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Slide Set— Epidemiology of Pediatric Tuberculosis in the United States, 1993–2010

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Slide 1

Epidemiology of Pediatric Tuberculosis in the United States, 1993—2010

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 2010,
    • 11,182 TB cases were reported among all age groups
    • 637 (5.7%) were pediatric
    • 365 (3.3%) in ages 0 – 4
    • 272 (2.4%) 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, 1993–2010

 

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

<15
yrs

1661

1659

1536

1356

1251

1077

1038

965

929

944

911

953

854

803

776

786

647

637

15-24
yrs

1821

1832

1697

1637

1674

1543

1518

1618

1597

1498

1573

1603

1541

1532

1580

1443

1278

1200

25-44 yrs

9590

9043

8200

7564

6884

6335

6062

5576

5610

5288

5074

4939

4740

4691

4316

4243

3887

3672

45-64 yrs

6197

6125

5960

5572

5278

4954

4860

4635

4515

4182

4283

4192

4124

4041

4040

3936

3429

3439

65+
yrs

5821

5540

5329

5076

4663

4378

4020

3515

3293

3142

2994

2811

2809

2664

2574

2497

2288

2230

Slide 5

TB Case Rates, All Ages, by Age Group 1993–2010

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Overall US

9.7

9.3

8.6

8.0

7.4

6.8

6.4

5.8

5.6

5.2

5.1

5.0

4.8

4.6

4.4

4.2

3.8

3.6

<15 yrs

2.9

2.9

2.7

2.3

2.2

1.9

1.8

1.6

1.5

1.6

1.5

1.6

1.4

1.3

1.3

1.3

1.1

1.0

15-24 yrs

5.0

5.1

4.7

4.5

4.6

4.1

4.0

4.1

4.0

3.7

3.8

3.9

3.7

3.6

3.7

3.4

2.9

2.8

25-44 yrs

11.6

10.9

9.8

9.0

8.2

7.6

7.3

6.6

6.6

6.3

6.0

5.9

5.7

5.6

5.2

5.1

4.7

4.5

45-64 yrs

12.5

12.0

11.4

10.4

9.5

8.7

8.2

7.4

7.0

6.3

6.2

5.9

5.7

5.4

5.3

5.0

4.3

4.2

65+ yrs

17.7

16.7

15.8

14.9

13.6

12.7

11.6

10.0

9.3

8.8

8.3

7.7

7.6

7.1

6.8

6.4

5.8

5.5

Note: Rates presented on a logarithmic scale

Slide 6

Percent of Pediatric TB Cases by Age Group 1993–2010
N=18,783

Age < 1

Age 1-4

Age 5-9

Age 10-14

Pediatric

9.9

49.1

22.7

18.3

Slide 7

Pediatric TB Cases by Age Group 1993–2010
N=18,783

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Age < 1

156

139

118

102

111

103

96

91

97

101

95

82

80

91

114

115

94

77

Age 1-4

859

856

776

668

623

535

506

453

446

455

452

468

397

391

352

381

309

288

Age 5-9

358

395

393

368

305

243

250

222

208

196

195

203

195

159

159

142

140

139

Age 10-14

288

269

249

218

212

196

186

199

178

192

169

200

182

162

151

148

104

133

 

