Current Refugee Resettlement
and TB Incidence Data
United States and Minnesota
MDH TB Advisory Committee
October 14, 2010
Marge Higgins and Deb Sodt
Refugee Arrivals to MN by Region of World
1979-2010*
8000
Number of arrivals
7000
6000
5000
4000
3000
2000
Southeast Asia
FSU
Sub-Saharan Africa
Middle East/North Africa
Refugee Health Program, Minnesota Department of Health
Eastern Europe
Other
1/1/2010 – 10/5/2010
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
0
1979
1000
“Well it all depends.
Where are these huddled
masses coming from?”
National Refugee Admissions Ceilings for
FY2007
Unallocated
29%
Africa
31%
Near East/
South Asia
8%
Latin America/
Caribbean
7%
Europe &
Central Asia
9%
East Asia
16%
N=70, 000
Africa
East Asia
Europe & Central Asia
Latin America/Caribbean
Near East/South Asia
Unallocated
Source: US Department of State
National Refugee Admissions Ceilings for
FY2008
Unallocated
13%
Africa
20%
Near East/
South Asia
35%
East Asia
25%
Latin America/
Caribbean
4%
Europe &
Central Asia
4%
N=80, 000
Africa
East Asia
Europe & Central Asia
Latin America/Caribbean
Near East/South Asia
Unallocated
Source: US Department of State
National Refugee Admissions Ceilings for
FY2009
Unallocated
6%
Near East/
South Asia
46%
Latin America/
Caribbean
6%
Africa
15%
Europe &
Central Asia
3%
East Asia
24%
N=80, 000
Africa
East Asia
Europe & Central Asia
Latin America/Caribbean
Near East/South Asia
Unallocated
Source: US Department of State
National Refugee Admissions Ceilings for
FY2010
Unallocated
6%
Africa
19%
East Asia
21%
Near East/
South Asia
45%
Latin America/
Caribbean
6%
Europe &
Central Asia
3%
N=80, 000
Africa
East Asia
Europe & Central Asia
Latin America/Caribbean
Near East/South Asia
Unallocated
Source: US Department of State
Largest Refugee Country of Origin
by State, Fiscal Year 2008
Burma
Sudan
Burundi
Iraq
Soviet Union
Cuba
Somalia
Iran
Bhutan
No Data
Data taken from the U.S. Department of Health and Human Services, located at
http://www.acf.hhs.gov/programs/orr/data/fy2008RA.htm
Primary Refugee Arrivals By State, FY2007
1. CALIFORNIA
6,706
2. TEXAS
4,401
3. MINNESOTA
3,198
4. NEW YORK
2,978
5. FLORIDA
2,691
6. WASHINGTON
2,216
7. ARIZONA
1,992
8. ILLINOIS
1,872
9. NORTH CAROLINA
1,810
10. GEORGIA
1,617
Total Admitted
48,281
Notifications to Minnesota: 3182 Primary Refugees, 259 Asylees, 6 Parolees and 4 Victims of Trafficking
Source: Office of Refugee Resettlement (ORR), U.S. DHHS
Primary Refugee Arrivals By State, FY2008
1. California
2. Texas
3. Florida
4. New York
5. Michigan
6. Arizona
7. Illinois
8. Georgia
9. North Carolina
10. Washington
15. Minnesota
9,480
5,130
3,723
3,631
3,298
3,006
2,429
2,325
2,278
2,254
1,329
Total admitted
60,193
* Numbers include Amerasian, Asylees (Derivatives), Entrants/Parolees and Primary Refugee arrivals
Source: U.S. Office of Refugee Resettlement
Primary Refugee Arrivals By State, FY2009
1. California
2. Texas
3. New York
4. Arizona
5. Florida
6. Michigan
7. Georgia
8. Washington
9. Illinois
10. North Carolina
25. Minnesota
11,278
8,212
4,412
4,320
4,193
3,500
3,272
2,581
2,561
2,247
994
Total admitted
74,654
* Numbers include Amerasian, Asylees (Derivatives), Entrants/Parolees and Primary Refugee arrivals
Source: U.S. Office of Refugee Resettlement
Kittson
2009 Primary Refugee Arrival
To Minnesota (N=1,265)
Lake
of the
Woods
Roseau
Koochiching
Marshall
St. Louis
Beltrami
Pennington
Polk
Cook
Clear
Water
Red Lake
Lake
Itasca
Mahnomen
Norman
Hubbard
Cass
Becker
Clay
Aitkin
Wadena
Crow Wing
Number of Refugees Arrival By
Initial County Of Resettlement
Carlton
Ottertail
Wilkin
Pine
Todd
Mille
Lacs
