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1997 Tuberculosis Cases Overview by 4jV64J

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									              TB Control: A goal needing continued vigilance




    2008 Annual Statistical Report

               Project Director: Sue Etkind, R.N., MS

                      Sue.Etkind@state.ma.us


          Division of Tuberculosis Prevention and Control
  Bureau of Infectious Disease Prevention, Response and Services
            Massachusetts Department of Public Health




Massachusetts Department of Public Health
Bureau of Infectious Disease Prevention, Response and Services
Division of Tuberculosis Prevention and Control

2008 Tuberculosis Overview
In 2008, 261 cases (case rate 4.11 per 100,000 population) of active
tuberculosis (TB) were reported to and verified by the Massachusetts
Department of Public Health, Division of TB Prevention and Control. Following a
period of stable TB case rates, TB cases declined in 2007 by 14%. However, this
was not sustained and the TB case rate increased by 17% in 2008. For 13
consecutive years the case rate was at or slightly above 4 per 100,000, while
case rate for the United States consistently declined.

                   Figure 1: TB Case Rates, United States and
                           Massachusetts, 1986-2008

               Case Rate Per 100,000
        16
        14
        12
        10
          8
          6
          4
          2
          0
              86     88      90      92      94      96      98     2000     02   04   06   08
                                                        YEAR

                                             US                             MA

     MDPH, Office of Integrated Surveillance and Informatics Services



Figure 1

Note: Case rates are based on estimated population for each year. 1990 and 2000 case rates
were calculated using 1990 and 2000 U.S census figures. All case rates are per 100,000
population.

Seventy-five percent of TB in Massachusetts is reported from the 23 largest
communities and two additional communities at higher risk of TB (Appendix 1).
Boston continues to have the highest incidence of TB (61 cases in 2008, case
rate 10.4 per 100,000). The proportion of Massachusetts TB cases reported in
Boston residents has remained between 22% and 25% since 2002.

Analysis of TB cases and case rates by county of residence reveals that 54% of
the cases were reported from the two largest counties, Suffolk (28%) and
Middlesex (26%). Three counties, Dukes, Hampshire, and Hampden had 1
percent of the state’s TB cases each. Three counties, Berkshire, Franklin and
Nantucket, reported no TB cases in 2008.


                                                                        1
           Figure 2: TB Cases and Case Rates by County,
                   Massachusetts, 2008 (N = 261)

  Barnstable             4 (2%), 1.80 per 100,000

      Other*               7 (3%), 1.12

   Plymouth 14 (5%), 3.0                                                 *Other Counties Include:
                                                                         Dukes<1%, Hampshire 1%,
                                                                         Hampden 1%
      Bristol       20 (8%), 3.74
                                                                         0 TB cases reported in
     Norfolk                                                             Berkshire, Dukes, Franklin,
                    22 (8%), 3.38
                                                                         Nantucket Counties

       Essex        23 (9%), 3.18

   Worcester        29 (11%), 3.86

   Middlesex        68 (26%), 4.64

     Suffolk        74 (28%), 10.73

                0          10         20        30       40        50         60        70        80
                                                      Percent
     MDPH, Office of Integrated Surveillance and Informatics Services



Figure 2

Demographic: Gender, Race/Ethnicity and Age
Gender
Of the 261 TB cases, 150 (58%) were in males and 111 (42%) were in females.
Males consistently have a higher TB case rate than females.


                            Figure 3: TB Case Rates by Gender
                                Massachusetts, 1995 - 2008

            Case Rate Per 100,000
       7

       6

       5

       4

       3

       2

       1

       0
           95       96      97      98     99   2000     01     02       03        04   05      06     07   08
                                                            YEAR

                                                     Male                Female
     MDPH, Office of Integrated Surveillance and Informatics Services




                                                                     2
Figure 3
Race/Ethnicity
The majority of the TB cases in 2008 occurred among persons who were
members of minority groups (208 cases, 80%): black (71 cases, 27%), Asian (94
cases, 36%), Hispanic (41 cases, 16%) and 2 persons reported with multiple
race (<1%).

                      Figure 4: TB Cases by Race/Ethnicity,
                          Massachusetts, 2008 (N=261)

                                             Other, 2, <1%
                      Hispanic,
                      41, 16%                                                   Asian/Pacific
                                                                                  Islander,
                                                                                   94, 36%




                White/Non-
                Hispanic,
                 53, 20%



                                                                  Black/Non-
                                                                   Hispanic,
                                                                   71, 27%

    MDPH, Office of Integrated Surveillance and Informatics Services



For blacks, the case rate has declined from 27.3 in 1995 to 20.1 per 100,000 in
2008. Asians continue to have a much higher case rate than any other
race/ethnicity group (39.1 per 100,000 in 2008).