Slide 8

TB Case Rates by Pediatric Age Groups 1993–2010
N=18,783

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Age < 1

4.0

3.6

3.1

2.7

2.9

2.7

2.5

2.4

2.4

2.5

2.3

2.0

1.9

2.2

2.6

2.7

2.2

1.8

Age 1-4

5.4

5.4

4.9

4.3

4.1

3.5

3.3

3.0

2.9

2.9

2.8

2.9

2.4

2.4

2.1

2.3

1.8

1.7

Age 5-9

1.9

2.1

2.1

1.9

1.5

1.2

1.3

1.1

1.0

1.0

1.0

1.0

1.0

0.8

0.8

0.7

0.7

0.7

Age 10-14

1.6

1.4

1.3

1.1

1.1

1.0

1.0

1.0

0.9

0.9

0.8

0.9

0.9

0.8

0.7

0.7

0.5

0.7

Note: Rates presented on a logarithmic scale

Slide 9

Pediatric TB Cases by Race/Ethnicity 1993–2010
N=18,783

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

White,
non-Hispanic

250

230

185

157

136

137

125

104

87

103

82

76

65

64

70

48

47

46

Black,
non-Hispanic

559

572

517

515

469

372

345

335

310

330

257

289

263

251

225

228

158

174

Hispanic

640

642

624

512

438

423

432

374

413

401

431

457

396

387

352

356

309

283

American Indian/
Alaskan Native

22

31

34

37

29

15

15

27

8

13

13

13

12

9

9

11

4

13

Asian/
Pacific Islander

184

181

175

134

178

128

116

122

111

94

123

114

108

89

117

138

123

113


Note: Unknown and multiple race/ethnicity not shown



Slide 10

Pediatric TB Case Rates by Race/Ethnicity 1993–2010
N=18,783

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

White, non-Hispanic

0.7

0.6

0.5

0.4

0.4

0.4

0.3

0.3

0.2

0.3

0.2

0.2

0.2

0.2

0.2

0.2

0.1

0.1

Black, non-Hispanic

6.7

6.8

6.1

6.1

5.5

4.4

4.1

3.7

3.4

3.7

2.9

3.3

3

2.9

2.6

2.7

1.8

2

Hispanic

8.4

8.1

7.6

6

5

4.6

4.6

3.5

3.7

3.5

3.6

3.7

3.1

3

2.6

2.6

2.2

1.9

Asian/Pacific Islander

9.3

8.8

8.2

6.1

7.8

5.5

4.8

5.6

4.9

4.1

5.2

4.7

4.3

3.4

4.4

5.1

4.4

4

Rates presented on a logarithmic scale.
American Indian/Alaska Native rate not shown because of small denominators

Slide 11

Pediatric TB Case Rates by Age Groups U.S.-born and Foreign-born, 1994–2010
N=17,054


 

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Age < 1, FB

45.7

40.8

65.2

25.8

48.9

72.6

37.4

29.4

12.1

70.3

23.1

11.2

28.2

16.6

39.4

17.4

15.8

Age 1-4, FB

43.6

46.5

33.1

33.7

34.3

31.8

30.0

27.0

25.2

29.9

33.6

22.8

21.2

20.6

19.1

18.4

14.3

Age 5-9, FB

23.1

16.4

14.4

12.7

10.4

16.5

10.3

14.2

10.2

12.5

11.6

10.5

6.5

8.5

8.3

8.4

8.0

Age 10-14, FB

12.2

13.3

11.5

10.7

9.4

9.8

9.5

7.9

9.3

7.7

10.1

8.6

8.5

6.4

7.3

4.4

7.0

 

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Age < 1, USB

3.3

2.9

2.4

2.7

2.3

2.3

2.1

2.2

2.5

2.7

2.1

1.9

2.0

2.7

2.4

2.2

1.8

Age 1-4, USB

4.4

4.1

3.6

3.4

2.9

2.7

2.4

2.3

2.4

2.2

2.3

2.0

2.0

1.8

2.0

1.6

1.5

Age 5-9, USB

1.3

1.5

1.4

1.1

0.9

0.8

0.8

0.6

0.6

0.6

0.7

0.6

0.6

0.5

0.4

0.5

0.4

Age 10-14, USB

0.8

0.7

0.6

0.6

0.6

0.5

0.5

0.5

0.5

0.4

0.5

0.4

0.4

0.4

0.3

0.3

0.4

Note: Rates presented on a logarithmic scale. Data not available before 1994.
USB = U.S.-born, FB=Foreign-born (unknown excluded from table and counts)


Slide 12

Number of U.S.- and Foreign-born Pediatric TB Cases and Foreign-born Percent, 1993–2010

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Foreign-born

413

386

353

313

287

249

265

255

269

249

268

280

245

200

205

198

140

151

U.S.-born

1232

1252

1181

1040

960

822

762

708

659

690

643

672

608

603

570

580

507

484

Percent foreign-born

24.9

23.3

23

23.1

22.9

23.1

25.5

26.4

29

26.4

29.4

29.4

28.7

24.9

26.4

25.2

21.6

23.7


Slide 13

Foreign-born Pediatric TB Cases by Birth Country* and 4-Year Interval, 1999–2010
N=2,725

