Reported Tuberculosis in the United States, 2022

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Executive Commentary

Introduction

This 2022 edition of Reported Tuberculosis in the United States describes cases of tuberculosis disease (TB) reported to the Centers for Disease Control and Prevention (CDC) since 1993. This year’s report emphasizes cases counted by reporting areas in 2022 and the ongoing effects of the COVID-19 pandemic on TB surveillance.

Information in this report summarizes incident cases of TB reported to CDC’s National Tuberculosis Surveillance System (NTSS) by each of the 50 U.S. states and the District of Columbia (DC) unless otherwise specified. In addition to the 50 U.S. states and DC, five U.S. territories (American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and the U.S. Virgin Islands) and three independent countries that are in compacts of free association with the United States (Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau) report incident cases of TB to CDC. NTSS has collected information on all newly reported cases of TB since 1953, and cases reported since 1993 are maintained in an electronic database. Small variations in historical data included in this edition, compared with previous editions, are attributable to updated information submitted in the interim by reporting areas.

Some jurisdictions require reporting of latent TB infection (LTBI), a related condition in which TB bacteria live in the body without making a person sick. However, LTBI is not required to be reported to CDC, so this report focuses exclusively on cases of TB disease reported to NTSS.

Several tables have been removed compared with previous years to streamline the report and emphasize the most relevant and useful data. Other tables have been reconfigured to more effectively and clearly describe trends in TB epidemiology. All genotyping tables in this year’s report are based on whole-genome sequencing. Tables describing trends in recent transmission are not included because CDC’s Tuberculosis Genotyping Information Management System (TB GIMS) transitioned from conventional genotyping methods to whole genome sequence-based genotyping in July 2022. Validation of recent transmission algorithms using this new method are ongoing.

Overall Trends

In 2022, the United States reported 8,331 TB cases and an incidence rate of 2.5 cases per 100,000 persons, representing a 5.9% increase in case count and 5.5% increase in incidence rate compared with 2021. The increase in 2022 marks the second year in a row in which TB incidence increased after reaching the lowest recorded incidence rate (2.2 cases per 100,000 persons) in 2020, coinciding with the beginning of the COVID-19 pandemic. Before the COVID-19 pandemic, TB case counts and incidence rates had been steadily decreasing in the United States since 1992. TB incidence declined substantially (by 19.4%) to 2.2 cases per 100,000 persons in 2020 (Table 1), likely because of factors associated with the COVID-19 pandemic.1,2 In 2021, TB incidence partially rebounded to 2.4 cases per 100,000 persons but remained 12.5% lower compared with 2019. In 2022, TB incidence further increased to 2.5 cases per 100,000 but remained 7.7% lower compared with 2019. TB incidence appears to be gradually returning to prepandemic levels but concerns about missed or delayed diagnosis and ongoing effects of pandemic-related disruptions to public health persist. To achieve TB elimination in the United States (defined as <1 case per million persons annually),3 timely testing, expanded treatment options, and innovative prevention campaigns are necessary in the United States and globally.

The National Vital Statistics System reported 602 TB-related deaths in 2021, the most recent year for which data are available. This is relatively steady (a 0.3% increase using unrounded numbers) compared with 2020. The mortality rate for 2021 remained 0.2 deaths per 100,000 persons, a 0.2% increase from 2020 when calculated using unrounded numbers (Table 1).

Half of all U.S. TB cases in 2022 were reported by four states combined: California (22.2%), Texas (13.2%), New York, including New York City (8.6%), and Florida (6.4%). Eight states had TB incidence rates (cases per 100,000 persons) above the national incidence rate: Alaska (13.0), Hawaii (7.0), California (4.7), Texas (3.7), New York (3.6), Washington (3.2), New Jersey (3.1), and Maryland (2.5). Incidence rates among the U.S. territories and freely associated states ranged from 0.7 (Puerto Rico) to 252.1 (Republic of the Marshall Islands); however, two territorial jurisdictions were unable to send data by the reporting deadline (Table 25).

