Tuberculosis in the United States Slide Set

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Tuberculosis in the United States—National Tuberculosis Surveillance System, Highlights from 2018. This slide set was prepared by the Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). It provides recent trends and highlights of data collected through the National Tuberculosis Surveillance System (NTSS) for 2018. Since 1953, through the cooperation of state and local health departments, CDC has collected information on newly reported cases of tuberculosis (TB) disease in the United States. The data presented here were collected by the revised TB case report introduced in 2009. Each individual TB case report (Report of Verified Case of Tuberculosis, or RVCT) is submitted electronically to CDC. The data for this slide set are based on TB case reports for 1993–2018 received by CDC as of June 6, 2019. All case counts and rates for years 1993–2017 have been updated and data from 2018 has been added.

Slide 1

During 2018, the United States reported the lowest number of TB cases (9,025) and lowest incidence rate (2.8 cases per 100,000 persons) on record. With the exception of 2015, the US TB case count and incidence rate have declined every year since 1992.

Slide 2

The annual incidence rate decrease (−1.3%) from 2017 to 2018 and percent decrease in case count (−0.7%, not shown) is the smallest year-to-year decrease since 1993, excluding an increase in 2015.

Slide 3

The National Vital Statistics System reported 515 TB-related deaths (0.2 deaths per 100,000 persons) for 2017, the most recent year for which data are available. This represents a 2.5% decrease in deaths and a 3.1% decrease in the mortality rate from 2016, although 2017 deaths remain higher than the historical low of 470 deaths (0.1 deaths per 100,000 persons) reported in 2015.

Slide 4

Among U.S. states, the majority of TB cases continue to be reported from California (23.2%), Texas (12.5%), New York (8.3%), and Florida (6.5%).

Slide 5

When considering incidence rates by reporting area, Alaska (8.5 cases per 100,000 persons) has the highest TB rate, followed by Hawaii (8.4), New York City (6.7), California (5.3), the District of Columbia (5.1), and Texas (3.9).

Slide 6

TB Case Rates by Age Group, United States, 1993–2016. During 2016, case rates in all age groups declined by >50% from their 1993 values: persons aged ≥65 years, from 17.7 cases/100,000 population in 1993 to 4.6 in 2016; adults aged 45–64 years, from 12.5 to 3.4; adults aged 25–44 years, from 11.6 to 3.3; persons aged 15–24 years, from 5.0 to 2.2; children aged 5 to 14 years, from 1.7 to 0.4; and children aged ≤4 years, from 5.2 to 1.1.

Slide 7

Reported TB Cases by Age Group, United States, 2016. Two percent of TB cases were among children aged 0–4 years; 2% were among those aged 5–14 years; 10% were among persons aged 15–24 years; 31% were among adults aged 25–44 years; 31% were among adults aged 45–64 years; and 24% were among adults aged ≥65 years.

Slide 8

TB Case Rates by Age Group and Sex, United States, 2016. Case rates tended to increase with age, ranging from <1 case/100,000 children aged 5–14 years to a high of 6.4 cases/100,000 men aged ≥65 years. As age increased, the case rate among men increased faster than women; the rates among men aged ≥45 years were approximately twice those among women of the same age.

Slide 9

TB Case Rates by Race/Ethnicity, United States, 2003–2016. By race/ethnicity, the rates indicate a declining trend in TB since 2003. Asians consistently had the highest yearly TB rates, but their rates declined from 29.3 cases/100,000 population in 2003 to 18.0 in 2016, a 38.6% decrease. Rates also declined among the following racial/ethnic groups: non-Hispanic blacks/African Americans, from 11.7 in 2003 to 4.9 in 2016 (–58.2%); Hispanics, from 10.2 to 4.5 (–55.8%); non-Hispanic whites, from 1.4 to 0.6 (–57.1%); American Indians and Alaska Natives, from 8.3 to 4.7 (–43.6%); and Native Hawaiian/Other Pacific Islanders, from 15.7 to 13.9 (–11.2%). Because of the low TB case counts and population estimates for Native Hawaiians/Other Pacific Islanders in the United States, case rates for this group might appear high. (Percentage change are based off of unrounded numbers.)