1999-2002 (n)

2003-2006 (n)

2007-2010 (n)

Mexico (375)

Mexico (324)

Mexico (125)

Somalia (79)

Somalia (65)

Ethiopia (68)

Philippines (67)

Philippines (63)

Philippines (57)

Haiti (38)

Haiti (45)

Haiti (42)

Viet Nam (36)

India (36)

Somalia (39)

Sudan (26)

Viet Nam (36)

Myanmar (36)

Other (417)

Other (424)

Other (327)

*Ranked by counts

Slide 14

States with the Greatest Percent of the U.S. Total Pediatric TB Cases, 1993–2010
N=18,783

California

Texas

New York

Florida

Illinois

Georgia

All Others

U.S. Total

24.2

12.1

8.3

5.3

4.5

4.4

41.2

Slide 15

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

Pediatric TB Cases

State

Number

Percent*

Rate**

California

4,536

7.3

3.3

Texas

2,277

7.2

2.5

New York

1,563

4.6

2.3

Florida

 988

4.5

1.8

Illinois

843

6.3

1.8

Georgia

830

7.7

2.5

All Others

7,746

6.0

1.2

Overall U.S.

18,783

6.2

1.8

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

Slide 16

States with Greatest Percent of Pediatric TB cases, 1993–2010

State

Number

Percent*

Rate**

Alaska

138

11.9

4.9

Rhode Island

89

10.8

2.5

Oklahoma

323

10.3

2.4

Minnesota

332

10.0

1.8

Delaware

57

9.3

2.0

Arizona

448

9.1

2.1

All Others

17,396

6.0

1.7

Overall U.S.

18,783

6.2

1.8

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

Slide 17

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

State

Number

Percent*

Rate**

Alaska

138

11.9

4.9

D.C.†

62

4.0

3.8

California

4,536

7.3

3.3

Texas

2,277

7.2

2.5

Georgia

830

7.7

2.5

Oklahoma

323

10.3

2.4

All Others

10,617

5.5

1.3

Overall U.S.

18,783

6.2

1.8

*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 18

Pediatric TB Cases by Case Verification Criterion*, 1993–2010
N=18,783

Laboratory Confirmed

Clinical Case

Provider Diagnosis

25%

51%

24%

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

Slide 19

Pediatric TB Cases by Case Verification Criterion and Age Group, 1993–2010
N=18,783

Age < 1 n=1,862

Laboratory Confirmed

Clinical Case

Provider Diagnosis

51%

25%

24%

Age 1-4 n=9,215

Laboratory Confirmed

Clinical Case

Provider Diagnosis

20%

53%

27%

Age 5-9 n=4,270

Laboratory Confirmed

Clinical Case

Provider Diagnosis

15%

60%

25%

Age 10-14 n=3,436

Laboratory Confirmed

Clinical Case

Provider Diagnosis

37%

46%

17%

Slide 20

Pediatric TB Cases by Site of Disease, 1993–2010

 

Both

Extrapulmonary

Pulmonary

Site of Disease

7.1%

22.2%

70.7%

Any extrapulmonary involvement*
(totaling 29.3%)

Lymphatic

18.9%

Meningeal

3.3%

Miliary

1.5%

Bone & Joint

1.4%

Other

4.2%

* 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 21

Pediatric TB Cases by Site of Disease and Age Group, 1993–2010
N=18,783

Age <1 n=1,862

 

Pulmonary

Extrapulmonary

Both

Site of Disease

75.0%

10.5%

14.5%

Age 1-4 n=9,215

 

Pulmonary

Extrapulmonary

Both

Site of Disease

71.7%

20.9%

7.4%

Age 5-9 n=4,270

 

Pulmonary

Extrapulmonary

Both

Site of Disease

69.9%

25.5%

4.6%

Age 10-14 n=3,436

 

Pulmonary

Extrapulmonary

Both

Site of Disease

66.4%

27.6%

6.0%

Slide 22

Percent of Pediatric TB Cases with Any Extrapulmonary Involvement* by Age Group and Selected Sites of Disease, 1993–2010
N=18,783

Site of Disease

Age < 1
(n=1,862)

Age 1-4
(n=9,215)

Age 5-9
(n=4,270)

Age 10-14
(n=3,436)