 

Demographics

Origin of Birth

Origin of birth is a prominent risk factor for TB in the United States because of the substantially greater risk of exposure to TB outside of the United States. In 2022, 6,148 (73.8%) cases of TB were reported among non-U.S.–born persons, and 2,142 (25.7%) cases were reported among U.S.-born persons; the incidence rate per 100,000 persons was 17.1 times higher among non-U.S.–born persons (13.0) than U.S.-born persons (0.8) (Table 8).

Among non-U.S.–born persons with TB in 2022, the most common countries of birth included Mexico (18.9%), the Philippines (10.9%), India (8.8%), Vietnam (8.2%), and China (6.0%) (Table 9). These countries have been the most common countries of birth among non-U.S.–born persons with TB since 2018, and they also represent substantial proportions of the non-U.S.–born population living in the United States.4 However, compared with 2021, the number of U.S. cases in 2022 increased by at least 20% among non-U.S.–born persons from Peru (+98.4%), Colombia (+57.8%), Afghanistan (+53.8%), El Salvador (+41.1%), Honduras (+37.3%), Thailand (+32.0%), Kenya (+31.6%), the Republic of the Marshall Islands (+31.4%), Guatemala (+29.8%), and Ecuador (+20.7%) (Table 9).

Among non-U.S.–born persons with TB, the percentage of cases by years since arrival in the United States decreases over time; the highest percentage of TB diagnoses occurs in the first few years since arrival in the United States. In spite of the reduced TB risk over time, approximately 1/3 of TB cases among non-U.S.–born persons occur 20 or more years after arrival in the United States.1,5 In 2022, the percentage of TB cases among non-U.S.–born persons that occurred within one year of arrival in the United States (16.9%) increased by 73.6% compared with 2021 (9.8%) and was the second highest percentage in the last decade. Also, in 2022 the percentage of cases by time since the person arrived in the United States was 13.6% for 1–4 years, 13.0% for 5–9 years, 8.2% for 10–14, 7.2% for 15–19, 8.7% for 20–24, 5.5% for 25–29, 6.6% for 30–34, 4.0% for 35–39, 9.7% for ≥40 years, and 6.5% for an unknown amount of time (Table 10).

The distribution of TB cases by origin of birth varies by state. States in which at least 90% of cases occurred among non-U.S.–born persons include Vermont (3 cases, 100%), Rhode Island (16 cases, 94.1%), Massachusetts (140, 91.5%), Idaho (10 cases, 90.9%), New Hampshire (10 cases, 90.9%). States in which less than 25% of cases occurred among non-U.S.–born persons include Wyoming (0 cases, 0%), Alaska (10 cases, 10.5%), and Mississippi (12, 22.2%) (Table 28).

Race/Ethnicity

The distribution of persons with TB and the TB incidence rates by race/ethnicity differs by origin of birth (Tables 3–4). Among U.S.-born persons in 2022, the highest percentage of cases occurred among non-Hispanic Black or African American persons (31.4%), followed by non-Hispanic White persons (26.3%) and Hispanic or Latino persons (25.0%). Non-Hispanic Native Hawaiian or Other Pacific Islander persons experienced the highest TB incidence rate (cases per 100,000 persons) among U.S.-born persons in 2022 (6.3), an increase compared with 5.2 in 2021. TB incidence among U.S.-born persons also increased among non-Hispanic American Indian or Alaska Native persons from 3.8 in 2021 to 4.5 in 2022 and among non-Hispanic Asian persons from 1.4 in 2021 to 1.8 in 2022. In spite of an overall decrease in TB incidence in the United States since 2019, incidence rates among non-Hispanic Native Hawaiian or Other Pacific Islander persons, non-Hispanic American Indian or Alaska Native persons, non-Hispanic Asian persons were higher in 2022 than in 2019 (Table 3).

Among non-U.S.–born persons in 2022, the highest percentage of cases occurred among non-Hispanic Asian persons (44.0%), followed by Hispanic or Latino persons (36.9%) and non-Hispanic Black or African American persons (10.4%). The highest TB incidence rate (cases per 100,000 persons) among non-U.S.–born persons occurred among persons of more than one race/ethnicity (31.2), but small overall population size estimates among persons of more than one race/ethnicity often lead to variability in incidence rates. The second highest incidence rates among non-U.S.–born persons occurred among non-Hispanic Native Hawaiian or Other Pacific Islander persons (27.8), followed by non-Hispanic Asian persons (22.7), non-Hispanic Black or African American persons (14.0), Hispanic or Latino persons (10.4), non-Hispanic White persons (3.5), and non-Hispanic American Indian or Alaska Native persons (0.0) (Table 4).