                   Figure 5: TB Case Rates by Race/Ethnicity,
                           Massachusetts, 1995-2008

               Case Rate Per 100,000
     70
     60
     50
     40
     30
     20
     10
      0
          95     96    97      98      99    2000     01     02        03      04     05     06      07    08
                                                    YEAR

                      White/NH                Black/NH                     Hispanic               Asian


                                                                            NH = Non-Hispanic
    MDPH, Office of Integrated Surveillance and Informatics Services        Excludes cases reporting multiple races




                                                                       3
Compared to white/non Hispanics, blacks were 21, Hispanics 10 and Asians 40
times more likely to be reported with TB disease.

                    Table 1: TB Case Rates by Race/Ethnicity,
                          Massachusetts, 2008 (N=259)

          Race                     No. Cases           Case Rate                   Odds Ratio
          Ethnicity                                                           (95% Confidence Interval)


          White/NH                        53                 0.99                         1
                                                                                   (reference 0.0)

          Black/NH                        71                20.67                      20.93
                                                                                   (14.46 , 30.33)
          Hispanic                        41                 9.56                       9.68
                                                                                    (6.32 , 14.83)
          Asian/ Pacific                  94                39.07                      39.56
          Islander                                                                 (27.90 , 56.17)


                                                                           NH = Non-Hispanic
    MDPH, Office of Integrated Surveillance and Informatics Services
                                                                           Excludes 2 cases reporting multiple races



Age
In 2008, 4 TB cases (2%) were in children < 15 years of age. Three of the 4
children (75%) were of minority communities. The number of children with TB
declined from 12 cases in 2007 to 4 cases in 2008.


   Figure 6: TB Case Rates in Children Age < 15 Years by Race,
                   Massachusetts, 1995 – 2008

               Case Rate Per 100,000
         4.5
           4
         3.5
           3
         2.5
           2
         1.5
           1
         0.5
           0
               95    96     97      98      99 2000 01 02                  03      04      05       06      07         08
                                                    YEAR
                                     TOTAL               White               Non-White
    MDPH, Office of Integrated Surveillance and Informatics Services




                                                                       4
In 2008, 46 (18%) TB cases were in persons age 65 years and older. Case rates
for this group have declined significantly from 8.8 in 1995 to 5.4 per 100,000 in
2008.

          Figure 7: TB Case Rates in Persons Age 65 and Over,
                       Massachusetts, 1995 – 2008

               Case Rate Per 100,000
        14

        12

        10

          8

          6

          4

          2

          0
              95     96      97    98       99 2000 01       02        03       04     05     06     07     08
                                                       YEAR

    MDPH, Office of Integrated Surveillance and Informatics Services



Age and Race/Ethnicity
Among TB cases reported in 2008, 2 (<1%) were in children less than 5 years of
age, 2 (<1%) were children ages 5-14, 39 (15%) were adolescents and young
adults ages 15-24, 97 (37%) were between the ages of 25-44, 75 (29%) were
between 45-64 and 46 (18%) were age 65 years and older.

                    Table 2. TB Cases by Age, Race/Ethnicity,
                          Massachusetts, 2008 (N=261)
    Age        White/NH           Black /NH     Hispanic        Asian/Pacific               Other*          Total
                                                                Islander


     <5            1 (50%)         1 (50%)            0                     0                 0            2 (<1%)

     5-14             0                 0             0                2 (100%)               0            2 (<1%)

    15-19             0            2 (29%)        4 (57%)              1 (14%)                0             7 (3%)

    20-24           3 (9%)        11 (34%)        6 (19%)              11 (34%)             1 (3%)         32 (12%)

    25-44          17 (17%)       29 (30%)       15 (16%)              35 (35%)             1 (1%)         97 (37%)

    45-64          18 (24%)       21 (28%)       12 (16%)              24 (32%)               0            75 (29%)

     65+           14 (30%)        7 (15%)        4 (9%)               21 (46%)               0            46 (18%)

    Total          53 (20%)       72 (27%)       42 (16%)              94 (36%)           2 (<1%)         261 (100%)


    MDPH, Office of Integrated Surveillance and Informatics Services            NH = Non-Hispanic
                                                                                Excludes 2 cases reporting multiple races




                                                                       5
Clinical Characteristics
Site of Disease
In 2008, 181 of the 261TB cases (69%) presented with the lung as the primary
site of disease. This was followed by cervical lymph node - 18 cases (7%),
miliary – 17 cases (7%) and pleural space - 12 cases (5%).

