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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

  1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
<15
yrs
1661 1659 1536 1356 1251 1077 1038 965 929 944 911 953 854 803 776 786 647 637 577 486
15-24
yrs
1821 1832 1697 1637 1674 1543 1518 1618 1597 1498 1573 1603 1541 1532 1580 1443 1278 1200 1033 1020
25-44 yrs 9590 9043 8200 7564 6884 6335 6062 5576 5610 5288 5074 4939 4740 4691 4316 4243 3887 3672 3367 3118
45-64 yrs 6197 6125 5960 5572 5278 4954 4860 4635 4515 4182 4283 4192 4124 4041 4040 3936 3429 3439 3293 3114
65+
yrs
5821 5540 5329 5076 4663 4378 4020 3515 3293 3142 2994 2811 2809 2664 2574 2497 2288 2230 2246 2204

Slide 5

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

  1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
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 3.4 3.2
<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 0.9 0.8
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 2.4 2.3
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 4.1 3.8
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 4 3.8
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 5.4 5.1

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

  1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Age < 1 156 139 118 102 111 103 96 91 97 101 95 82 80 91 114 115 94 77 72 58
Age 1-4 859 856 776 668 623 535 506 453 446 455 452 468 397 391 352 381 309 288 279 202
Age 5-9 358 395 393 368 305 243 250 222 208 196 195 203 195 159 159 142 140 139 96 109
Age 10-14 288 269 249 218 212 196 186 199 178 192 169 200 182 162 151 148 104 133 130 117

 

Slide 8

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

  1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
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 1.8 1.5
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 1.7 1.3
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 0.5 0.5
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 0.7 0.5

Note: Rates presented on a logarithmic scale

Slide 9

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

  1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
White,
non-Hispanic
250 230 185 157 136 137 125 104 87 103 82 76 65 64 70 48 47 46 47 36
Black,
non-Hispanic
559 572 517 515 469 372 345 335 310 330 257 289 263 251 225 228 158 177 157 125
Hispanic 639 642 624 512 438 423 432 374 413 401 431 457 396 387 353 357 310 283 255 187
American Indian/
Alaskan Native
22 31 34 37 29 15 15 27 8 13 13 13 12 9 9 10 4 13 12 19
Asian/
Pacific Islander
151 158 146 110 138 97 97 95 94 82 115 103 99 84 104 132 107 93 87 104

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

  1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
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 0.1 0.1 0.1 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 1.9 2.1 1.9 1.5
Hispanic 8.4 8.1 7.6 6 5 4.6 4.6 3.5 3.8 3.5 3.7 3.8 3.2 3 2.6 2.6 2.2 2 1.7 1.3
Asian/Pacific Islander 7.6 7.7 6.8 5 6.1 4.1 4 4.6 4.4 3.7 5.1 4.4 4.1 3.4 4.1 5.1 4 3.4 3.2 3.7

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


  1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Age < 1, FB 3.3 2.8 2.4 2.7 2.3 2.3 2.1 2.2 2.6 2.6 2.2 1.9 2.1 2.6 2.5 2.2 1.7 1.8 1.4
Age 1-4, FB 4.4 4.1 3.6 3.4 2.9 2.7 2.4 2.3 2.4 2.2 2.3 2 2 1.8 2 1.6 1.5 1.4 1
Age 5-9, FB 1.3 1.4 1.3 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 0.5 0.3 0.4
Age 10-14, FB 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 0.4 0.3


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


  1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Age < 1, FB 23.3 106.3 45.1 177.6 43.5 55.7 53.7 69.7 9.3 25.4 9.4 16.2 217.8 32.4 52.8 7.8 26.7 5.6 22.4
Age 1-4, FB 61.1 56.6 37.8 38.6 32.3 34.2 28.5 24.8 24.1 34.5 32.5 24.1 21.9 25.3 19.6 17 12.4 17.7 18
Age 5-9, FB 22.7 22.7 16.6 13.2 9.9 15.3 11.1 15.2 9.8 12 10.7 11.2 6 9.2 8.1 8.5 7.4 4.5 6.7
Age 10-14, FB 14.8 16 12.1 10.6 9.2 7.9 8.6 8.6 9.3 7.7 10.8 9.2 7.8 6.9 8.1 4.1 6.5 6.3 6.2


