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Slide Set— Epidemiology of Pediatric Tuberculosis in the United States, 1993–2012

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Slide 1

Epidemiology of Pediatric Tuberculosis in the United States, 1993—2012

Surveillance, Epidemiology, and Outbreak Investigations Branch Division of Tuberculosis Elimination
Centers for Disease Control and Prevention (CDC)
 

Slide 2

Pediatric TB—Background

  • Definition of pediatric tuberculosis (TB): TB disease in a person <15 years old
  • In 2012,
    • 9,945 TB cases were reported among all age groups
    • 486 (4.9%) were pediatric
    • 260 (2.6%) in ages 0 – 4
    • 226 (2.3%) in ages 5 - 14

Slide 3

2009 TB Case Definition and Verification

  • Incident case of disease
  • Case verification categories:
    1. Laboratory confirmed cases (Gold Standard):
      • Positive culture or nucleic acid amplification test
      • Positive AFB smear when culture not attainable
    2. Clinical case definition
      • Positive tuberculin skin test or positive interferon gamma release assay
      • Signs and symptoms of TB disease
      • Current treatment for TB disease
      • Completed diagnostic evaluation
    3. Provider diagnosis:
      • Diagnosed by health care provider
      • Does not fulfill all criteria necessary to meet laboratory or clinical case definitions

Slide 4

TB Cases, All Ages, by Age Group, 1993–2012

Slide 4

TB Cases, All Ages, by Age Group, 1993–2012

 19931994199519961997199819992000200120022003200420052006200720082009201020112012
<15
yrs
1661165915361356125110771038965929944911953854803776786647637577486
15-24
yrs
18211832169716371674154315181618159714981573160315411532158014431278120010331020
25-44 yrs95909043820075646884633560625576561052885074493947404691431642433887367233673118
45-64 yrs61976125596055725278495448604635451541824283419241244041404039363429343932933114
65+
yrs
58215540532950764663437840203515329331422994281128092664257424972288223022462204

Slide 5

TB Case Rates, All Ages, by Age Group 1993–2012

 19931994199519961997199819992000200120022003200420052006200720082009201020112012
Overall US9.79.38.68.07.46.86.45.85.65.25.15.04.84.64.44.23.83.63.43.2
<15 yrs2.92.92.72.32.21.91.81.61.51.61.51.61.41.31.31.31.11.00.90.8
15-24 yrs5.05.14.74.54.64.14.04.14.03.73.83.93.73.63.73.42.92.82.42.3
25-44 yrs11.610.99.89.08.27.67.36.66.66.36.05.95.75.65.25.14.74.54.13.8
45-64 yrs12.512.011.410.49.58.78.27.47.06.36.25.95.75.45.35.04.34.243.8
65+ yrs17.716.715.814.913.612.711.610.09.38.88.37.77.67.16.86.45.85.55.45.1

Note: Rates presented on a logarithmic scale

Slide 6

Percent of Pediatric TB Cases by Age Group 1993–2012
N=19,840

 

Age < 1

Age 1-4

Age 5-9

Age 10-14

Pediatric

10.0

48.9

22.5

18.6

Slide 7

Pediatric TB Cases by Age Group 1993–2012
N=19,840

 19931994199519961997199819992000200120022003200420052006200720082009201020112012
Age < 11561391181021111039691971019582809111411594777258
Age 1-4859856776668623535506453446455452468397391352381309288279202
Age 5-935839539336830524325022220819619520319515915914214013996109
Age 10-14288269249218212196186199178192169200182162151148104133130117

 

Slide 8

TB Case Rates by Pediatric Age Groups 1993–2012
N=19,840

 19931994199519961997199819992000200120022003200420052006200720082009201020112012
Age < 14.03.63.12.72.92.72.52.42.42.52.32.01.92.22.62.72.21.81.81.5
Age 1-45.45.44.94.34.13.53.33.02.92.92.82.92.42.42.12.31.81.71.71.3
Age 5-91.92.12.11.91.51.21.31.11.01.01.01.01.00.80.80.70.70.70.50.5
Age 10-141.61.41.31.11.11.01.01.00.90.90.80.90.90.80.70.70.50.70.70.5

