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Tuberculosis Among American Indians and Alaskan Natives -- United States, 1985

In 1985, 22,201 cases of tuberculosis were reported to CDC, for an incidence rate of 9.3 cases per 100,000 U.S. population (1). Three hundred and ninety-seven (2) of the 22,170 patients with known race were American Indians and Alaskan Natives. The incidence rate for this group was 25.0/100,000 population, 4.4 times the rate of 5.7/100,000 for the white population (2).

The 397 tuberculosis cases among American Indians and Alaskan Natives were reported from 144 (5) of the nation's 3,138 counties (Figure 1). Three hundred and eighty-five (97) of these cases were reported from the 32 states with reservations (Table 1). Eleven of these states reported 326 (82) of these 385 cases. In these 11 states, the ratio of the incidence of tuberculosis among American Indians and Alaskan Natives to the incidence among all other races ranged from 4.2 in Oklahoma to 30.4 in South Dakota and 31.4 in Minnesota. American Indians and Alaskan Natives accounted for large proportions of reported tuberculosis cases in Alaska and South Dakota (71 and 62, respectively); however, they only comprise 14 of the Alaskan population and 7 of the South Dakota population.

The median age of American Indians and Alaskan Natives with tuberculosis was 45 years. One hundred and thirty-eight (35) of the 397 patients were less than 35 years of age. Reported by: Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Paleopathological evidence has demonstrated the existence of tuberculosis in the Americas in pre-Columbian times (3). However, the high rates of morbidity and mortality from tuberculosis observed among American Indians at the end of the last century have been attributed to increased contact with the white civilization (4). This is also believed to be the case in Alaska, where the morbidity rates from tuberculosis in the early 1950s were the highest ever reported in the medical literature (5). Active case-finding, treatment, and extensive use of preventive chemotherapy in the 1950s and 1960s markedly reduced tuberculosis mortality and morbidity in Alaska (6). However, the incidence rate of tuberculosis among Alaskan Natives in 1985 was still 10-fold higher than the national average. In some states, the risk of tuberculosis was up to 30-fold higher among American Indians than among other races.

Because tuberculosis among American Indians and Alaskan Natives is concentrated in well-defined geographic pockets, intensive use of preventive measures may be particularly effective. In 1985, 35 of American Indians and Alaskan Natives with tuberculosis were under 35 years of age, the age group for which preventive therapy is routinely recommended for infected persons with no additional risk factors (7). Directly observed therapy and incentives for compliance should also decrease morbidity.

In addition, the prevalence of diabetes mellitus, which is a recognized risk factor for tuberculosis, has increased among most American Indian and Alaskan Native populations during the past 50 years and now ranges up to 50 (8). Preventive chemotherapy is recommended for patients with diabetes who are infected with the tubercle bacillus, regardless of their age (7). Tuberculin skin testing is recommended for all young adult American Indians and Alaskan Natives as well as for diabetics of any age. Preventive therapy should be administered according to the current guidelines (7).

Intentional isoniazid overdosage has been reported among American Indians (9), as it has among other populations (10). Thus, physicians should be familiar with treatment of isoniazid toxicity (11). Because of the risk of overdosage with self- administered therapy, directly observed therapy should be used for persons with a history of depression or suicidal tendencies.

References

  1. CDC. Tuberculosis--United States, 1985. MMWR 1986;35:699-703.

  2. CDC. Tuberculosis in minorities--United States. MMWR 1987;36:77-80.

  3. Buikstra JE, ed. Prehistoric tuberculosis in the Americas. Evanston, Illinois: Northwestern University Archaeological Program, 1981.

  4. Matthews W. Consumption among the Indians. NY Med J 1887;45:1-3.

  5. Comstock GW, Philip RN. Decline of the tuberculosis epidemic in Alaska. Public Health Rep 1961;76:19-24.

  6. Johnson MW. Results of 20 years of tuberculosis control in Alaska. Health Serv Rep 1973;88:247-54.

  7. American Thoracic Society, CDC. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986;134:355-63.

  8. Sievers ML, Fisher JR. Diabetes in North American Indians. In: Diabetes in America. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1985:chapter XI, 1-19; DHHS publication no. (NIH)85-1468.

  9. Sievers ML, Cynamon MH, Bittker TE. Intentional isoniazid overdosage among southwestern American Indians. Am J Psychiatry 1975;132:662-5.

  10. Blanchard PD, Yao JDC, McAlpine DE, Hurt RD. Isoniazid overdose in the Cambodian population of Olmsted County, Minnesota. JAMA 1986;256:3131-3.

  11. Sievers ML, Herrier RN. Treatment of acute isoniazid toxicity. Am J Hosp Pharm 1975;32: 202-6.

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