                                  Figure 8: TB Cases by
                                 Primary Site of Disease,
                               Massachusetts, 2008 (N=261)
                                                            Bone and
                              Pleural, 12, 5%               or/Joint,
                                                            8, 3%
                    Other*, 17, 7%

       Peritoneal, 8, 3%

         Miliary, 17, 7%


     Lymphatic:                                                                      Pulmonary,
     Cervical, 18, 7%                                                                181, 69%


                                                                                     *Other:
                                                                                     Other Site: 8, 3%
                                                                                     Lymphatic:Intrathoracic: 1, <1%
                                                                                     Meningeal: 1, <1%
                                                                                     Lymphatic:Other: 3, 1%
    MDPH, Office of Integrated Surveillance and Informatics Services                 Genitourinary: 4, 2%



In 2008, 35 TB cases (13%) had multiple sites of disease. The proportion of TB
cases with multiple sites has increased since 2004 reflecting the increasing
complexity of TB cases in recent years.

                               Figure 9. TB Cases with
                               Multiple Sites of Disease
                              Massachusetts, 1995 – 2008

                  Percent of Cases
       16
       14
       12
       10
         8
         6
         4
         2
         0
             95     96   97    98     99 2000 01          02     03        04   05      06    07    08
                                                    YEAR

    MDPH, Office of Integrated Surveillance and Informatics Services




                                                                       6
Chest Radiography Results
Of the 261TB cases, 218 (84%) had pulmonary involvement. Of those,163 (75%)
presented with non-cavitary pulmonary disease at time of diagnosis. Fifty-cases
(23%) presented with cavitary disease, 4 cases (2%) had a report of a normal
chest x-ray and 1 (<1%) case did not have x-ray done at time of diagnosis.
                   Figure 10. Pulmonary Involvement TB Cases
                              by Chest X-ray Results
                          Massachusetts, 2008 (N=218)
                                      Normal, 4, 2%                    Not Done,
                                                                         1, 0%
                     Cavitary,
                     50, 23%




                                                                                    Non-cavitary,
                                                                                   consistant with
                                                                                   TB, 163, 75%




    MDPH, Office of Integrated Surveillance and Informatics Services



Skin Test Results
Of the 261 TB cases, 207 (80%) had positive tuberculin skin test results
recorded, 8 cases (3%) were documented to be anergic, 22 cases (8%) had
negative results, 5 cases (2%) had unknown results, and 19 cases (7%) did not
have skin testing done.

       Figure 11. TB Cases by Tuberculin Skin Test Results,
                   Massachusetts, 2008 (N=261)

                                  Anergic, 8, 3% Unknown, 5,
                         Not Done,                   2%
                          19, 7%

               Not
         Significant, 22,
               8%




                                                                              Positive, 207,
                                                                                  80%



    MDPH, Office of Integrated Surveillance and Informatics Services




                                                                          7
Bacteriologic Confirmation
In 2008, 198 (76%) of the 261 TB cases were bacteriologically confirmed. This
represents a bacteriologically substantiated incidence rate of 3.1 per 100,000
population. The proportion of TB cases with bacteriologic confirmation has
decreased since 1999. Mycobacteriologic cultures are essential for TB treatment
as it is only from positive cultures that drug susceptibility testing can be
performed.

            Figure 12. Bacteriologically* Confirmed TB Cases
                      Massachusetts, 1995 – 2008

              Percent of Cases
       90

       80

       70

       60

       50

       40
            95    96     97     98     99 2000 01           02     03      04    05     06     07    08
                                                    YEAR

                                                                           *TB cases with either a positive
                                                                           sputum culture or a positive culture
    MDPH, Office of Integrated Surveillance and Informatics Services       of tissue/other body fluids.




Of the 198 bacteriologically confirmed cases, drug susceptibility tests were
performed on isolates from 193 (98%) cases. Thirty-eight (20%) of the 193
isolates were resistant to one or more anti-tuberculosis drug. Eighteen cases
(47% of 38 cases or 9% of 193 cases) had isolates resistant to isoniazid (INH),
either alone or in combination with other agents. In 2008, there were 3 multi-drug
resistant TB (MDR-TB) cases (resistant to INH and rifampin (RIF), with or without
resistance to any other drugs). A review of bacteriology data from 1993 to 2008,
found no extremely drug resistant (XDR-TB) cases (defined as an MDR-TB case,
with additional resistance to any fluoroquinolone and at least one injectable
second-line drugs such as amikacin, kanamycin or capreomycin).