Slide 10

TB Case Rates by Age Group and Race/Ethnicity, United States, 2016. After infancy (ages 0–4 years), risk typically increased with age across all racial/ethnic groups, except among Native Hawaiians/Other Pacific Islanders, which did not indicate a trend. Rates were consistently higher among minority racial/ethnic groups than among non-Hispanic whites. Rates were the highest among Asians and Native Hawaiians/Other Pacific Islanders. Because of the low TB case counts and population estimates for Native Hawaiians/Other Pacific Islanders in the United States, case rates for this group might appear high.

Slide 11

Reported TB Cases by Race/Ethnicity, United States, 2016. During 2016, approximately 86% of all reported TB cases occurred among racial/ethnic minorities: Asians, 35%; Hispanics, 28%; non-Hispanic blacks/African Americans, 21%; American Indians/Alaska Natives, 1%; and Native Hawaiians/Other Pacific Islanders, 1%. In contrast, 13% of cases occurred among non-Hispanic whites. Persons reporting two or more races, not including persons of Hispanic or Latino ethnicity, accounted for 1% of all cases. Unknown or missing data on race accounted for <0.5% of all cases.

Slide 12

Number of TB Cases Among U.S.-Born versus Non-U.S.–Born Persons, United States 1993–2016. The graph illustrates the increase in the percentage of cases occurring among non-U.S.–born persons during the study period, from 30% in 1993 to 69% in 2016. Overall, the number of cases among non-U.S.–born remained stable before 2009, with approximately 7,400–8,000 cases/year. During 2009, the number decreased to 6,999, and that trend continued through 2013, with the number of cases among non-U.S.–born persons decreasing to 6,222. However, in 2014 and 2015 the number of cases among non-U.S.–born persons increased to a high of 6,406 in 2015. In 2016, the number of cases decreased from 2015 to 6,351 cases. Among U.S.-born persons the number of cases decreased from >17,000 in 1993 to 2,901 in 2016.

Slide 13

Trends in TB Cases Among Non-U.S.–Born Persons, United States, 1993–2016. The percentage of TB cases accounted for among non-U.S.–born persons increased from 30% in 1993 to 69% in 2016.

Slide 14

Reported TB Cases by Origin and Race/Ethnicity, United States, 2016. Among U.S.-born persons with TB in 2016, 37% were non-Hispanic black/African American; 31% were non-Hispanic white, 21% were Hispanic/Latino; 5% were Asian; 4% were American Indian/Alaska Native; and 1% were Native Hawaiian/Other Pacific Islander. Persons reporting two or more races totaled <1% of cases among U.S.-born persons. Among non-U.S.–born persons with TB, 48% were Asian; 31% were Hispanic/Latino; 14% were non-Hispanic black/African American; 5% were non-Hispanic white; 1% were Native Hawaiian/Pacific Islander; and 1% were persons reporting two or more races, not including persons of Hispanic/Latino origin. Cases among American Indians/Alaska Natives constituted 0.3% of the cases among non-U.S.–born persons and are not included on the charts.

Slide 15

Percentage of Non-U.S.–Born Persons Among TB Cases, United States, 2006 and 2016. The number of states with <25% of their TB cases occurring among non-U.S.–born persons decreased from 6 states in 2006 to 4 states in 2016. The number of states with ≥25%–49% of cases among non-U.S.–born persons decreased from 16 states and DC in 2006 to 8 states in 2016. However, the number of states that had ≥50% of their cases among non-U.S.–born persons increased from 28 states in 2006 to 38 states and DC in 2016.

Slide 16

TB Case Rates Among U.S.-Born versus Non-U.S.–Born Persons, United States, 1993–2016. TB rates among non-U.S.–born remain higher than those among the U.S.-born population. During 1993–2016, the rate among U.S.-born persons decreased from 7.4 cases/100,000 population to 1.1, whereas the rates among non-U.S.–born persons decreased from 34.0 cases/100,000 population to 14.7.