Age

TB incidence rates are higher among adults than among children; among persons 5 years and older, incidence rates increase with age.1 TB risk increases with age because of a combination of age-related changes in TB exposure, risk of comorbidities, and immune function.6–8 In 2022, persons 65 years and older had the highest TB incidence rate (cases per 100,000 persons) (3.9), and children aged 5–14 years had the lowest TB incidence rate (0.4). Incidence rates were steady or increased in 2022 compared with 2021 for all age groups, and the largest increase occurred among persons aged 15–24, which changed by 24.2% from 1.5 in 2021 to 1.9 in 2022. However, compared with 2019, TB incidence rates in 2022 remained the same or lower for each age group (Table 5). Among U.S.-born persons, age-specific incidence rates continued to be highest among persons 65 years and older (1.0), 0–4 years (1.0), and 45–64 years (1.0) (Table 6). Among non-U.S.–born persons, age-specific incidence rates were highest among 65 years and older (22.2), followed by persons aged 15–24 years (16.3) and 0–4 years (11.8). The incidence rate among non-U.S.–born persons aged 0–4 years increased by 265% from 3.2 in 2021 to 11.8 in 2022 (Table 7).

Sex

In 2022, male persons accounted for 61.9% of TB cases in the United States, including 62.5% of cases among U.S.-born persons and 61.9% of cases among non-U.S.–born persons. For U.S.-born persons and non-U.S.–persons in 2022, the percentage of cases was higher for male persons compared with female persons at every age group except ages 5–14 years. Among persons aged 5–14 years, 53.4% of cases among non-U.S.–born persons and 54.3% of cases among U.S.-born persons occurred among female persons (Table 21).

Risk Factors

Comorbid Conditions

Medical conditions or therapies that weaken or suppress the immune system can increase the risk for TB. Diabetes mellitus (24.3%) remains the most commonly reported medical risk factor among persons with TB and was reported by a larger percentage of non-U.S.–born persons with TB (26.9%) compared with U.S.-born persons with TB (17.1%) (Table 22). Among persons with TB in 2022 who were alive at diagnosis, human immunodeficiency virus (HIV) status was known for 89.5%, and 4.3% of persons with TB and known HIV status were coinfected with HIV (Table 17). Tumor necrosis factor-alpha (TNF-α) antagonist therapy was reported for 1.0% of cases, and 0.7% of persons had received a solid organ transplant. Other immunocompromising conditions or therapies were reported for 9.5% of cases (Table 22).

Congregate Settings

Living in congregate settings, including homeless shelters, correctional facilities, and long-term care facilities, is a risk factor for TB because shared airspace and poor ventilation can facilitate TB exposure and transmission. People experiencing homelessness also face challenges accessing medical care that can delay diagnosis and disrupt treatment.9 Among persons aged ≥15 years with TB in 2022, 392 (5.0%) reported experiencing homelessness within the 12 months preceding TB diagnosis (Table 32). This compares with 341 (4.5%) TB cases in 2021 among persons aged ≥15 years with reported homelessness in the past year.5

During 2022, 141 (1.8%) TB cases were diagnosed among current long-term care facility residents aged ≥15 years (Table 32) compared with 1.5% in 2021.

Substance Use

Substance use is also a TB risk factor; it can have physiological effects that increase risk for TB but is often a proxy for other epidemiologically important factors that increase exposure to TB.10 Substance use can also present a barrier to TB diagnosis and treatment, increasing potential infectiousness and the risk of further TB transmission.10,11 The most commonly reported type of substance use during the year preceding diagnosis among persons with TB aged ≥15 years was excess alcohol use (9.1%), followed by noninjecting drug use (7.2%), and injecting drug use (1.0%) (Table 32).