                                                                       8
                                Table 3. TB Drug Resistance
                                   Massachusetts, 2008
       TB Cases                                                                     (N=261)

       Bacteriologically confirmed cases                                       198 (76% of 261)
       Drug susceptibility tests performed                                     193 (98% of 198)
       Resistance to any anti-TB drug                                          38 (20% of 193)
       Resistant to isoniazid (alone or in combination                          18 (9% of 193)
       with other)
       Resistant to at least isoniazid and rifampin                             3 (2% of 193)
       (MDR-TB)
       Resistant to at least isoniazid and rifampin, plus                           None
       any fluoroquinolone and at least one of the three
       injectable second-line drugs (XDR-TB)



      MDPH, Office of Integrated Surveillance and Informatics Services


Note: drug resistance is defined as greater than 1 percent bacterial population resistance to any
concentration of that drug. Multi-drug resistance is defined as resistance to isoniazid (INH) and
rifampin (RIF), with or without any other drug resistance.

Between 2003 and 2006, the proportion of cases caused by Mycobacterium.
tuberculosis resistant to anti-tuberculosis drugs increased from 9% to 19%. In
2008, the rate of drug resistance of 20% is the highest reported.

                Figure 13. Bacteriologically Confirmed TB Cases
                          With Drug Resistant Isolates
                          Massachusetts, 1995 – 2008
            Percent of Cases
     25

     20

     15

     10

       5

       0
           95    96      97      98      99     2000     01      02       03   04    05    06     07   08
                                                       YEAR


      MDPH, Office of Integrated Surveillance and Informatics Services




                                                                      9
The largest number of the drug resistant isolates were from Asian TB cases 17
(45%); then blacks, 8 cases (21%); Hispanics, 7 cases (18%) and whites, 6
cases (16%).

       Figure 14. Drug Resistant TB Cases by Race/Ethnicity,
                   Massachusetts, 2008 (N=38)
                           White/NH,
                            6, 16%




                                                                            Asian/Pacific
                                                                              Islander,
                 Hispanic,                                                     17, 45%
                  7, 18%




                                 Black/NH,
                                  8, 21%
    MDPH, Office of Integrated Surveillance and Informatics Services         NH = Non-Hispanic



Of the 38 TB cases with drug resistant M. tuberculosis isolates, 36 (95%) were
persons born outside the United States. Countries of origin included: Vietnam -
6 cases (16%), India – 6 cases (16%) and Dominican Republic - 3 cases (8%).
The remaining 23 (60%) cases were from 19 different countries.

         Figure 15. Drug Resistant TB Cases by Place of Birth,
                     Massachusetts, 2008 (N= 38)
                     N. America,                                                  Portugal - 1
                        2, 5%                                    Europe, 2, 5%    Russian Federation - 1
           United States (main land) - 2



            Africa, 6, 16%
        Ethiopia - 2 , Cape
        Verde - 1, Kenya - 1,
        Morocco - 1 Uganda -1

                                                                                       Asia, 17, 45%
                                                                                      Vietnam - 6 India - 6
                  Latin America,                                                      Nepal - 2, China - 1
                     11, 29%                                                          Myanmar – 1, Thailand - 1



       Dominican Republic - 3
       Barbados - 1, Brazil -1
       Ecuador - 1, El Salvador - 1
       Guatemala – 1, Haiti -1
       Mexico -1, Peru -1

    MDPH, Office of Integrated Surveillance and Informatics Services




                                                                       10
Of the 38 TB cases with drug resistant M. tuberculosis, 3 cases (8%) had
isolates that were resistant to isoniazid (INH) alone, 8 cases (21%) resistant to
INH and streptomycin (SM), and 13 cases (34%) resistant to SM alone. In 2008,
there were 3 cases (8%) with multi–drug resistant TB (MDR-TB). The remaining
11 cases (25%) were due to M. tuberculosis resistant to other combinations of
TB drugs.