Grant
Douglas
Stevens
Pope
Kanabec
0
Morrison
Benton
Traverse
Stearns
1- 10
Isanti
Big Stone
Sherburne
Swift
Kandiyohi
Chisago
11 - 30
Washing-
31 - 50
Anoka
Meeker
71
Wright
Chippewa
Hennepin
Hennepin
Lac Qui Parle
McLeod
Renville
Ram-ton
sey
51 - 100
Carver
Scott
Yellow Medicine
201 - 300
Dakota
Sibley
Lincoln
Lyon
Redwood
Le
Sueur
Nicollet
Rice
601 - 800
Goodhue
Wabasha
Brown
Pipestone
Murray
Cottonwood
Rock
Nobles
Jackson
Watonwan
Martin
Blue Earth
Faribault
Waseca
Steele
Freeborn
Dodge
Mower
Olmsted
Winona
Fillmore
Houston
Primary Refugee Arrivals, Minnesota
1/1/2010 – 10/5/2010
Congo (DR) FSU
Ethiopia
Bhutan
2%
1%
5%
9%
Haiti
1%
Other
6%
Iraq
9%
Burma
36%
Somalia
31%
N=1,916
“Other” includes Cameroon, China (incl. Tibet), Colombia, Cuba, Eritrea, FSU*, Iran, Kenya, Laos (Hmong),
Liberia, Rwanda, Sierra Leone, Sudan and Togo
*“FSU” includes Belarus, Kyrgyzstan, Moldova, Ukraine and Uzbekistan
Refugee Health Program, Minnesota Department of Health
Top 6 MN Counties of Primary
Refugee Resettlement
1.
2.
3.
4.
5.
6.
2009
Ramsey
673
Hennepin
283
Anoka
81
Olmsted
78
Scott
36
Dakota
26
Total
1,177
1.
2.
3.
4.
5.
6.
2010*
Ramsey 1,191
Hennepin
359
Stearns
113
Olmsted
78
Anoka
64
Rice
23
Total
1,828
*1/1/2010- 10/05/2010
Refugee Health Program, Minnesota Department of Health
Country of Origin by County of Resettlement, 2009
125
600
100
480
Burma
Bhutan
Somalia
Eritrea
Ethiopia
Other
360
240
120
Somalia
FSU
Liberia
Ethiopia
Bhutan
Eritrea
Other
75
50
25
0
0
Ramsey
Hennepin
N=673
N=283
60
50
50
40
40
30
FSU
Iraq
Other
20
10
Iraq
Somalia
Sudan
Other
30
20
10
0
Anoka
N=81
Refugee Health Program, Minnesota Department of Health
0
Olmsted
N=78
Country of Origin by County of Resettlement, 2010*
225
700
200
580
Burma
Somalia
Bhutan
Iraq
Ethiopia
Eritrea
Congo (DR)
Other
460
340
220
100
175
Somalia
Ethiopia
Bhutan
FSU
Congo (DR)
Other
150
125
100
75
50
25
0
-20
Ramsey
Hennepin
N=1,191
N=359
60
110
100
90
80
70
60
50
40
30
20
10
0
50
40
Somalia
Iraq
30
Other
20
Iraq
Somalia
Other
10
Stearns
N=113
Refugee Health Program, Minnesota Department of Health
0
Olmsted
N=78
Primary Refugees without U.S. Ties (Free Cases)
Minnesota, 2009
Eritrea
6%
Ethiopia
1%
Bhutan
15%
Somalia
32%
Burma
20%
Iraq
26%
N=179
14% of arrivals
Jul - Dec 2008: The first 44 refugees without U.S. Ties arrived in Minnesota.
They were from Iraq and settled in Olmsted Co.
Refugee Health Program, Minnesota Department of Health
Primary Refugees without U.S. Ties (Free Cases)
Minnesota, 2010*
Congo (DR)
3%
Ethiopia
3%
Bhutan
9%
Eritrea
2%
Other
1%
Somalia
44%
Iraq
12%
N=864
Burma
26%
„Other‟ includes Cuba and Sudan
Refugee Health Program, Minnesota Department of Health
45% of arrivals
*1/1/2010- 10/05/2010
Immigrant vs.Refugee
Class B1 arrivals
Class B1 Arrivals 2007
2008
2009
2010
Refugee
Immigrant
94
114
73
116
92
106
271
109
Immigrant arrivals:
• More difficult to locate
• No VOLAG or other resettlement service
available to assist with health issues
• Uninsured
• Resettle in counties not familiar with
refugee & TB Class follow-up screening
Resettlement Challenges
• Significant, rapid changes in the number
and demographics of refugee arrivals
• Secondary migration
• ‘Free’ and ‘Special Medical’ Cases
 Demands increased coordination and communication
between MDH, LPH, providers and Volags and
refugees
 Optimizing communication between various different
resources to support the individual / family
Reported TB Cases*
United States, 1977–2009
No. of Cases
28,000
26,000
24,000
22,000
20,000
18,000
16,000
14,000
12,000
10,000
1977
1980
1984
1987
1990
1993
1996
1999
2002
2005
Year
*Updated as of March, 2010.
