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Epidemiology of Tuberculosis (TB):

Global, National, and Tri-State (Indiana,

Michigan, and Ohio)

Premal Bhatt, MPH & Karthik Kondapally, MBBS, MPH

Epidemiology Investigators, TB/HAI Program

Bureau of Infectious Diseases

Tri‐State Tuberculosis (TB) Clinical Intensive WorkshopSeptember 25, 2018-September 27, 2018

Global TB Epidemiology

• TB is the ninth leading cause of death worldwide and the 

leading cause from a single infectious agent, ranking above 

HIV/AIDS.

• An estimated 10.4 million people fell ill with TB in 2016: 90% 

were adults, 65% were male, 10% were people living with 

HIV (74% in Africa) and 56% were in five countries: India, 

Indonesia, China, the Philippines and Pakistan. 

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Global TB Epidemiology

• In 2016, over 490,000 new MDR‐TB cases 

reported globally

• Almost half (47%) of new MDR‐TB cases in 

2016 were reported in India, Philippines, and 

Russian Federation 

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2017 TB Epidemiology‐U.S.

• 9,093 TB cases reported in 2017

• 2.8 cases per 100,000 population

• Rate decreased by 2.5% compared to 2016

• The rate of TB among persons born outside the 

U.S. in 2017 was 15 times the rate among U.S.‐

born persons

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2017 TB Epidemiology‐U.S.

• Highest TB rate among persons born outside the U.S. was among Asians (27.0 per 100,000 persons)

• Among U.S. born persons, highest proportion of TB cases were reported among blacks (37.1%)

Tuberculosis (TB) Incidence Overall and Among U.S.‐Born and Persons Born outside the U.S.

Source: https://www.cdc.gov/mmwr/volumes/66/wr/mm6611a2.htm

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2017 TB Epidemiology – Tri‐State

Indiana

• 100 cases• 1.5 per 100,000

• 72% Pulmonary

• 72% Lab‐Confirmed

• Highest Burden: 37 cases in Marion (Indianapolis)

Ohio

• 151 cases• 1.3 per 100,000

• 68% Pulmonary

• 48% Lab‐Confirmed

• Highest Burden: 53 cases in Franklin (Columbus)

Michigan

• 133 cases• 1.3 per 100,000

• 50% Pulmonary

• 68% Lab‐Confirmed

• Highest Burden: 43 cases in Wayne (Detroit)

TB Cases and Rates, 2013‐2017

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

0

50

100

150

200

250

300

2013 2014 2015 2016 2017

Cases per 100,000 Population

Number of Cases

Indiana Michigan Ohio Indiana Michigan Ohio

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Indiana TB Cases by County, 2017

Michigan TB Cases by County, 2017

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9

Trumbull

1

Lawrence

1

Washington

1

Van Wert

Butler

7Warren1

Montgomery

4

Ashland

Williams

Defiance

Paulding

Fulton

Henry

Lucas

Wood

Ottawa

Sandusky

SenecaHancock

1Putnam

Allen

Wyandot

MercerAuglaize

Darke

Hardin

Marion

ShelbyLogan Union

1MiamiChampaign

Delaware

PrebleGreene

2Clinton

Fayette

Madison

Hamilton Clermont

Brown Adams

Highland

Scioto

Pike Jackson

Gallia

Ross

Pickaway

Vinton

Meigs

Athens

Hocking

PerryFairfield

Licking

MorrowKnox

Crawford

Huron

Erie Lorain

Medina

Wayne

Holmes

Summit

Stark

Tuscarawas

Lake1

Ashtabula

Geauga

Portage

Mahoning

Columbiana

Carroll

Jefferson

Coshocton

MuskingumGuernsey Belmont

MonroeNoble

Morgan

Franklin

Harrison

Cuyahoga

Clark

Richland

Number of Cases

01 ‐ 4

10+5 ‐ 9

1

3

27

1

53

6

4

1

1

3 2

2

1

2

1

1

1

2

18

Ohio TB Cases by County, 2017

TB Cases by Site of Disease, 201772.0%

14.0% 14.0%

49.6%

36.8%

13.5%

67.5%

21.2%

11.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pulmonary Extra‐Pulmonary Concurrent

Proportion of Cases (%)

Site of Disease

Indiana Michigan Ohio

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Contact Investigations, 2017