             Figure 16. TB Cases By Drug Resistance Pattern
                      Massachusetts, 2008 (N = 38)
                                         Isoniazid (INH)
                    MDR (at least         Alone, 3, 8%
                       INH +
                     Rifampin),                                               Streptomycin
                       3, 8%                                                   (SM) Alone,
                                                                                 13, 34%




              Isoniazid/
            Streptomycin,
               8, 21%                                                              *OTHER:
                                                                                   3 KAN
                                                                                   2 CIP
                                                                                   1 INH/SM/ETH
                                                                                   1 INH/SM/KAN
                                                                                   1 INH/SM/EMB
                                                                   Other *,        1 INH/PZA
                                                                                   1 SM/PZA
                                                                   11, 29%         1 PZA

     MDPH, Office of Integrated Surveillance and Informatics Services




Higher Risk Group Profile
Cases in Non-U.S. Born Persons
The non-U.S. born (defined as persons born outside the United States and its
territories) remain the group at highest risk for TB disease in Massachusetts. Of
the 261 TB cases in 2008, 215 (82%) occurred in persons not born in the U.S.
Over the years, non-U.S. born persons have accounted for an increasing
proportion of the TB cases in Massachusetts, from 35% in 1984, 51% in 1991,
71% in 2000 and 82% in 2008. However, despite the increase in the proportion
of non-U.S. born TB cases, the number of non-U.S. born TB cases has not
changed greatly over time.




                                                              11
                                   Figure 17. Tuberculosis Cases by Place of Birth,
                                             Massachusetts, 1995 - 2008

                               Percent of Cases
              90
              80
              70
              60
              50
              40
              30
              20
              10
                      0
                          95        96    97        98        99    2000    01        02        03      04      05        06        07         08

                                                               US Born           Non-US Born
                                                                                                             *US Born cases includes those
        MDPH, Office of Integrated Surveillance and Informatics Services                                      born in U.S. territories




      Figure 18. Trends in TB Cases in Non-US Born Persons,
                    Massachusetts, 1995 - 2008
                          300                                                                                                        90

                                                                                                                                     80
                          250
                                                                                                                                     70
                                                                                                                                          Percent of Cases




                          200                                                                                                        60
    Number of Cases




                                                                                                                                     50
                          150
                                                                                                                                     40

                          100                                                                                                        30

                                                                                                                                     20
                           50
                                                                                                                                     10

                               0                                                                                                     0
                                    95   96    97        98    99   2000   01    02        03    04     05     06    07        08

                                                Number of Cases                                       Percent of Cases

                                                                                 YEAR

        MDPH, Office of Integrated Surveillance and Informatics Services




Analysis of the 2008 TB cases by world regions reveals that the majority of the
non-U.S. born TB cases are from Asia, 96 cases (37%), with the highest
numbers (37 cases) from Southeast Asia. Sixty-three cases (24%) were from
Latin America, particularly from the Caribbean (33 cases). Forty-five (18%) of the
TB cases were from Africa, mostly from East Africa (25 cases). (See appendix 3)

Fifty-nine percent of the 215 non-U.S. born persons with TB in 2008 were from 9

                                                                                                12
countries: China and India each accounted for 23 cases (11%) followed by
Vietnam - 22 cases (10%), and Haiti - 16 cases (7%). Brazil, Dominican
Republic and Kenya each accounted for 9 cases (4%). Portugal and Ethiopia
each accounted for 8 cases (4%). The remaining 88 cases (41%) included in
persons from 44 different countries.


                                    Figure 19. TB Cases
                               Place of Birth by World Regions,
                                Massachusetts, 2008 (N=261)
                                           Europe,      Eastern Europe, 3, 1%
                                           17, 6%       Southern Europe, 14, 5%
               N. America,
                 40, 15%
                                                                                Asia, 98, 38%
           US*, 40, 15%                                                         Eastern Asia, 25, 10%
                                                                                South Central Asia, 31, 12%
                                                                                South Eastern Asia, 37, 14%
                                                                                Western Asia, 3, 1%


        Africa, 45, 17%
     Eastern Africa, 25, 10%
     Middle/North Africa, 7, 3%
     Southern Africa 1, <1%
                                                                 Caribbean, 33, 13%
     Western Africa 12, 5%
                                              Latin America, Central America, 12, 5%
                                                 63, 24%     South America 18, 7%

    MDPH, Office of Integrated Surveillance and Informatics Services            *US Born cases includes those
                                                                                 born in U.S. territories




Country of origin data and the date of entry into the U.S. were collected
consistently starting in 1993. Between 1993 and 2008: 3,105 non-U.S. born TB
cases were reported in Massachusetts: of those, the majority were from Asia -
1,408 cases (45%), Latin America - 917 cases (29%), Africa - 524 cases (17%),
Europe - 239 cases (8%) and 24 cases (1%) from areas of the world including
Canada and Australia. Analysis by periods (1993-1998, 1999-2003 and 2004-
2008) indicates an increase in the proportion of TB cases in persons from
Africa from 12% to 20%.




