risk Factors*by Type of Risk Factor, Minnesota, 2013-2017

Medical risk factor**Cases (N=794)

No. (%)

Diabetes 115 (14)

Immunosuppressive condition (not HIV/AIDS) or therapy***

65 (8)

End stage renal disease 21 (3)

Weight loss/undernutrition/malabsorption 13 (2)

Other: e.g. chronic kidney disease, active smoking, hematologic disease

24 (3)

*Conditions or therapies that increase risk for progression from latent TB infection to active TB disease, not including

HIV/AIDS

**Patients could have > 1 medical condition

***Includes TNF α antagonist therapy and post-organ transplantation 23

TB Cases by HIV Status and Place of Birth, Minnesota, 2013-2017

HIV StatusNon U.S.-Born Cases

No. (%)U.S.-Born Cases

No. (%)Total

No. (%)

Negative 610 (92) 122 (91) 732 (92)

Positive 32 (5) 3 (2) 35 (4)

Not Offered 18 (3) 9 (7) 27 (3)

Total 660 (100) 134 (100) 794 (100)

24

HIV Testing in Persons with TB,Minnesota, 2008-2017

0

10

20

30

40

50

60

70

80

90

100

0

50

100

150

200

250 % o

f eligible TB

cases w/ H

IV resu

ltN

o. o

f el

igib

le T

B c

ases

*

No. of eligible cases* Percent of eligible cases with HIV result

National objective on HIV testing expandedto all TB patients starting in 2010

25*Alive at time of diagnosis

TB-HIV Co-infected Cases,United States and Minnesota, 2008-2017

0

1

2

3

4

5

6

7

8

9

10

% C

o-i

nfe

cted

Percent coinfection-U.S. Percent coinfection-MN

Year No. Co-infected in MN

2008 11

2009 7

2010 6

2011 3

2012 6

2013 4

2014 4

2015 9

2016 11

2017 7

26

U.S. Mean = 7%

MN Mean = 4%

TB Cases by Site of Disease, Minnesota, 2013-2017

Extrapulmonary33%

Both12%

Pulmonary55%

Top five extrapulmonarysites of disease*

Cases (N=357)**No. (%)

Lymphatic 199 (56)

Musculoskeletal 73 (20)

Pleural 37 (10)

Peritoneal 23 (6)

Genitourinary 15 (4)

27N = 794

* Patients may have multiple extrapulmonary sites of disease

** Includes TB cases with and without concurrent pulmonary disease

TB Cases by Site of Disease and Place of Birth, Minnesota, 2013-2017

0

10

20

30

40

50

60

70

80

90

100

Non U.S.-Born U.S.-Born All

% o

f C

ases

Pulmonary only Extrapulmonary*

* Includes cases with or without concurrent pulmonary disease28

29

TB Cases by Case Verification Criteria*, Minnesota, 2013-2017

N = 794

Lab-confirmed79%

Provider diagnosis3%

Clinical case definition

18%

*Based on the public health surveillance definition for TB [CDC. (2009, June) CDC Tuberculosis Surveillance Data Training: Report of Verified Case of Tuberculosis (RVCT) Instruction Manual. Atlanta, GA: U.S. Department of Health and Human Services,CDC. (Appendix A - Tuberculosis Case Definition for Public Health Surveillance)]

TB Cases by Mycobacterial Culture Result, Minnesota, 2013-2017

Positive for M.tbc78%

Negative for M.tbc*18%

Not done4%

30

N = 794

*No growth or growth of other Mycobacterium species not part of M.tb complex

TB Cases with Pulmonary Involvement byInitial Sputum AFB Smear Result, Minnesota, 2013-2017

Positive40%

Negative46%

Not done*14%

*59% of pulmonary cases without sputum smear results were under 15 years of age31

N = 534

TB Cases with Pulmonary Involvement by Chest Imaging* Result, Minnesota, 2013-2017

Normal< 1%

Abnormal, cavitary TB

31%

Abnormal, non-cavitary TB

67%

Abnormal, not consistent with TB

1%

* From initial chest x-ray or chest CT scan32

N = 534

TB Cases by Drug Susceptibility Patterns and Year,Minnesota, 2013-2017

* Culture-confirmed cases with drug susceptibility results available† Resistance to at least one first-line anti-TB drug [i.e., isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), or ethambutol (EMB)]** INH-resistant cases may also be resistant to other drugs‡ Multi-drug resistant TB, defined as resistance to at least INH and rifampin

Year

Cases With Susceptibility

Results*

Any DrugResistance†

No. (%)

INH-Resistant**

No. (%)MDR-TB‡No. (%)

2013 113 24 (21) 13 (12) 0 (0)

2014 105 25 (24) 19 (18) 1 (1)

2015 115 16 (14) 9 (8) 0 (0)

2016 136 29 (21) 19 (14) 8 (6)

2017 141 32 (23) 22 (16) 9 (6)

Total 610 126 (21) 82 (13) 18 (3)

33

TB Cases by Drug Susceptibility Patterns and Place of Birth, Minnesota, 2013–2017

* Culture-confirmed cases with drug susceptibility results available† Resistance to at least one first-line anti-TB drug [i.e., isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), or ethambutol (EMB)]** INH-resistant cases may also be resistant to other drugs‡ Multi-drug resistant TB, defined as resistance to at least INH and rifampin

Place of birth

Cases With Susceptibility

Results*

Any DrugResistance†

No. (%)

INH-Resistant**

No. (%)MDR-TB‡No. (%)

Non U.S.-Born Cases

526 115 (22) 74 (14) 17 (3)

U.S.-Born Cases 84 11 (13) 8 (10) 1 (1)

Total 610 126 (21) 82 (13) 18 (3)

34

TB Cases by Mode of Treatment Administration, Minnesota, 2013-2017

Year Started treatment At least some DOT* Completely self-administered

2013 150 99% <1%

2014 146 98% 2%

2015 146 99% <1%

2016 168 98% 2%

2017 176 99% 1%

Total 786 99% 1%

* DOT = Directly Observed Therapy35

Type of Provider Started treatment At least some DOT* Completely self-administered

Public 444 99% <1%

Private only 342 97% 3%

Treatment Completion and Length of Therapy Among TB Cases,Minnesota, 2012-2016

Year Started Treatment*

CompletedWithin 12 mos.**

No. (%)

CompletedOverall**No. (%)

2012 133 127 (96) 130 (98)

2013 125 118 (94) 123 (98)

2014 122 113 (93) 120 (98)

2015 125 119 (95) 122 (98)

2016 138 130 (94) 132 (96)

Total 643 607 (94) 627 (98)

* Patients for whom < 12 months of therapy is indicated. This excludes: patients with rifampin resistance, meningeal TB, TB in

bone or skeletal system, TB in CNS, children 14 years of age or younger with disseminated TB, patients who died or moved out

of US within 366 days of starting treatment.

** Treatment completion data as of 1/14/201936