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2002 Surveillance Slides

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Tuberculosis in the United States

National Surveillance System Highlights from 2002

Slide 1 (title slide): Tuberculosis in the United States: National Surveillance System, Highlights from 2002.  This slide set was prepared by the Division of Tuberculosis Elimination, Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (DHHS).  It provides highlights from the data collected through the national TB surveillance system for 2002.  Since 1953, through the cooperation of state and local health departments, CDC has collected information on the numbers of reported TB cases in the United States.  The data presented here were primarily collected via the expanded TB case report introduced in 1993.  Currently, each individual TB case report (Report of Verified Case of Tuberculosis, or RVCT) is submitted electronically via the Tuberculosis Information Management System (TIMS).

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Slide 2: Reported TB Cases, United States, 1982-2002.  The resurgence of TB in the mid- 1980s was marked by several years of slightly increasing case counts followed by a substantial rise for several years. The total number of TB cases peaked in 1992. From 1992 until 2002, the total number of TB cases decreased 5%-7% annually, and 2002 marks the tenth year of decline in the total number of TB cases reported in the United States since the peak of the resurgence. In 2002, a total of 15,075 TB cases were reported from the 50 states and the District of Columbia.  This represents a 6% decrease from 2001 and a 43% decline from 1992. (Note:  A provisional total of 15,078 was reported in the MMWR in March 2003.)

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Slide 3: TB Morbidity, United States, 1998-2002.  This slide provides the total number of reported U.S. TB cases and the associated TB rates for each of the past 5 years.  Rate is defined as cases per 100,000. The number of TB cases decreased from 18,361 in 1998 to 15,075 in 2002, and the TB rate also decreased from 6.8 in 1998 to 5.2 in 2002.

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Slide 4: TB Case Rates, United States, 2002. This map shows TB rates for 2002. Twenty-four states had a rate of less than or equal to 3.5 TB cases per 100,000, the interim goal for the year 2000 established by the Advisory Council for the Elimination of Tuberculosis. This group of states has remained fairly constant over the last decade; five states (CT, MI, NM, OR, and PA) joined the group in 2000, one state (MO) joined the group in 2001 (also in 1998 for one year only), and one state (DE) joined the group in 2002. States with a rate above the national average include the seven states that reported at least 500 cases in 2002: CA, FL, GA, IL, NJ, NY, and TX. These seven states accounted for 60% of the national total and have experienced substantial overall decreases in cases and rates since 1992. 

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Slide 5: TB Case Rates by Age Group, United States, 1992-2002. This slide shows the last decade’s declining trend in TB rates by age group.  The largest declines occurred in children under 15 years of age (from 3.1 per 100,000 in 1992 to 1.5 in 2002) and in adults aged 25 to 44 years (from 12.7 to 6.2), 45 to 64 years (from 13.4 to 6.3), and 65 years and older (from 18.7 to 8.8), each group having decreased approximately 50%.  The rate declined by approximately 33% in those 15 to 24 years of age (from 5.5 to 3.7), and the rate has remained at or below approximately 4 per 100,000 for the past 5 years.

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Slide 6: Reported TB Cases by Age Group, United States, 2002. This pie chart shows the age distribution of persons reported with TB in 2002. Six percent were children under 15 years of age and 10% were 15- to 24-year-olds, while 35% were 25 to 44 years of age, 28% were 45- to 64-year-olds, and 21% were at least 65 years old.

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Slide 7: TB Case Rates by Age Group and Sex, United States, 2002. This slide graphs the TB rates in 2002 by age group and sex. It shows that rates increase with age, ranging from a low of less than 2 per 100,000 in children to a high of 12 per 100,000 in men over 65 years old. The rates in adult men are approximately twice those in women.

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Slide 8: TB Case Rates by Race/Ethnicity, United States, 1992-2002. This slide shows the declining trend in TB rates by race/ethnicity during the last decade. Asians and Pacific Islanders had the highest TB rates, which declined from 46 per 100,000 in 1992 to 28 in 2002, but the least percentage decline over the decade (40%). Rates declined more than 50% over the decade in the other racial/ethnic groups: among non-Hispanic blacks from 32 in 1992 to 13 in 2002, among Hispanics from 22 to 10, among American Indians and Alaska Natives from 16 to 7, and among non-Hispanic whites from 4 to 2.

Several important factors likely contribute to the disproportionate burden of TB in minorities. In foreign-born persons from countries where TB is common, active TB disease may result from infection acquired in the country of origin. In racial and ethnic minorities, unequal distribution of TB risk factors, such as HIV infection, may also contribute to increased exposure to TB or to an increased risk of developing active TB once infected with M. tuberculosis. However, much of the increased risk of TB in minorities has been linked to lower socioeconomic status and the effects of crowding, particularly among U.S.-born persons.