                                                            13
                 Figure 20. TB Cases by Place of Birth among
              Non-US Born, Massachusetts, 1993-2008 (N= 3,105)

              100%
                                  8%                8%                     7%
              90%

              80%                                                         28%
                                  31%               29%
              70%                                                                              OTHER *
                                                                                               EUROPE
    Percent




              60%
                                  12%               19%                   20%                  LATIN AMERICA
              50%                                                                              AFRICA
              40%                                                                              ASIA

              30%
                                  48%               44%                   44%
              20%

              10%
               0%
                             1993-1998           1999-2003              2004-2008
                                                    Year                            * Other includes 22 cases from
                                                                                    Canada and Australia (<1%)
     MDPH, Office of Integrated Surveillance and Informatics Services



For many populations, the risk of developing TB disease is highest during the
first few years after arrival in the U.S. Analysis of the 3,105 non-U.S. born TB
cases indicates that 1,565 cases (50%) developed TB disease within 5 years of
arriving in the U.S. For the remaining 1,540 non-U.S. born TB case, 552 (36%)
cases were diagnosed with TB within 6 -10 years, 383 (25%) within 11-15 years
and 607 (39%) more than 15 years of arrival into the U.S.

       Figure 21. Time Interval Between Arrival in the US and TB
                Diagnosis Among Non-US Born Cases,
                Massachusetts,1993 – 2008 (N=3,105)
                           100%
                                           16%
                            90%                                   19%                         24%
                            80%            16%                    11%
                            70%                                                               10%
                                                                  15%
                 Percent




                            60%            20%                                                18%
                            50%
                            40%                                   29%
                                           25%                                                25%
                            30%
                            20%
                                           23%                    27%                         24%
                            10%
                             0%
                                        1993-1998              1999-2003                2004-2008
                                                                 Year
                                             <=1         2-5     6 - 10         11 - 15     >15
      MDPH, Office of Integrated Surveillance and Informatics Services



Analysis of 1,565 non-U.S. born TB cases who developed TB within 5 years of
arrival indicates that for Asians with TB, the number with TB within 5 years
                                                                  14
declined from 46% in 1993-1998 to 38% reported in 2004-2008. However, for
Africans, the proportion of persons who are diagnosed with TB soon after
arrival has increased from 20% in 1993-1998 to 29% in 2004 - 2008.


     Figure 22. Percent of Non-US born Cases Diagnosed with
       TB within 5 Years of Arrival to the US by Continent of
          Origin, Massachusetts, 1993 – 2008 (N=1,565)
              Percent of Cases
        50
        45
        40
        35
        30
        25
        20
        15
        10
          5
          0
                      Asia                   Africa             Latin America       Europe
                                                        Year

                               1993-1998          1999-2003             2004-2008

     MDPH, Office of Integrated Surveillance and Informatics Services



 Non-U.S. Born vs. U.S born
Persons reported with TB who were non-U.S. born were more likely to be
between 25 - 44 years old (46% vs. 25%). Young children were more likely to be
U.S. born. However, it is possible that many parents of the U.S. born children
were non-U.S. born. Information on the country of origin of the parents is not
available. A greater proportion of those age 65 years and older were U.S.-born
(31% vs. 15%)




                                                         15
          Figure 23. Percent of Non-US Born and US* Born TB
                         Cases by Age Group
                 Massachusetts, 1993 – 2008 (N=4,485)

           Percent of Cases
     50

     40

     30

     20

     10

      0
                <5          5-14          15-19       20-24   25-44               45-64         65+
                                                    Age Group
                                          US Born        Non-US Born

                                                                             *US Born cases includes those
     MDPH, Office of Integrated Surveillance and Informatics Services         born in U.S. territories



Analysis of the 4,485 TB cases in total or by time period indicates that TB in the
U.S. born was more likely to be pulmonary disease than in the non-U.S. born.

               Figure 24. Percent of Non-US Born and US Born*
                            Pulmonary** TB Cases
                     Massachusetts, 1993-2008 (N=4,485)
                 Percent of Cases
          90
          80
                                          80
          70
          60                      72                                         67                 Pulmonary
                                                                                                (1993-1998)
          50
                         78                                                                     Pulmonary
          40                                                            61                      (1998-2003)
          30                                                    63
                                                                                                Pulmonary
          20                                                                                    (2004-2008)
          10
           0
                            US Born                           Non-US Born
                                                                              *US Born cases includes Puerto Rico
                                                                              **TB cases with primary or additional
     MDPH, Office of Integrated Surveillance and Informatics Services         disease sites of pulmonary




Cases in the Homeless Population

                                                               16
A homeless person is defined as one who lacks a fixed, regular and adequate
night time residence. This includes a person who resides in a shelter, welfare
hotel, on the street, or in a single room occupancy hotel, and who is not paying
rent, does not own a home and is not steadily living with relatives or friends.