Clinical Characteristics

Primary Reason for Tuberculosis Evaluation

Similar to past years, experiencing TB symptoms was the primary reason for TB evaluation for the majority (60.2%) of persons with TB in the United States in 2022. Active case-finding methods, including investigation of close contacts to an infectious TB case and planned screening or “targeted testing” of groups expected to have elevated prevalence of TB infection, were reported as the primary reason for TB evaluation for 15.3% of TB cases (Table 31) compared with 13.8% of 2021 cases.1

Site of Disease

TB most commonly affects the lungs but can cause disease in any part of the body; 81.0% of U.S. TB cases had pulmonary involvement, a slight increase compared with 78.6% in 2021. Among the 18.8% of U.S. TB cases with only extrapulmonary TB, the most common sites affected were the lymphatic system (26.1%) and pleura (22.1%). TB meningitis, a particularly serious form of the disease, accounted for 5.8% of extrapulmonary-only cases (Table 19).

TB Treatment and Drug Resistance

Effective treatment for TB disease includes providing multiple anti-TB drugs over a sufficient period of time to cure the patient, prevent development of drug resistance, and minimize the risk of transmission to others. The most common initial treatment regimen for drug-susceptible TB and in situations where drug-susceptibility is unknown includes isoniazid, H; rifampin, R; pyrazinamide, Z; and ethambutol, E (HRZE).12 Other four-drug regimens might be appropriate for a variety of public health or clinical reasons, including drug resistance, interactions or contraindications, or supply chain problems related to one or more drugs in the HRZE regimen.13,14 Also in 2022, CDC released interim guidance for a four-drug 4-month regimen including isoniazid, rifapentine, pyrazinamide, and moxifloxacin (RPT-MOX) as a treatment option for people 12 years of age and older with drug-susceptible pulmonary TB.15

Since 2007, more than 90% of persons with TB who were alive at diagnosis had initial drug regimen information that included at least four drugs. Among persons with TB who were alive at diagnosis and had initial drug regimen information in 2022, 81.1% began treatment with HRZE and 13.0% began treatment with a four-drug regimen other than HRZE, including 17 (1.6%) persons who began treatment with RPT-MOX. Since only 6.0% received no initial drug therapy or a less than four drug regimen, the vast majority (94.0%) of TB patients alive at diagnosis reported in the United States are likely to have received appropriate initial TB therapy (Table 14).

Anti-TB drug resistance is a concern in the United States and globally. Resistance to isoniazid, one of the most common anti-TB drugs, can be a precursor to multidrug-resistant (MDR) TB, which is defined as resistance to at least isoniazid and rifampin.16 During 2022, resistance to at least isoniazid at initial diagnosis was reported for 528 (8.4%) cases, including 90 (1.4%) MDR cases in the United States (Table 11). Among U.S.-born persons, 86 (5.7%) cases were INH-resistant TB, including 11 (0.7%) cases of MDR TB (Table 12). Among non-U.S.–born persons, 439 (9.3%) cases were INH-resistant TB, including 77 (1.6%) cases of MDR TB (Table 13).

Pre-XDR TB is caused by an organism that is resistant to isoniazid, rifampin, and a fluoroquinolone or by an organism that is resistant to isoniazid, rifampin, and a second-line injectable drug (amikacin, capreomycin, and kanamycin). XDR TB is caused by an organism that is resistant to isoniazid, rifampin, a fluroquinolone, and a second-line injectable drug (amikacin, capreomycin, and kanamycin) or by an organism that is resistant to isoniazid, rifampin, a fluoroquinolone, and bedaquiline or linezolid.16 In 2022, 16 (0.3%) cases of pre-XDR TB and 5 (0.1%) cases of XDR TB were reported in the United States (Table 11).

Drug resistance is more commonly observed among persons who have previously been diagnosed with TB. Among U.S.-born persons diagnosed with TB in 2022, the percentage of persons with INH-resistant TB was 8.5% among persons who had a previous TB diagnosis compared with 5.6% among persons who had not previously been diagnosed with TB (Table 12). Among non-U.S.–born persons diagnosed with TB in 2022, the percentage of persons with INH-resistant TB was 18.0% among persons who had previously been diagnosed with TB compared with 8.6% among persons who had not previously had TB (Table 13). Stringent guidelines for TB treatment in the United States, including diligent follow-up efforts by public health personnel, greatly reduce the risk of developing drug-resistant TB.