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

  1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Foreign-born 413 386 353 313 287 249 265 255 269 249 268 280 243 200 206 203 140 152 120
U.S.-born 1231 1252 1181 1040 960 822 762 708 659 690 643 671 607 603 570 582 507 484 457
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 28.6 24.9 26.5 25.9 21.6 23.9 20.8

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

California Texas New York Florida Illinois Georgia All Others
U.S. Total 23.9 12.4 8.2 5.3 4.4 4.4 41.3

Slide 16

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

Pediatric TB Cases

State Number Percent* Rate**
California 4,751 7.1 3.1
Texas 2,453 7.2 2.4
New York 1,617 4.6 2.2
Florida 1,060 4.6 1.7
Illinois 879 7.7 2.4
Georgia 877 6.3 1.7
All Others 8,203 5.9 1.2
Overall U.S. 19,840 6.2 1.7

*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

State Number Percent* Rate**
Alaska 153 11.9 4.9
Rhode Island 93 10.7 2.4
Oklahoma 347 10.5 2.3
Minnesota 365 10.1 1.7
Delaware 32 9.1 1
Arizona 177 9 1
All Others 18,673 6 1.7
Overall U.S. 19,840 6.2 1.7

*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

State Number Percent* Rate**
Alaska 153 11.9 4.9
D.C.† 66 4 3.6
California 4,751 7.1 3.1
Texas 2,453 7.2 2.4
Georgia 93 10.7 2.4
Oklahoma 879 7.7 2.4
All Others 11,445 5.5 1.2
Overall U.S. 19,840 6.2 1.7

*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 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 7.9 19.4 22 19.5
Meningeal 8.2 3.8 1.6 2
Miliary 4.7 1.1 0.5 1.2
Bone & Joint 0.4 1.3 1.7 2.4
Other 3.5 2.6 4.5 8.7
Total 24.7 28.2 30.3 33.8

*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 Disease U.S.-born Foreign-born
Lymphatic 7.20% 17.70%
Meningeal 8.60% 2.80%
Miliary 4.90% 3.60%
Bone & Joint 0.30% 0.70%
Other 3.40% 3.60%
Total 24.40% 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 Disease U.S.-born Foreign-born
Lymphatic 19.50% 18.60%
Meningeal 4.20% 2.00%
Miliary 1.20% 0.90%
Bone & Joint 1.10% 2.20%
Other 2.70% 2.00%
Total 28.70% 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 Disease U.S.-born Foreign-born
Lymphatic 23.30% 19.70%
Meningeal 2.00% 1.00%
Miliary 0.50% 0.60%
Bone & Joint 1.30% 2.40%
Other 4.60% 4.30%
Total 31.70% 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 Disease U.S.-born Foreign-born
Lymphatic 20.30% 18.70%
Meningeal 2.00% 2.00%
Miliary 1.50% 0.70%
Bone & Joint 2.10% 2.70%
Other 9.80% 7.40%
Total 35.70% 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

  1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Resistance to any 1st line drug 31 43 31 38 38 28 28 27 38 33 31 40 38 27 24 44 32 22 17
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 11.3 21.4 19.4 13.8 11.1
MDR TB 6 6 4 6 4 6 5 1 3 4 3 1 5 4 4 5 3 2 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 1.3 2

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*

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
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 68.3 66.3 64.9
Self-Administered only 64.3 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 3.5 4.8 5.2
DOT and Self-Administered 12.1 19.1 22.3 22.1 22.5 23.4 26 24 26 26.3 29.3 25.7 27.9 30.1 32 27 28.1 29.6

*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*

Outcome Cases %
Completed treatment 17,858 95.4
Moved 397 2.1
Lost to follow-up 160 0.9
Died 102 0.5
Other** 202 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 32

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

Age Group Cases Deaths* % of Cases
Age<1 1,862 34 1.8
Age 1-4 9,211 61 0.7
Age 5-9 4,269 27 0.6
Age 10-14 3,435 24 0.7

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

 
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