Adapted from CDC
2010
National Decrease in TB Cases
2009
• # cases down 10.6% from 2008
• Incidence rate down 11.4%
• Decrease began in late 2008 and started to level
off in August 2009
• The decrease appears to be “real” and not a
result of underreporting
– Dramatic decrease in TB drug prescriptions nationally
– Fewer PH lab TB specimens were culture-positive
• # of foreign-born cases decreased more than
U.S.-born, especially among those in the U.S.
for < 2 years
Source: CDC
National Decrease in TB Cases
2009, cont‟d
• Possible explanations
– Revised Technical Instructions for overseas
panel physicians
– Fewer undocumented living in United States
due to anti-immigration activity and/or poor
economy??
Source: CDC
Reported TB Cases,
Minnesota,
1989-2009
Tuberculosis Disease,
Minnesota, 2009
23 (26%) of
counties
reported at
least one TB
case in 2009
Cases of Tuberculosis by Risk Category,
Minnesota, 2005-2009
Risk Category*
2005
(N=199)
No. (%)
2009
2008
Cumulative
2006
2007
(N=217) (N=238) (N=211) (N=161) (N=1,026)
No. (%)
No. (%) No. (%) No. (%) No. (%)
Foreign-born
173 (87)
175 (81) 203 (85) 155 (73) 129 (80)
Substance abuse†
835 (81)
14 ( 7)
13 ( 6)
16 ( 7)
21 (10)
10 ( 6)
74 ( 7)
4 ( 2)
5 ( 2)
6 ( 3)
11 ( 5)
4 ( 2)
30 ( 3)
12 ( 6)
8 ( 4)
12 ( 5)
11 ( 5)
7 ( 4)
50 ( 5)
Other medical condition** 16 ( 8)
31 (14)
39 (16)
23 (11)
23 (14)
132 (13)
Homeless
HIV-infected
Inmate
4 ( 2)
3 ( 1)
2 ( 1)
5 ( 2)
3 ( 2)
17 ( 2)
Nursing home resident
1 ( 1)
1 (<1)
1 (<1)
3 ( 1)
1 ( 1)
7 ( 1)
* Risk categories are not mutually exclusive.
†
Alcohol abuse and/or illicit drug use
** Silicosis, diabetes, prolonged corticosteroid therapy or other immunosuppressive therapy, hematologic/
reticuloendothelial disease, end-stage renal disease, substantial weight loss (not TB-related) or
undernutrition
Tuberculosis Cases by Method of Case
Identification, Minnesota, 2005-2009
How Identified
Presented with symptoms
TB contact investigation
2005
No. (%)
156 (78)
2006
No. (%)
2007
No. ( %)
2008
No. ( %)
2009
No. ( %)
170 (78) 193 (81) 163 (77) 131 (81)
8 ( 4)
10 ( 5)
15 ( 6)
27 (13)
10 ( 6)
Refugee health exam (domestic)
15 ( 8)
17 ( 8)
13 ( 5)
6 ( 3)
1 ( 1)
Pre-immigration exam (overseas)
6 ( 3)
5 ( 2)
7 ( 3)
4 ( 2)
3 ( 2)
14 ( 7)
15 ( 7)
10 ( 4)
11 ( 5)
16 (10)
199 (100)
217 (100)
Other*
Total
238 (100) 211 (100) 161 (100)
* e.g., occupational screening, other targeted tuberculin skin testing, etc.
TB Cases Transferred from Other Jurisdictions
by Place of Birth, MN, 2005-2010*
Year
2005
2006
2007
2008
2009
2010*
* As of 10/11/10
Foreign-Born
Cases
No. (%)
8
17
10
16
8
8
67
( 62)
( 89)
(100)
(100)
( 89)
( 89)
(88%)
U.S.-Born
Cases
No. (%)
5
2
0
0
1
1
9
(38)
(11)
( 0)
( 0)
(11)
(11)
(12%)
Total
No.
13
19
10
16
9
9
76
Minnesota TB Cases
January-September 2010
•
•
•
•
•
97 cases (down 7% from 2009)
15 (17%) of counties
No MDR
4 (4%) HIV+
How identified? (January-June only)
–
–
–
–
–
85% presented with symptoms
13% “other”
2% contact investigation
0% refugee screening
0% pre-immigration screening (“TB Class condition”)
Do we need to change
strategies?
What does this mean for
TB control in Minnesota in
the next 5-10 years?