Directly Observed Therapy and Completion of Treatment

Directly observed therapy (DOT) involves direct observation by a trained individual of a patient ingesting anti-TB medications to ensure patients adhere to their prescribed therapy; it can include in-person and video DOT.17 DOT is a critical case management strategy to achieve completion of TB therapy, helping prevent TB from spreading to others and avoiding development of drug-resistant TB. For cases reported in 2020, the most recent year for which data are available, TB treatment was administered using exclusively DOT for 61.5% of patients, and 31.0% received TB treatment with a combination of DOT and self-administered therapy (Table 15).

Successful completion of TB treatment is important to prevent TB recurrence and drug resistance. TB treatment completion remained relatively steady for cases reported in 2020, the most recent year for which data are available. An uncomplicated course of treatment for drug-susceptible TB takes about 4–6 months to complete; however, drug resistance or other factors can require treatment for >1 year. Among 2020 patients eligible to complete TB treatment within 1 year, 89.0% completed treatment within 1 year, compared with 90.1% in 2019, and 94.7% ever completed TB treatment, compared with 95.7% in 2019. The percentage of patients who did not complete treatment was 4.3% in 2019 compared with 5.3% in 2020 (Table 16).

Case Outcome

Among all TB cases diagnosed during 2020, 11.8% (n=845) of persons died, compared with 10.0% (n=892) in 2019. Death was attributed to TB disease or TB treatment for 325 (38.5%) persons which is the largest number in a single year since 2011 (347 deaths). Of the 845 deaths, 208 (24.6%) occurred in persons who were dead at the time of diagnosis; TB was reported as a cause of death for 28.8%. The remaining 637 (75.4%) deaths occurred after diagnosis, of which 265 (41.6%) were related to TB disease or therapy (Table 18).

Molecular Surveillance

TB genotyping is a laboratory-based approach used to analyze genetic material (e.g., DNA) of Mycobacterium tuberculosis; characterizing distinct genetic patterns facilitates distinguishing certain M. tuberculosis strains from others. This is the first year CDC is reporting genotyping results using wgMLSType (whole-genome multilocus sequence type), a typing method based on whole-genome sequencing. In previous years conventional genotyping methods (spoligotyping and mycobacterial interspersed repetitive unit-variable number tandem repeats [MIRU-VNTR]) were used to report genotyping results. Whole-genome sequencing methods examine nearly the entire M. tuberculosis genome compared with conventional methods that examine a small portion. CDC transitioned to using wgMLSType exclusively for genotyping in July 2022, although wgMLSType is available for all M. tuberculosis isolates since January 2018. Genotype surveillance coverage, defined as the percentage of culture-positive TB cases with a genotyped isolate, was 96.0% in 2022 (Table 33).

A TB case is considered clustered if the wgMLSType of the case’s isolate matched one or more cases’ isolates in the same county or county-equivalent area during the 3-year period 2020–2022. Clustered TB cases might indicate recent TB transmission. CDC generates cluster alerts (i.e., medium alert and high alert) based on the degree of geospatial concentration of cases with matching wgMLSType within the same county or county-equivalent area compared with the concentration of the wgMLSType outside of the given county or county-equivalent. CDC reviews medium and high alerts weekly for possible programmatic follow-up.

The percentage of clustered genotyped cases during 2019–2021 (19.2%) based on conventional genotyping methods in last year’s report1 compares with 16.9% clustering during 2020–2022 based on whole-genome sequencing methods (Table 23). Clustering percentages were 37.1% among U.S.-born persons during 2020–2022 compared with 34.6% reported in 2019–2021, and 10.0% among non-U.S.–born persons in 2020–2022 compared with 13.5% in 2019–2021.1 The number of clusters reported nationally also declined in 2020–2022 (987) compared with 2019–2021 (1,241),1 a 20.5% reduction when using whole-genome sequencing from last year’s report using conventional genotyping (Table 24).