Slide 17

TB Case Rates Among U.S.-Born versus Non-U.S.–Born Persons, United States, 1993–2016. The chart presents the same data as on Slide 17, but uses a logarithmic scale to better illustrate the trends. The trend lines indicate a greater rate of decrease among U.S.-born, compared with non-U.S.–born, persons during the study period.

Slide 18

Countries of Birth Among Non-U.S.–Born Persons Reported with TB, United States, 2016. The top seven countries are displayed in the chart; those countries have remained relatively constant since 1986, when information regarding country of birth was first reported by all areas submitting reports to CDC. During 2016, the top seven countries accounted for 60% of all cases among non-U.S.–born persons, with Mexico accounting for 19%; the Philippines, 12%; India, 9%; Vietnam, 8%; China, 6%; Guatemala, 3%; and Haiti, 3%. Persons from 135 other countries each accounted for ≤2% of the total, but altogether, accounted for 40% of non-U.S.–born persons reported with TB.

Slide 19

Percentage of Non-U.S.–Born Persons with TB, by Time of Residence in U.S. Before Diagnosis, 2016. The chart indicates that the distribution for the top three countries of birth is Mexico, the Philippines, and India. Among persons born in Mexico, 11.2% had been in the United States for <1 year; 6.5%, 1–4 years; 8.4%, 5–9 years; 22.9%, 10–19 years; and 39.8% for ≥20 years. Among persons born in the Philippines, 11.6% had been in the United States for <1 year; 9.9%, 1–4 years; 12.4%, 5–9 years; 21.4%, 10–19 years; and 33.2%, ≥20 years. Among persons born in India, 21.1% had been in the United States for <1 year; 26.8%, 1–4 years; 13.2%, 5–9 years; 18.8%, 10–19 years; and 13.8%, ≥20 years. Values for unknown length of residence in the United States for these top three countries ranged from 6.3 to 11.5% for 2016. For all other non-U.S.–born persons, 20.4% had been in the United States for <1 year; 17.9%, 1–4 years; 12.9%, 5–9 years; 18.1%, 10–19 years; 22.8%, ≥20 years; and 7.9%, unknown length of residence. Overall, 17.6% had been in the United States for <1 year; 15.6%, 1–4 years; 12.0%, 5–9 years; 19.5%, 10–19 years; 26.5%, ≥20 years; and 8.8%, unknown length of residence.

Slide 20

Primary Anti-TB Drug Resistance, United States, 1993–2016. The graph starts in 1993, the year in which the individual TB case reports submitted to the national surveillance system began collecting information regarding initial susceptibility test results for patients with culture-positive TB. Data were available for >86.9% of culture-positive cases for each year. Primary resistance was calculated by using data from persons with no reported prior TB episode. Resistance to at least isoniazid was 8.2% in 1993; however, by 2016, this had increased to 8.7%. Resistance to at least isoniazid and rifampin, known as multidrug-resistant TB (MDR TB), was 2.5% in 1993. The percent of primary MDR TB has remained approximately stable since it decreased to 1.0% in 1998. In 2016 the percent of primary MDR TB was 1.2%.

Slide 21

Primary MDR-TB, United States, 1993–2016. This graph focuses on trends in primary multidrug-resistant TB (MDR-TB), which is based on initial isolates from persons with no prior history of TB. The number of primary MDR-TB cases, represented by the bars, decreased steadily from 407 in 1993 to 115 in 2001, with a slight increase to 132 in 2002. Since then, the total number of primary MDR-TB cases has fluctuated from 70 to 103 cases, with 78 cases reported for 2016. Primary MDR-TB, indicated by the trend line, decreased from 2.5% in 1993 to approximately 1.0% in 1998, and has fluctuated approximately 1.0% since then. During 2016, the percentage was 1.2%.