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Slide 9: Reported TB Cases by Race/Ethnicity, United States, 2002. In 2002, 80% of all reported TB cases occurred in racial and ethnic minorities (30% in non-Hispanic blacks, 27% in Hispanics, 22% in Asians and Pacific Islanders, and 1% in American Indians and Alaska Natives), whereas 20% of cases occurred in non-Hispanic whites.

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Slide 10: TB Case Rates by Age Group and Race/Ethnicity, United States, 2002. This slide presents TB rates in 2002 by age group and race/ethnicity. Risk increased with age across racial and ethnic groups, and rates were consistently higher in minority racial and ethnic groups than in non-Hispanic whites. Rates were the highest in Asians and Pacific Islanders, particularly in adult age groups.The impact of non-U.S. birth is a consideration in interpreting rate variations by race/ethnicity. For example, 95% of cases in the Asian/Pacific Islander group occurred in foreign-born persons, compared with 75% of cases in Hispanics and 23% of cases in non-Hispanic blacks.

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Slide 11: Number of TB Cases in U.S.-born vs. Foreign-born Persons, United States, 1992-2002. This graph plots the number of U.S.-born vs. foreign-born persons reported with TB each year, from 1992 through 2002. This graph illustrates the sharp increase in the percentage of cases occurring in foreign-born persons during this period, which increased from 27% in 1992 to 51% in 2002, the first year the percentage exceeded 50%.  Overall, the number of cases in foreign-born persons remained at approximately 7,000-8,000 each year, whereas the number in U.S.-born persons substantially decreased from more than 19,000 in 1992 to less than 7,500 in 2002.

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Slide 12: Trends in TB Cases in Foreign-born Persons, United States, 1986-2002. This slide shows trends in TB cases in foreign-born persons in the United States from 1986, when information on country of birth was first reported by all areas submitting reports to CDC, through 2002. The number of TB cases in foreign-born persons increased from nearly 5,000 in 1986 to 7,000-8,000 each year since 1991. The percentage of TB cases accounted for by foreign-born persons increased from less than 25% in 1986 to 51% in 2002.

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Slide 13:  Percentage of TB Cases Among Foreign-born Persons, United States, 1992 and 2002. The percentage of the total number of TB cases that occurred in foreign-born persons in each state is highlighted for 1992 and 2002 in these two side-by-side maps. The number of states with at least 50% of cases in the foreign born increased from 4 (CA, HI, MA, RI) in 1992 to 22 in 2002, and the number of states with at least 70% increased from one (HI) in 1992 to seven (CA, CO, HI, ID, MA, MN, NH) in 2002.

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Slide 14: TB Case Rates in U.S.-born vs. Foreign-born Persons, United States, 1992-2002. TB rates in foreign-born persons remain substantially higher than those in the U.S.-born population. From 1992 through 2002, the rates in U.S.-born persons decreased from 8 per 100,000 to 3, whereas the rates in foreign-born persons decreased from 34 per 100,000 to 23.

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Slide 15: TB Case Rates in U.S.-born vs. Foreign-born Persons, United States, 1992-2002. This is the same as Slide 14 but the rates are presented on a logarithmic scale to provide a better comparison of the trend in TB rates among the U.S.-born and foreign-born. The lines show a marked rate of decline among the U.S.-born compared with a minimal decline for the foreign-born during the past decade.

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Slide 16: Countries of Birth for Foreign-born Persons Reported with TB, United States, 2002. This slide shows the overall distribution of the countries of birth for foreign-born persons reported with TB in 2002. The countries have remained relatively constant since 1986, when information on country of birth was first reported by all areas submitting reports to CDC. Seven countries accounted for more than 60% of the total, with Mexico accounting for 25%; the Philippines, 11%; Vietnam 8%, and India, 7%. Persons from China accounted for 5%; from Haiti and South Korea, each 3%. Persons from more than 140 other countries each accounted for 2% or less of the total but altogether accounted for 38% of foreign-born persons reported with TB.

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Slide 17: Length of U.S. Residence Prior to TB Diagnosis, United States, 2002. The length of U.S. residence among foreign-born persons prior to their TB diagnosis in 2002 is shown in these stacked bars. Overall, approximately 23% had been in the United States for less than 1 year, 28% between 1 and 4 years, and 49% for at least 5 years. The distribution is also shown for the top three countries of birth: the Philippines, Mexico, and Vietnam. Among persons born in the Philippines, 35% had been in the United States for less than 1 year, 16% between 1 and 4 years, and 49% for at least 5 years. Among persons born in Mexico, 18% had been in the United States for less than 1 year, 28% between 1 and 4 years, and 53% for at least 5 years. Among persons born in Vietnam, 21% had been in the United States for less than 1 year, 13% between 1 and 4 years, and 67% for at least 5 years.