Lymphatic

8.0

19.4

22.0

19.5

Meningeal

8.0

3.7

1.6

1.8

Miliary

5.3

1.3

0.5

1.2

Bone & Joint

0.4

1.3

1.6

2.4

Other

3.3

2.6

4.3

8.6

Total

25.0

28.3

30.0

33.5

*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 23

Percent of TB Cases in Children Age < 1 Year With Any Extrapulmonary Involvement*, 1993–2010
N=1,862

Site of Disease

U.S.-born

Foreign-born

Lymphatic

7.3%

17.2%

Meningeal

8.4%

3.0%

Miliary

5.5%

3.7%

Bone & Joint

0.3%

0.8%

Other

3.3%

2.2%

Total

24.9%

26.9%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 24

Percent of TB Cases in Children Age 1 - 4 Years With Any Extrapulmonary Involvement*, 1993–2010
N=9,215

Site of Disease

U.S.-born

Foreign-born

Lymphatic

19.7%

18.5%

Meningeal

4.1%

2.0%

Miliary

1.3%

1.1%

Bone & Joint

1.1%

2.0%

Other

2.7%

2.0%

Total

28.9%

25.6%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 25

Percent of TB Cases in Children Age 5 - 9 Years With Any Extrapulmonary Involvement*, 1993–2010
N=4,270

Site of Disease

U.S.-born

Foreign-born

Lymphatic

23.2%

19.8%

Meningeal

1.8%

1.1%

Miliary

0.5%

0.6%

Bone & Joint

1.3%

2.3%

Other

4.4%

4.2%

Total

31.2%

28.0%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 26

Percent of TB Cases in Children Age 10-14 Years With Any Extrapulmonary Involvement*, 1993–2010
N=3,436

Site of Disease

U.S.-born

Foreign-born

Lymphatic

20.2%

18.7%

Meningeal

1.9%

1.8%

Miliary

1.7%

0.7%

Bone & Joint

2.1%

2.8%

Other

9.4%

7.5%

Total

35.3%

31.5%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 27

Pediatric TB Cases by HIV Status, 1993–2009*
N=18,146

  • Information on HIV result is not available for the majority of pediatric TB cases (77.6%)
     
  • 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 (4.2%)

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

Slide 28

Number and Percent of Culture-confirmed Pediatric TB Cases with Drug Resistance, 1993–2009

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Resistance to any 1st line drug

31

43

31

38

38

28

28

27

38

33

31

40

38

27

24

45

32

Percent with resistance to any 1st line drug

9.7

13.3

10.3

12.7

13.4

12.2

12.3

11.3

15

14.7

14.8

17.4

18.2

13.3

11.4

21.7

19.4

MDR TB

6

6

4

6

4

6

5

1

3

4

3

1

5

4

4

5

3

Percent with MDR TB

1.9

1.9

1.3

2

1.4

2.6

2.2

0.4

1.2

1.8

1.4

0.4

2.4

2

1.9

2.4

1.8

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

Slide 29

Pediatric TB Cases by Use of Directly Observed Therapy (DOT), 1993–2008
N=17,445*

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

DOT only

22.1

26.9

41

47.4

55.5

58.3

56.6

61.7

61.9

64.5

63.5

65.8

64.6

65.2

63.7

68.5

Self-Administered only

64.4

51

34.5

28.2

20.1

17.1

15.1

13.4

11.3

7.6

6.3

6.3

6.6

4.7

4

3.6

DOT and Self-Administered

12.1

19.1

22.3

22.1

22.5

23.4

26

24

26

26.3

29.3

25.8

28.1

30.1

32

26.5

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

Slide 30

Pediatric TB Cases by Treatment Outcome 1993–2008
N=17,445*

Outcome

Cases

%

Completed treatment

16,601

95.2

Moved

397

2.3

Lost to follow-up

158

0.9

Died

95

0.5

Other**

194

1.1

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 31

Deaths Occurring Among Pediatric TB Cases, by Age Group, 1993–2008
N=17,499

Age Group

Cases

Deaths*

% of Cases

Age<1

1,691

32

1.9

Age 1-4

8,618

58

0.7

Age 5-9

3,991

22

0.6

Age 10-14

3,199

24

0.8

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

 
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