Slide 22

Primary Isoniazid Resistance Among U.S.-Born versus Non-U.S.–Born Persons, United States, 1993–2016. On the basis of initial isolates from persons with no prior history of TB, the percentage of isoniazid resistance has remained higher among non-U.S.–born persons than among U.S.-born persons for all years measured. Among non-U.S.–born persons, the percentage declined from 12.1% in 1993 to 10.0% in 2016. In U.S.-born persons, the percentage decreased from 6.7% in 1993 to a low of 4.2% in 2007. From 2008 to 2016 the percentage of cases ranged from 5.2% in 2008 to a high of 7.5% in 2014. During 2016, the percentage of primary isoniazid resistance among U.S.-born cases was 5.9%.

Slide 23

Slide 24. Primary MDR-TB in U.S.-born vs. Non-U.S.–born Persons, United States, 1993–2016. This graph highlights primary MDR-TB in U.S.-born versus non-U.S.–born persons. The percentage with primary MDR-TB has declined among both groups since 1993, although the decline in the U.S.-born has been greater. As a result, the proportion of primary MDR-TB cases in the US that are attributed to non-U.S.–born persons increased from approximately 25% in 1993 to 90% in 2016 (not shown on slide). Among the U.S.-born, the percentage with primary MDR-TB has been less than 1% since 1997 and was 0.4% in 2016. The percentage among non-U.S.–born persons has fluctuated year by year, although it has remained between 1.2 and 1.8% since 1995. In 2016 the percentage of primary MDR-TB among non-U.S.–born persons was 1.5%.

Slide 24

The vast majority (89.2%) of patients in 2016 who were eligible, completed treatment within 1 year of diagnosis. An additional 6.4% of these patients completed treatment >1 year after diagnosis.

Slide 25

During 2018, 605 isoniazid-resistant TB cases were reported in the United States, a 3% decrease from 625 cases during 2017. However, as a percentage of all TB cases, the proportion that were resistant to isoniazid has remained relatively steady at approximately 9%.

Slide 26

Volatility associated with small case counts is also a concern for MDR TB cases reported in the United States. During 2018, a previous notable increase in MDR TB cases (from 97 cases during 2016 to 128 cases during 2017) was reversed, with 98 MDR TB cases being reported for 2018.

Slide 27

The percentage of all cases occurring among persons with no previous history of TB disease that was MDR TB (i.e., primary MDR TB) has remained steady for the past several years at approximately 1%.

Slide 28

Coinfection with HIV is a major risk factor for progression of latent TB infection to TB disease. Starting in this edition of the report, we are limiting HIV coinfection trend data to 2011–2018 because HIV status data before 2011 had <90% completeness and data were most likely not missing at random, which can result in overestimation of HIV coinfection. Among 2018 cases that were alive at diagnosis, HIV status was known for 87.9%, and 5.1% of persons with known HIV status were coinfected with HIV. Among TB cases diagnosed in persons 25–44 years of age, 92.4% had known HIV status, and 8.3% of these persons where HIV positive.

Slide 29

Among reported risk factors for TB, diabetes mellitus (19.8%) was most commonly reported, followed by having been a close contact of a person with infectious TB (7.7%) or an immunocompromising condition other than HIV (7.3%). Having been a contact of a person with infectious TB was proportionately more common among US-born persons (15.9%), compared with non-US–born persons (4.2%). Diabetes mellitus, however, was proportionately more common among non-US–born persons (22.0%), compared with US-born persons (14.6%).

Slide 30

Definition for Tuberculosis Genotyping in the United States. This slide shows the schematic for sequential assignment of unique spoligotypes and initial 12-locus MIRU-VNTR combination or 24-locus MIRU-VNTR combination.

Slide 31

National Tuberculosis Genotyping Surveillance Coverage by Year, United States, 2004–2016. This slide shows the increase in genotyping surveillance coverage from 2004 to 2016. In 2004 the proportion of positive cultures with at least one genotyped isolate was 52.6%; in 2016 it was 96.4%. The national goal for genotyping surveillance coverage is 94.0%.