Note: Rates presented on a logarithmic scale

Slide 9

Pediatric TB Cases by Race/Ethnicity 1993–2012
N=19,840

 19931994199519961997199819992000200120022003200420052006200720082009201020112012
White,
non-Hispanic
2502301851571361371251048710382766564704847464736
Black,
non-Hispanic
559572517515469372345335310330257289263251225228158177157125
Hispanic639642624512438423432374413401431457396387353357310283255187
American Indian/
Alaskan Native
223134372915152781313131299104131219
Asian/
Pacific Islander
151158146110138979795948211510399841041321079387104

Note: Unknown, multiple race/ethnicity, and Native Hawaiian and Other Pacific Islander not shown



Slide 10

Pediatric TB Case Rates by Race/Ethnicity 1993–2012
N=19,840

 19931994199519961997199819992000200120022003200420052006200720082009201020112012
White, non-Hispanic0.70.60.50.40.40.40.30.30.20.30.20.20.20.20.20.10.10.10.10.1
Black, non-Hispanic6.76.86.16.15.54.44.13.73.43.72.93.332.92.62.71.92.11.91.5
Hispanic8.48.17.6654.64.63.53.83.53.73.83.232.62.62.221.71.3
Asian/Pacific Islander7.67.76.856.14.144.64.43.75.14.44.13.44.15.143.43.23.7

Rates presented on a logarithmic scale.
Note: Unknown, multiple race / ethnicity, American Indian/Alaska Native, and Native Hawaiian and Other Pacific Islander
rates not shown because of small denominators

Slide 11

Pediatric TB Case Rates by Age Groups U.S.-born, 1994–2012
N=14, 780


 1994199519961997199819992000200120022003200420052006200720082009201020112012
Age < 1, FB3.32.82.42.72.32.32.12.22.62.62.21.92.12.62.52.21.71.81.4
Age 1-4, FB4.44.13.63.42.92.72.42.32.42.22.3221.821.61.51.41
Age 5-9, FB1.31.41.31.10.90.80.80.60.60.60.70.60.60.50.40.50.50.30.4
Age 10-14, FB0.80.70.60.60.60.50.50.50.50.40.50.40.40.40.30.30.40.40.3


Note: Rates presented on a logarithmic scale. Data is not available before 1994.
 


 

Slide 12

Pediatric TB Case Rates by Age Groups Foreign-born, 1994–2012
N=4, 986


 1994199519961997199819992000200120022003200420052006200720082009201020112012
Age < 1, FB23.3106.345.1177.643.555.753.769.79.325.49.416.2217.832.452.87.826.75.622.4
Age 1-4, FB61.156.637.838.632.334.228.524.824.134.532.524.121.925.319.61712.417.718
Age 5-9, FB22.722.716.613.29.915.311.115.29.81210.711.269.28.18.57.44.56.7
Age 10-14, FB14.81612.110.69.27.98.68.69.37.710.89.27.86.98.14.16.56.36.2


Note: Rates presented on a logarithmic scale. Data is not available before 1994.
 

Slide 13

Number of U.S.- and Foreign-born Pediatric TB Cases and Foreign-born Percent, 1993–2012

 1994199519961997199819992000200120022003200420052006200720082009201020112012
Foreign-born413386353313287249265255269249268280243200206203140152120
U.S.-born1231125211811040960822762708659690643671607603570582507484457
Percent foreign-born24.923.32323.122.923.125.526.42926.429.429.428.624.926.525.921.623.920.8

Slide 14

Foreign-born Pediatric TB Cases by Birth Country* and 6-Year Interval, 1995–2012
N=4,187

1999-2002 (n)2003-2006 (n)2007-2012 (n)
Mexico (651)Mexico (515)Mexico (159)
Philippines (154)Somalia (109)Ethiopia (86)
Viet Nam (94)Philippines (94)Philippines (78)
Somalia (78)Haiti (70)Haiti (53)
Russia (54)Viet Nam (52)Somalia (53)
Haiti (52)India (48)Myanmar (53)
Other (639)Other (621)Other (474)

*Ranked by counts

Slide 15

States with the Greatest Percent of the U.S. Total Pediatric TB Cases, 1993–2012
N=19,840

 CaliforniaTexasNew YorkFloridaIllinoisGeorgiaAll Others
U.S. Total23.912.48.25.34.44.441.3