Of the 261 cases of TB reported in 2008, 8 cases (3%, case rate 24.9 per
100,000 estimated homeless) were reported to have been homeless. Among the
8 homeless cases, 3 (38%) were reported in the City of Boston.
The Massachusetts Bureau of Health Statistics, Research and Evaluation estimates that there are
approximately 31,100 homeless persons statewide. Case rates were calculated based on these
figures.


                  Figure 25. TB Cases Among the Homeless,
                         Massachusetts, 1995 - 2008

                Number of Cases
        20
        18
        16
        14
        12
        10
         8
         6
         4
         2
         0
             95     96     97     98     99 2000 01            02       03   04   05   06   07   08

                                                    YEAR

     MDPH, Office of Integrated Surveillance and Informatics Services



Cases in Correctional Facilities
Since 1995, the numbers of TB cases diagnosed in persons residing in
correctional facilities had remained generally constant, with no more than 5
cases per year (1995 - 5 cases, 1998 - 4 cases, 2003 - 5 cases). In 2006, 10
cases (4%, case rate 41.5 per 100,000 incarcerated) were diagnosed in persons
held in Massachusetts’s correctional facilities. During that year, a cluster of TB
cases occurred relating to a single facility. In 2008, 5 cases (2%, case rate 20.0
per 100,000 incarcerated) were diagnosed in correctional facilities.
Note: The Massachusetts Department of Corrections estimates the average daily inmate census
at 11,174 for state correctional facilities and at 13,888 for county correctional facilities.
http://www.mass.gov/Eeops/docs/doc/research_reports/4th_07_overcrowding.pdf




                                                               17
                  Figure 26. TB Cases in Correctional Facilities
                          Massachusetts, 1992 - 2008
              Number of Cases
       12

       10

         8

         6

         4

         2

         0
             92         94        96        98       2000          02        04    06    08
                                                     Year
    MDPH, Office of Integrated Surveillance and Informatics Services



Cases in Long Term Care Facilities
In 2008, 4 cases (2%) of TB were reported in persons residing in long term care
facilities at time of diagnosis – all 4 cases were in nursing homes.


             Figure 27. TB Cases in Long Term Care Facilities,
                        Massachusetts, 1995 - 2008

             Number of Cases
       12

       10

         8

         6

         4

         2

         0
             95    96        97   98      99     2000 01           02   03    04   05   06    07   08

                                                         YEAR

     MDPH, Office of Integrated Surveillance and Informatics Services




Cases Among those who Abuse Substances
                                                              18
In 2008, 23 cases (9%) of TB were reported as substance users (defined as a
person who has excessive use of alcohol or who engaged in either injecting or
non-injecting drug use within 1 year of diagnosis with TB). Twelve (52%) of the
23 substance users were U.S. born. Fifteen of the 23 cases (65%, 10 non-U.S.
and 5 U.S. born) engaged only in alcohol use, 5 cases (22%, 5 U.S. born)
engaged only in injecting/non-injecting drug use, and 3 cases (13%, 1 non-U.S.
and 2 U.S. born) engaged in both alcohol and drug use.

                Figure 28. TB Cases with Substance Abuse,
                        Massachusetts, 1994 - 2008
               Percent of Cases
        16
        14
        12
        10
         8
         6
         4
         2
         0
               94          96          98        2000          02      04           06          08
                                                   Year
                                                                            Substance User - person reported
                                  US born*                                  with excessive use of alcohol,
                                  Non-US Born Substance User                injecting or non-injecting drugs
                                                                            within 1 year of diagnosis.

    MDPH, Office of Integrated Surveillance and Informatics Services        *US Born cases includes those born
                                                                            in U.S. territories




TB/AIDS Cases

Matches of the TB registry to the HIV/AIDS case registry have taken place
annually since 1992. In 1993, the AIDS case definition was revised to include
anyone with HIV infection with TB disease at any site. Between 1982 and 2008,
735 TB/AIDS cases were identified. In 2008, 18 TB cases (6.9%) were identified
as being co-infected with HIV.




                                                               19
         Figure 29. Percent of TB Cases Diagnosed With AIDS
                     Massachusetts, 1982 - 2008
                           (TB/AIDS = 735)
             Percent of Cases
    14
    12
    10                                                                                             2008– 6.9%

     8
     6
     4
     2
     0
         82     84    86      88     90     92      94     96      98   2000   02        04        06        08
                                                           YEAR

    MDPH, Office of Integrated Surveillance and Informatics Services



Minority group members accounted for the majority of the TB/AIDS cases (591
cases, 80%). When compared to the reported AIDS cases and TB cases, a
greater proportion of TB/AIDS cases were black (25% of AIDS cases and 26% of
TB, 57% of TB/AIDS).


