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# Tuberculosis Morbidity -- United States, 1994

In 1994, a total of 24,361 cases of tuberculosis (TB) (9.4 cases per 100,000 population) were reported to CDC from the 50 states, the District of Columbia, and New York City, a 3.7% decrease from 1993 (25,287 cases {9.8 cases per 100,000}) (1). However, the number of cases reported in 1994 was a 9.7% increase over 1985 (22,201 cases) Figure_1, the year with the lowest number of reported TB cases since national reporting began in 1953. This report summarizes TB surveillance data for 1994 and compares the findings with 1992 and 1993.

During 1994, a total of 27 states reported fewer TB cases than in 1993; in comparison, during 1993, 31 states reported fewer cases than in 1992 Table_1. Sixteen states reported fewer cases in both 1993 and 1994 than in 1992 and 1993. Six states reported an increased number of cases in both 1993 and 1994 than in 1992 and 1993 Table_1.

During 1994, TB cases reported among persons born outside the United States and its territories (i.e., foreign-born persons) accounted for 31.9% (7627 of 23,905) of total reported cases (excludes 456 persons with unknown country of origin), compared with 29.6% (7354 of 24,818) of reported cases in 1993 (excludes 469 persons with unknown country of origin). Compared with 1993, in 1994 the number of reported cases among persons born in the United States decreased by 6.8%, and the number of cases among foreign-born persons increased by 3.7%. The number of cases occurring in U.S.-born persons decreased in all age groups except for children aged less than 15 years; in this age group, the number of cases in 1994 increased 0.4%. In comparison, the number of reported cases among foreign-born persons increased in all age groups except for children aged less than 15 years; in this age group, the number of cases decreased by 7.5% in 1994. The country of origin was known for 7483 (98.1%) foreign-born persons with cases reported in 1994; six countries (Haiti, India, Mexico, People's Republic of China, Philippines, and Vietnam) accounted for 64.8% of these cases. However, these countries accounted for only 35.2% of the foreign-born population in the United States in 1990 (2). Of the 4907 foreign-born persons reported in 1994 whose records contained information on month and year of immigration, TB was diagnosed in 1474 (30.0%) less than 1 year after entering the United States.

Beginning in January 1993, TB surveillance was expanded to collect additional information concerning each case, including results of human immunodeficiency virus (HIV)-antibody testing, occupation, history of substance abuse, homelessness, residence in a correctional or long-term-care facility, initial antituberculosis drug therapy and results of drug-susceptibility testing (3). Selected characteristics were analyzed for cases in reporting areas where greater than or equal to 75% of records contained information for 1994. Based on information from 51 of the reporting areas, 53.7% of cases had been prescribed the initial four-drug regimen recommended by the American Thoracic Society and CDC (isoniazid {INH}, rifampin {RIF}, pyrazinamide {PZA}, and either ethambutol or streptomycin) (4); 22.4% of patients had been prescribed INH, RIF, and PZA; 6.8% of patients had been prescribed INH and RIF. In less than or equal to 25 reporting areas, use of illegal drugs and alcohol among patients ranged from 3.3% for injecting drugs to 15.9% for alcohol. In 31 reporting areas, 64.9% of patients were unemployed. In 40 reporting areas, 5.7% of persons were homeless; in 50 reporting areas, 4.6% resided in correctional institutions, and in 48 reporting areas, 6.0% resided in long-term-care facilities. HIV-test results were available for 36.4% of all patients aged 25-44 years; however, only nine areas reported this information for greater than or equal to 75% of records.

Drug-susceptibility results for Mycobacterium tuberculosis isolates were reported for 81.7% of persons with culture-positive TB in 1994. For 28 states, drug-susceptibility results were available for greater than or equal to 75% of cases; 8.0% of cases were resistant to at least isoniazid (INH), and 2.2% were resistant to at least INH and rifampin (RIF). The 28 states reporting drug-susceptibility results accounted for 64% of the culture-positive cases reported in 1994 and included 12 states in which the reported prevalence of INH and RIF resistance was greater than or equal to 1% in 1993 (1) or in the previous national survey in 1991 (5). Reported by: Div of Tuberculosis Elimination, National Center for Prevention Svcs, CDC.

### Editorial Note

Editorial Note: From 1985 through 1992, the number of TB cases reported annually in the United States increased 20%, from 22,201 to 26,673 (6). Factors that have been associated with the resurgence of TB have included the HIV/acquired immunodeficiency syndrome (AIDS) epidemic; immigration of persons from countries where TB incidence rates are 10-30 times higher than in the United States; transmission of TB among persons residing in congregate settings such as hospitals, prisons, and homeless shelters; and declines in resources for TB control (6). From 1992 through 1994, the number of TB cases reported annually decreased 8.7%, in part reflecting the impact of federal resources to assist state and local TB-control efforts, including directly observed therapy (DOT), tuberculin screening and preventive therapy for persons at high risk for TB infection, and support for programs to prevent TB among HIV-infected persons.

Although the expansion of the TB surveillance system in 1993 was implemented to enable more complete characterization of TB morbidity in specific risk groups, reporting has been incomplete for some factors. For example, in 1994, only 28 states reported results of drug-susceptibility testing for greater than or equal to 75% of cases, and information about HIV infection was provided for only approximately one third of case reports. To measure accurately the proportion of TB cases attributable to HIV infection and to ensure the optimal provision of services to HIV-infected persons with TB infection and disease, the Advisory Committee for the Elimination of Tuberculosis has recommended that all patients in whom TB has been diagnosed should be offered counseling and HIV testing and that all HIV-infected persons, with or without AIDS, should be given a tuberculin skin test (7). Collaborative efforts involving state and local TB and HIV/AIDS surveillance programs are needed to establish guidelines to preserve confidentiality to ensure that HIV-test results for reported TB cases are shared between programs and that this information is reported to CDC to aid in characterizing TB morbidity in these and other risk groups.