Slide 16

States with Greatest Numbers of Pediatric TB Cases, 1993–2012

Pediatric TB Cases

StateNumberPercent* Rate**
California4,7517.13.1
Texas2,4537.22.4
New York1,6174.62.2
Florida1,0604.61.7
Illinois8797.72.4
Georgia8776.31.7
All Others8,2035.91.2
Overall U.S.19,8406.21.7

*Average percent of total state cases that are pediatric, for all years
**Time-averaged annual rate per 100,000

Slide 17

States with Greatest Percent of Pediatric TB cases, 1993–2012

StateNumberPercent*Rate**
Alaska15311.94.9
Rhode Island9310.72.4
Oklahoma34710.52.3
Minnesota36510.11.7
Delaware329.11
Arizona17791
All Others18,67361.7
Overall U.S.19,8406.21.7

*Average percent of total state cases that are pediatric, for all years
**Time-averaged annual rate per 100,000
 

Slide 18

States with Greatest Rate of Pediatric TB Cases, 1993–2010

StateNumberPercent*Rate**
Alaska15311.94.9
D.C.†6643.6
California4,7517.13.1
Texas2,4537.22.4
Georgia9310.72.4
Oklahoma8797.72.4
All Others11,4455.51.2
Overall U.S.19,8406.21.7

*Average percent of total state cases that are pediatric, for all years
**Time-averaged rate per 100,000
†D.C. (District of Columbia) is a distinct reporting jurisdiction

Slide 19

Pediatric TB Cases by Case Verification Criterion*, 1993–2012
N=19,840

Laboratory Confirmed

Clinical Case

Provider Diagnosis

26%

51%

23%

*Based on the public health surveillance definition for TB [MMWR 1997:46(No. RR-10):40-41]

Slide 20

Pediatric TB Cases by Case Verification Criterion and Age Group, 1993–2012
N=19,840

Age < 1 n=1,992

Laboratory Confirmed

Clinical Case

Provider Diagnosis

51%

26%

23%

Age 1-4 n=9,692

Laboratory Confirmed

Clinical Case

Provider Diagnosis

20%

54%

25%

Age 5-9 n=4,474

Laboratory Confirmed

Clinical Case

Provider Diagnosis

16%

60%

24%

Age 10-14 n=3,436

Laboratory Confirmed

Clinical Case

Provider Diagnosis

37%

46%

16%

Slide 21

Pediatric TB Cases by Site of Disease, 1993–2012

 

Both

Extrapulmonary

Pulmonary

Site of Disease

7.2%

22.2%

70.6%

Any extrapulmonary involvement*
(totaling 29.4%)

Lymphatic

18.8%

Meningeal

3.4%

Miliary

1.4%

Bone & Joint

1.5%

Other

4.3%

* Any extrapulmonary involvement which includes cases that are extrapulmonary only and both.
Patients may have more than one disease site but are counted in mutually exclusive categories for
surveillance purposes.

Slide 22

Pediatric TB Cases by Site of Disease and Age Group, 1993–2012
N=19,840

Age <1 n=1,992

 

Pulmonary

Extrapulmonary

Both

Site of Disease

75.3%

10.4%

14.3%

Age 1-4 n=9,215

 

Pulmonary

Extrapulmonary

Both

Site of Disease

71.7%

20.9%

7.3%

Age 5-9 n=4,270

 

Pulmonary

Extrapulmonary

Both

Site of Disease

69.6%

25.6%

4.7%

Age 10-14 n=3,436

 

Pulmonary

Extrapulmonary

Both

Site of Disease

66.1%

27.8%

6.0%

Slide 23

Percent of Pediatric TB Cases with Any Extrapulmonary Involvement* by Age Group and Selected Sites of Disease, 1993–2012
N=19,840

Site of DiseaseAge < 1
(n=1,862)
Age 1-4
(n=9,215)
Age 5-9
(n=4,270)
Age 10-14
(n=3,436)
Lymphatic7.919.42219.5
Meningeal8.23.81.62
Miliary4.71.10.51.2
Bone & Joint0.41.31.72.4
Other3.52.64.58.7
Total24.728.230.333.8

*Any extrapulmonary involvement includes extrapulmonary only and both Note: Combine the total extrapulmonary percent shown with the pulmonary percent in slide #21 to obtain 100% for each age group.