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Slide 18: Primary Anti-TB Drug Resistance, United States, 1993-2002. Primary drug resistance is estimated for the previous 10 years.  The graph starts in 1993 because this is the year in which the individual TB case reports submitted to the national surveillance system began collecting information on initial susceptibility test results (for isolates) from patients with culture-positive TB. Data were available for more than 85% of culture-positive cases for each year. Primary resistance was estimated by using data from persons with no reported prior TB episode. Resistance to at least isoniazid remained between 7 and 8%.  However, resistance to at least isoniazid and rifampin known as multidrug-resistant TB (MDR TB) decreased from 2.5% in 1993 to 1.0% each year during 1998-2001, with an increase to 1.2% in 2002.

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Slide 19: Primary MDR TB, United States, 1993-2002. This graph focuses on trends in primary MDR TB (based on initial isolates from persons with no prior history of TB) in the United States from 1993 through 2002. The number of MDR TB cases, represented by bars, steadily declined from 410 in 1993 to 116 in 2001, with an increase to 121 cases in 2002. The percentage of cases with primary MDR TB, shown by the line, decreased from 2.5% in 1993 to 1.0% each year during 1998-2001, with an increase to 1.2% in 2002. 

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Slide 20: Primary Isoniazid Resistance in U.S.-born vs. Foreign-born Persons, United States, 1993-2002. This graph shows primary isoniazid resistance in U.S.-born vs. foreign-born persons. Among foreign-born persons, the percentage of isoniazid resistance (based on initial isolates from persons with no prior history of TB) was approximately two times higher than among U.S.-born persons. The percentage declined from 12.4 in 1993 to 9.6 in 2001 among foreign-born persons but then increased to 10.6% in 2002. Among U.S.-born persons, the percentage decreased from 6.8 in 1993 to 4.0 in 2002.

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Slide 21:  Primary MDR TB in U.S.-born vs. Foreign-born Persons, United States, 1993-2002. This graph highlights primary MDR TB in U.S.-born versus foreign-born persons. Both groups have seen decreases in the percentage of cases with primary MDR TB, although the decline in the U.S.-born has been greater. As a result, the proportion of primary MDR TB cases reported in foreign-born persons increased from approximately 25% in 1993 to 70% each year during 1999-2002. In 2002, for the first time since data on drug resistance has been collected by the national system, the percentage of U.S.-born persons with MDR TB increased, from 0.6% in 2001 to 0.8% in 2002.

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Slide 22: Completeness of HIV Test Results in Persons with TB by Age Group, United States, 1993-2001. This slide shows the completeness of reporting of HIV test results in persons with TB by age group from 1993 through 2001. The percentage of those with test results increased from 30% among all ages in 1993 to 49% in 2001. Among adults aged 25-44 years, the percentage increased from 46% to 62% in 2001. The numerator includes cases with positive, negative, or indeterminate HIV test results and cases from California in persons reported with AIDS (HIV test results are not reported from California). All cases from California in 2001 had an unknown HIV status.

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Slide 23: Estimated HIV Coinfection in Persons Reported with TB, United States, 1993-2001. This slide provides minimum estimates of HIV coinfection among persons reported with TB from 1993 through 2001. Since the addition of HIV to the individual TB case report in 1993, incomplete reporting has provided a challenge to calculating reliable estimates. Results from the cross-matching of TB and AIDS registries have been used to supplement reported HIV test results. For all ages, the estimated percentage of HIV coinfection in persons reported with TB decreased from 15% to 8% overall and from 29% to 15% in persons aged 25 to 44 during this period.

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Slide 24: Mode of Treatment Administration in Persons Reported with TB, United States, 1993-2000. In 1993, the reporting areas began collecting information about mode of treatment administration on the individual TB case report form. This slide is based on data received at CDC by April 2003. Treatment administered as only directly observed therapy (DOT) increased from approximately 22% in 1993 to 52% in 2000, the latest year with available data. The proportion of patients who received at least some portion of their treatment as DOT (based on combining the percentage of patients who received only DOT and the percentage for whom some portion was self-administered), also increased. In 2000, the proportion of patients who received at least some portion of their treatment as DOT was 78%.

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Slide 25: Completion of TB Therapy, United States, 1993-2000. The reporting areas began collecting information on completion of therapy in 1993 through the individual TB case report form. This slide is based on data received at CDC by April 2003. Patients with an initial isolate resistant to rifampin and children with meningeal, bone or joint, or miliary disease were excluded from the calculations. Overall completion remained at approximately 90%; however, completion of therapy in 1 year or less increased from <65% in 1993 to approximately 80% in 1998, 1999, and 2000.  The current DHHS Healthy People 2010 objective is completion of therapy in 1 year or less in 90% of patients. CDC is working with state and local health departments to evaluate reasons for apparently delayed completion of therapy, which may vary by jurisdiction.

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Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

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