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

2. 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 Decrease from 9094 cases in IR = Lowest case counts in the U.S. Ever recorded.
CDC Reported Tuberculosis in the United States, 2017

3. Number of Tuberculosis Cases
Indiana,
Stagnant trend within 10 years.
116 cases reported in % increase from 2017.
Incidence rate of 1.7 per 100,000 persons in 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 Below nat’l avg

4. Indiana TB cases County numbers Marion County: 38 cases5 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

5. TB Cases and Incidence Rates84 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
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

6. 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

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

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

9. 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

10. Number of TB Cases by Place of Birth,
Indiana,
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

11. 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

12. 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)

13. 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

14. 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.

15. Number of TB Deaths Indiana, 2014-2018

16. 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

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

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

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

20. 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

21. 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

22. 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.

23. 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

24. 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

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