                        Figure 30. TB/AIDS , AIDS*, and TB**
                     Cases by Race, Massachusetts, 1982 – 2008
                                   (TB/AIDS = 735)
              Percent of Cases
     70
                       57
     60                                           53
     50

     40
                                                                                                                  31
                                                                                    27        26
     30                                                   25
                20            21                                 21
     20                                                                                                 15
     10
                                       2                                1
         0

                     TB/AIDS                               AIDS                                TB
                            WHITE             BLACK              HISPANIC                ASIAN

                                                                               *AIDS Excludes Those Diagnosed With TB
    MDPH, Office of Integrated Surveillance and Informatics Services           **TB Cases from 1993-2008




Of the 735 TB/AIDS cases reported between 1982 and 2008, 358 (49%) were

                                                                   20
persons born outside of the U.S. and its territories. The majority of the non-U.S.
born cases (54%) were from Haiti.

               Figure 31. TB/AIDS Cases by Place of Birth
                       Massachusetts,1982 – 2008
                             (TB/AIDS = 735)


                                                                                              Other
                                                                                              Countries
   US Born*                                                                                   46%
   52%
                                                     Non-US Born
                                                     48%
                                                                                               Haiti
                                                                                               54%




                        (N = 735)                                             (N = 358)

                                                                         *US Born cases includes those born
     MDPH, Office of Integrated Surveillance and Informatics Services    in U.S. territories




Analysis of TB disease site among TB/AIDS cases demonstrates that 344 (47%)
had only pulmonary involvement, 265 (36%) had only extra-pulmonary disease
and 124 (17%) had both pulmonary and extra-pulmonary involvement.


           Figure 32. TB/AIDS Cases by Site of TB Disease,
                     Massachusetts, 1982 – 2008
                           (TB/AIDS = 735)
                      Pulmonary/
                        Extra-
                      pulmonary,
                       126, 17%


                                                                             Pulmonary,
                                                                              344, 47%



                  Extra-
              pulmonary, 265,
                   36%



     MDPH, Office of Integrated Surveillance and Informatics Services



Among all reported TB/AIDS cases, the most common reported risk for acquiring
HIV infection was injecting drug use (238, 32%) followed by presumed

                                                                    21
heterosexual contact (186, 25%), men who have sex with men (103, 14%) and
heterosexual contact with someone known to be infected or at risk (90, 12%).
Compared to AIDS cases, a greater proportion of TB/AIDS cases contracted HIV
infection through presumed heterosexual contact (25% vs. 9%).

           Figure 33. Percent of TB/AIDS and AIDS* Cases by
                       HIV Transmission Category
                       Massachusetts, 1982 – 2008
                             (TB/AIDS = 735 )
         Percent of Cases
  50

  40                36
                                   32    33

  30                                                                        25

  20                                                                                           16
             14                                                11                                   12
                                                        12
                                                                                 9
  10

   0
               MSM                   IDU            HETEROSEXUAL            PRESUMED           OTHER
                                                                          HETEROSEXUAL

                                               TB/AIDS              AIDS          IDU=Injection drug use
                                                                                  MSM=Male sex with male
                                                                                 *AIDS excludes those
                                                                                 diagnosed with TB
       MDPH, Office of Integrated Surveillance and Informatics Services


Note: Heterosexual risk is defined as sexual contact with someone of the opposite sex who is
known to be HIV infected or to be at risk for HIV infection. Presumed heterosexual contact is
defined as an individual with no other reported risk who has sexual partners of unknown HIV or
risk status.

At time of AIDS diagnosis, 43% of the TB/AIDS cases resided in the City of
Boston as compared to 25% of the TB cases and 31% of the AIDS cases.




                                                                 22
  Figure 35. Proportion of TB/AIDS , AIDS*, and TB**
Cases Residing in Boston * Massachusetts, 1982 – 2008
                   (TB/AIDS = 735)
           Percent of Cases
   60

   50
                       43
   40
                                                                                 31
   30                                                 25

   20

   10

    0
                  TB/AIDS                            TB*                       AIDS

                                                                   *Residence at time of AIDS diagnosis
                                                                   **TB Cases from 1993-2008
MDPH, Office of Integrated Surveillance and Informatics Services




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