In 1994, the number and proportion of foreign-born persons with TB increased substantially; approximately one third of these persons were in the United States less than 1 year before diagnosis. Detection and treatment of TB among immigrants and refugees requires improved screening efforts and prompt reporting to state and local public health authorities. Local TB-control programs may need to ensure appropriate testing, prophylaxis, and treatment for immigrants and refugees from countries where TB incidence rates are high (8).

Maintaining the decline in TB morbidity and reaching the goal of eliminating TB in the United States will require sustained prevention and control efforts -- especially rapid diagnosis and ensured completion of treatment (e.g., DOT), and prompt and complete reporting. Implementation of recommended infection-control measures in hospitals can prevent nosocomial transmission of M. tuberculosis (9). In addition, tuberculin screening programs that target persons at highest risk (especially close contacts of persons with active cases) ensure the most effective use of limited resources and appropriate use of preventive therapy.

### References

1. CDC. Reported tuberculosis in the United States, 1993. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994.

2. Bureau of the Census. 1990 census population: the foreign-born population in the United States. Washington, DC: US Department of Commerce, Economics and Statistical Administration, 1993.

3. CDC. Expanded tuberculosis surveillance and tuberculosis morbidity -- United States, 1993. MMWR 1994;43:361-6.

4. CDC. Initial therapy for tuberculosis in the era of multidrug resistance: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1993;42(no. RR-7):1-8.

5. Bloch AB, Cauthen GM, Onorato IM, et al. Nationwide survey of drug-resistant tuberculosis in the United States. JAMA 1994;271:665-71.

6. Cantwell MF, Snider DE, Cauthen GM, Onorato IM. Epidemiology of tuberculosis in the United States, 1985 through 1992. JAMA 1994;272:535-9.

7. CDC. Tuberculosis and human immunodeficiency virus infection: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR 1989;38:236-8,243-50.

8. McKenna MT, McCray E, Onorato I. The epidemiology of tuberculosis among foreign-born persons in the United States, 1986-1993. N Engl

9. Wenger PN, Otten J, Breeden A, Orfas D, Beck-Sague CM, Jarvis WR. Control of nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis among healthcare workers and HIV-infected patients. Lancet 1995;345:235-40.

Figure_1

Table_1
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TABLE 1. Reported tuberculosis cases and percentage change, by state and year
-- United States, 1992-1994
=============================================================================
No. cases                 % Change
-----------------------  ---------------------
State                1992     1993     1994   1992-1993   1993-1994
-------------------------------------------------------------------
Alabama               418      487      433     +16.5       -11.9
Alaska                 57       57       93       0         +63.2
Arizona               259      231      249     -10.8       + 7.8
Arkansas              257      209      264     -18.7       +26.3
California          5,382    5,170    4,859     - 3.9       - 6.0
Colorado              104      104       94       0         - 9.6
Connecticut           156      155      148     - 0.6       - 4.5
Delaware               55       66       57     +20.0       -13.6
District
of Columbia          146      161      121     +10.3       -24.8
Florida             1,707    1,655    1,762     - 3.0       + 6.5
Georgia               893      812      740     - 9.1       - 8.9
Hawaii                273      251      247     - 8.1       - 1.6
Idaho                  26       11       13     -57.7       +18.2
Illinois            1,270    1,237    1,117     - 2.6       - 9.7
Indiana               247      248      211     + 0.4       -14.9
Iowa                   49       59       66     +20.4       +11.9
Kansas                 56       80       84     +42.9       + 5.0
Kentucky              402      404      347     + 0.5       -14.1
Louisiana             373      367      433     - 1.6       +18.0
Maine                  24       28       35     +16.7       +25.0
Maryland              442      417      363     - 5.7       -13.0
Massachusetts         428      370      329     -13.6       -11.1
Michigan              495      480      462     - 3.0       - 3.8
Minnesota             165      144      140     -12.7       - 2.8
Mississippi           281      279      278     - 0.7       - 0.4
Missouri              245      257      260     + 4.9       + 1.2
Montana                16       22       24     +37.5       + 9.1
Nebraska               28       23       22     -17.9       - 4.6
Nevada                 99       99      126       0         +27.3
New Hampshire          18       26       17     +44.4       -34.6
New Jersey            984      912      855     - 7.3       - 6.3
New Mexico             88       74       81     -15.9       + 9.5
New York            4,574    3,953    3,636     -13.6       - 8.0
North Carolina        604      594      566     - 1.7       - 4.7
North Dakota           11        7       10     -36.4       +42.9
Ohio                  358      315      337     -12.0       + 7.0
Oklahoma              216      209      261     - 3.2       +24.9
Oregon                145      154      165     + 6.2       + 7.1
Pennsylvania          758      749      621     - 1.2       -17.1
Rhode Island           54       64       56     +18.5       -12.5
South Carolina        387      401      387     + 3.6       - 3.5
South Dakota           32       16       28     -50.0       +75.0
Tennessee             527      556      520     + 5.5       - 6.5
Texas               2,510    2,396    2,542     - 4.5       + 6.1
Utah                   78       46       55     -41.0       +19.6
Vermont                 7        7       10       0         +42.9
Virginia              457      458      372     + 0.2       -18.9
Washington            306      285      264     - 6.9       - 7.4
West Virginia          92       75       80     -18.5       + 6.7
Wisconsin             106      100      109     - 5.7       + 9.0
Wyoming                 8        7       12     -12.5       +71.4

Total              26,673   25,287   24,361     - 5.2       - 3.7
=============================================================================
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