Among clustered cases, the percentage that were in medium or high alert clusters during 2020–2022 was 65.7% compared with 38.3% reported using conventional genotyping in 2019–2021.1 Percentages of clustered cases in alerted clusters varied across population subgroups during 2020–2022. By origin of birth, percentages of clustered cases in alerted clusters were higher among U.S.-born persons (72.8%) compared with non-U.S.–born persons (56.9%). By race/ethnicity, percentages were highest among American Indian or Alaska Native persons (96.1%) and lowest among Hispanic or Latino persons (54.2%). By age group, percentages were highest among persons aged 0–4 (79.2%) and lowest among persons aged 65 or older (60.5%). Among risk factors for TB disease, persons residing in correctional facilities at the time of TB diagnosis had the highest percentage in alerted clusters (75%) (Table 23).

Conclusion

In 2022, reported TB cases and incidence rates in the United States increased for the second year in a row but remained lower than levels reported prior to the COVID-19 pandemic. The pandemic caused substantial changes in immigration and travel, health care and public health services, social exposures, and mortality, which likely led to a combination of TB underdiagnosis and a true reduction in TB incidence in the United States throughout 2020–2021. In 2022, the pandemic waned, but the effects of the pandemic on the public health workforce and public health resources persisted.18–20

Compared with prepandemic 2019 levels, TB incidence rates remained the same or lower for both U.S.-born and non-U.S.–born persons and all age groups except U.S.-born persons aged 5–14 years and non-U.S.–born persons aged 0–4 years. TB among young children is particularly concerning because is usually results from recent transmission instead of reactivation of long-standing LTBI. TB incidence remained steady or below prepandemic levels for most U.S.-born race and ethnicity groups, but increased among American Indian or Alaska Native persons, Native Hawaiian or Other Pacific Islander persons, and Asian persons, increasing the TB disparities experienced by those populations.

Birth outside of the United States remains a key risk factor for TB, with a TB incidence rate 17.1 times higher in non-U.S.–born persons compared with U.S.-born persons in 2022. The number of TB cases diagnosed among non-U.S.–born persons within the first year after arrival in the United States nearly doubled compared with 2021 and reached the highest level since 2016. Even though the most common countries of birth among people diagnosed with TB in the United States has remained steady for many years, small but noteworthy increases occurred among persons born in several Central and South American countries as well as Afghanistan. Changes in the number of TB cases diagnosed among non-U.S.–born persons by years since arrival and country of birth might reflect changes in migration patterns, including increased arrivals among persons evacuating from conflict zones.21–23

In addition to birth origin, social and medical factors can increase the risk of being infected with TB and progression to TB disease. Diabetes mellitus affects approximately 10% of the U.S. population24 but was reported in 2022 for about one-quarter of persons with TB. Diabetes can increase the risk of developing TB disease among persons with TB infection,25 as can other immunocompromising conditions such as HIV and renal failure. Even though the prevalences of some social risk factors, such as residing in a congregate setting and substance use, have declined among persons with TB over the last decade,1 these factors continue to affect a substantial number of persons with TB in the United States.

Because of the two-year reporting lag for TB case outcomes data, this report is the first to include treatment outcome data for TB cases diagnosed during the first year of the COVID-19 pandemic. The number of deaths attributed to TB disease or TB treatment in 2020 was the highest since 2011, especially among persons who died after diagnosis. This is consistent with a higher TB-related death rate reported in 2020 vital statistics data.1 However, decreases in treatment completion and directly observed therapy for cases diagnosed in 2020 were minimal, suggesting that in spite of the staffing and resource challenges that health departments faced in 2020, TB programs were able to ensure treatment completion rates similar to the levels observed in the years before the COVID-19 pandemic.

TB epidemiology appears to be returning to prepandemic levels in many respects, and invigorated efforts are necessary to achieve TB elimination in the United States. Testing for TB is critical for populations at higher risk for TB infection and progression, including people with weak immune systems due to HIV, renal failure, or other conditions such as diabetes. Increased efforts to detect and treat LTBI are also needed to accelerate progress towards TB elimination. Innovations such as shorter regimens15 and video-directly observed therapy17 should be considered, in combination with other proven TB prevention activities, to test and treat persons at risk for TB.

References
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