Indiana Michigan Ohio

Number of Sputum‐Smear Positive Cases 35 52 50

Number of Contacts 387 827 901

Number of Contacts w/ TB Disease 4 6 3

Number of Contacts w/ LTBI 88 63 63

TB Case Rates by Age Group, 2017

0.24 0.26

1.30

2.20

1.20

2.60

0.520.41

0.95

1.251.35

2.79

0.000.10

1.00

2.10

1.10

1.90

0.00

0.50

1.00

1.50

2.00

2.50

3.00

<5 years 5‐14 years 15‐24 years 25‐44 years 45‐64 years ≥65 years

Rate per 100,000 Population

Age Group

Indiana Michigan Ohio

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TB Cases by U.S. Born vs. Persons Born outside the U.S.,  2013‐2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

2013 2014 2015 2016 2017

Proportion of Cases (%)

Year

Indiana, U.S. Michigan, U.S. Ohio, U.S.

Indiana, Born outside U.S. Michigan, Born outside U.S. Ohio, Born outside U.S.

Top 6 Countries of Birth for TB Cases, 2017

Indiana Michigan Ohio

United States – 27 United States – 48 United States – 44

Burma – 17 India – 13 Somalia – 17

Mexico – 12 Mexico – 7 Bhutan – 12

India – 9 Philippines – 6 India – 11

Philippines – 6 Vietnam – 6 Vietnam – 9

El Salvador – 4 Laos – 5 China/Philippines – 6

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TB Cases by Race, 2017

0.0%

34.4%

39.7%

0.0%

25.8%

1.5%

34.6%

23.3%

0.0%

30.1%

0.0%

43.0%

11.0%

1.0%

23.0%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0%

American Indian/Alaskan Native

Asian

Black/African American

Native Hawaiian/Other Pacific Islander

White

Proportion of Cases (%)

Indiana Michigan Ohio

TB Cases with HIV Co‐infection, 2013‐2017

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

2013 2014 2015 2016 2017

Proportion of Cases (%)

Year

Indiana Michigan Ohio

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Risk Factors Among TB Cases, 2017

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

Excess Alcohol Use

Diabetes Mellitus

Contact to TB patient

Non‐Injecting Drug Use

Homeless

Immunosuppression (not HIV/AIDS)

Incomplete LTBI Therapy

End‐Stage Renal disease

Long‐term Care Facility

Correction Facility

Unemployment

Proportion of Cases (%)

Indiana Michigan Ohio

Drug Resistance Among TB Cases, 2013‐2017

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

2013 2014 2015 2016 2017

Proportion of Cases

Isoniazid Mono‐Resistance

Indiana Michigan Ohio

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

2013 2014 2015 2016 2017

Proportion of Cases

Multi‐Drug Resistance

Indiana Michigan Ohio

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Conclusions• Ohio has the highest number of cases, but Indiana has the highest rate

• Highest burden groups are similar among all three states

o Persons born outside the U.S.

o Pulmonary

o ≥ age 65 (previous years had 25‐44 as highest burden)

• Contact investigation data nearly identical for Ohio and Michigan, very different for Indiana

• Most common risk factors:

o Unemployment

o Diabetes

o Excess alcohol use

• HIV co‐infection cases increased for Indiana and Michigan; remains low, but still concerning

• Proportion of drug resistance increased in all three states

o Indiana – mono‐resistance and multi‐drug resistance

o Michigan – mono‐resistance

o Ohio – multi‐drug resistance

Contact Information TB Program, Ohio Department of Health

(614) 466‐2381

Sarah Mitchell, MS, LNHASupervisor, TB/Healthcare‐Associated Infections ProgramTB ControllerEmail: Sarah.Mitchell@odh.ohio.gov

April Justice, RNInfectious Disease Control ConsultantEmail: April.Justice@odh.ohio.gov

Karthik Kondapally, MBBS, MPHEpidemiology Investigator 3Email: Karthik.Kondapally@odh.ohio.gov

Nicole Hagans, BSN, RNInfectious Disease Control ConsultantEmail: Nicole.Hagans@odh.ohio.gov

Premal Bhatt, MPHEpidemiology Investigator 2Email: Premal.Bhatt@odh.ohio.gov

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Contact Information 

Indiana

Sang Thao, MPHTB Epidemiologist

Indiana State Department of Health

TB/Refugee Health Division

Phone: (317) 233‐7841

Fax: (317) 233‐7747

sthao@isdh.in.gov

Michigan

Shona R. Smith, MPHTuberculosis Epidemiologist

Michigan Department of Health and Human Services

Communicable Disease Division

Phone: (517) 284‐4956 

Fax: (517) 335‐8263 

smiths79@michigan.gov