Slide 24

Percent of TB Cases in Children Age < 1 Year With Any Extrapulmonary Involvement*, 1993–2012
N=1,992

Site of DiseaseU.S.-bornForeign-born
Lymphatic7.20%17.70%
Meningeal8.60%2.80%
Miliary4.90%3.60%
Bone & Joint0.30%0.70%
Other3.40%3.60%
Total24.40%28.40%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 25

Percent of TB Cases in Children Age 1 - 4 Years With Any Extrapulmonary Involvement*, 1993–2012
N=9,692

Site of DiseaseU.S.-bornForeign-born
Lymphatic19.50%18.60%
Meningeal4.20%2.00%
Miliary1.20%0.90%
Bone & Joint1.10%2.20%
Other2.70%2.00%
Total28.70%25.70%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 26

Percent of TB Cases in Children Age 5 - 9 Years With Any Extrapulmonary Involvement*, 1993–2012
N=4,474

Site of DiseaseU.S.-bornForeign-born
Lymphatic23.30%19.70%
Meningeal2.00%1.00%
Miliary0.50%0.60%
Bone & Joint1.30%2.40%
Other4.60%4.30%
Total31.70%28.00%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 27

Percent of TB Cases in Children Age 10-14 Years With Any Extrapulmonary Involvement*, 1993–2012
N=3,682

Site of DiseaseU.S.-bornForeign-born
Lymphatic20.30%18.70%
Meningeal2.00%2.00%
Miliary1.50%0.70%
Bone & Joint2.10%2.70%
Other9.80%7.40%
Total35.70%31.50%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 28

Pediatric TB Cases by HIV Status, 1993–2011*
N=19,354

  • Information on HIV result is not available for the majority of pediatric TB cases (75.9%)
     
  • Percent of pediatric TB cases with HIV-positive test results, minimum estimate** (0.9%)
     
  • Percent of pediatric cases with HIV-positive test results of those patients with known results (3.7%)

*California HIV data missing from 2004 – 2010; Vermont HIV data through 2006 only.
**Pediatric TB cases with positive HIV test results divided by all pediatric TB cases.
California only reported positive HIV test results based on TB and AIDS registry matching through 2004; all other California TB cases were classified as “Unknown.”

Slide 29

Number and Percent of Culture-confirmed Pediatric TB Cases with Drug Resistance, 1993–2011

 1993199419951996199719981999200020012002200320042005200620072008200920102011
Resistance to any 1st line drug31433138382828273833314038272444322217
Percent with resistance to any 1st line drug9.713.310.312.713.412.212.311.31514.714.817.418.213.311.321.419.413.811.1
MDR TB6646465134315445323
Percent with MDR TB1.91.91.321.42.62.20.41.21.81.40.42.421.92.41.81.32

First line drugs are Isoniazid, Rifampin, Pyrazinamide and Ethambutol
MDR TB = resistance to at least Isoniazid and Rifampin

Slide 30

Pediatric TB Cases by Use of Directly Observed Therapy (DOT), 1993–2010
N=18,719*

 199319941995199619971998199920002001200220032004200520062007200820092010
DOT only22.126.94147.455.558.356.661.761.964.563.565.864.665.263.768.366.364.9
Self-Administered only64.35134.528.220.117.115.113.411.37.66.36.36.64.743.54.85.2
DOT and Self-Administered12.119.122.322.122.523.426242626.329.325.727.930.1322728.129.6

*Pediatric TB cases with patient alive at diagnosis and started on treatment

Slide 31

Pediatric TB Cases by Treatment Outcome 1993–2010
N=18,719*

OutcomeCases%
Completed treatment17,85895.4
Moved3972.1
Lost to follow-up1600.9
Died1020.5
Other**2021.1

Note: Cause of death not recorded in TB case reports
*Pediatric TB cases with patient alive at diagnosis and started on treatment
**Other includes refused, other, unknown and missing

Slide 32

Deaths Occurring Among Pediatric TB Cases, by Age Group, 1993–2010
N=18,877

Age GroupCasesDeaths*% of Cases
Age<11,862341.8
Age 1-49,211610.7
Age 5-94,269270.6
Age 10-143,435240.7

Note: Cause of death not recorded in TB case reports
*Death includes died during therapy or dead at TB diagnosis

 
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  • Page last updated: April 21, 2014
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