Slide 32

Number of County-based Tuberculosis Genotype Clusters by Cluster Size, United States, 2014–2016. This slide shows the number of county-based TB genotype clusters by the size of the clusters; genotype cluster is defined as two or more cases with matching spoligotype and 24-locus MIRU-VNTR (GENType) within a county during the specified three year time period. In the 2014–2016 three year time period, there were 878 two-case clusters, 263 three-case clusters, 105 four-case clusters, 43 five-case clusters, 25 six-case clusters, 26 seven-case clusters, 14 eight-case clusters, 10 nine-case clusters, and 37 case clusters that were greater or equal to 10 in size.

Slide 33

Tuberculosis Genotype Clusters by TB GIMS Alert Levels, United States, 2014–2016. This slide shows a chart with percentage of genotype clusters by alert level. Alert level is determined by the log likelihood ratio statistic (LLR) for a given cluster, identifying higher than expected geospatial concentrations for a TB genotype cluster in a specific county, compared to the national distribution of that genotype; TB GIMS generates alert level notifications based on this statistic: “No alert” is indicated if LLR is between 0–<5, “medium” is for LLR of 5–<10 and “high” alert is for clusters with LLR ≥10. In the 2014–2016 three year time period, high alerts made up 6% of the total, medium alerts were 23%, and no alert were 71%.

Slide 34

For more information, please contact Division of Tuberculosis Elimination at http://www.cdc.gov/tb/.

Slide 35

During 2018, 21.8% of all 2018 TB patients aged ≥15 years reported being unemployed; an additional 33.7% of TB patients were not seeking employment or were retired.

Slide 36

Successful therapy completion for TB patients is a major performance indicator for TB programs. Among patients during 2016 who were alive at diagnosis, 87.2% had completed TB treatment successfully. Among TB patients who had not completed treatment, 6.7% of all patients died before completing TB treatment; 1.3% were lost to follow-up before completing treatment; and 4.5% did not complete treatment for other or unknown reasons. Of note, only 29 patients (0.3%) had to permanently stop TB treatment because of an adverse treatment event.

Slide 37

Among TB cases diagnosed during 2016, a total of 833 (9.0%) patients died, with 315 (37.8%) of those deaths attributed to TB disease or TB treatment.

Slide 38

Of the 833 deaths, 206 (24.7%) were dead at the time of TB diagnosis; 33.5% of those deaths were attributed to TB. The remaining 627 (75.3%) deaths occurred after diagnosis; 39.2% of these deaths were attributed to TB.

Slide 39

Time required for a patient’s positive sputum culture to convert to negative is a key indicator of treatment effectiveness. Among 5,115 cases during 2016 with positive sputum cultures, 4,215 (82.4%) had documented sputum culture conversion to negative. Among the 809 (15.8%) cases for which sputum culture conversion was undocumented, the most common reason was that the patient had died (30.3%) before sputum culture conversion; however, a substantial proportion of these cases (36.8%) did not have a known reason reported for not having documented sputum culture conversion.

Slide 40

This slide shows the schematic for sequential assignment of unique spoligotypes and initial 12-locus MIRU-VNTR combination or 24-locus MIRU-VNTR combination.

Slide 41

This slide shows the increase in genotyping surveillance coverage from 2004 to 2018. In 2004 the proportion of culture confirmed TB cases with at least one genotyped isolate was 52.6%; in 2018 it was 96.3%. The national goal for genotyping surveillance coverage is 94.0%.

Slide 42

This slide shows the number of county-based TB genotype clusters by the size of the clusters; a genotype cluster is defined as two or more cases with matching spoligotype and 24-locus MIRU-VNTR (GENType) within a county during the specified three year time period. In the 2016–2018 three year time period, there were 893 two-case clusters, 224 three-case clusters, 90 four-case clusters, 42 five-case clusters, 33 six-case clusters, 21 seven-case clusters, 5 eight-case clusters, 12 nine-case clusters, and 29 case clusters that were greater or equal to 10 in size.

Slide 43

Clusters are classified into alert levels on the basis of a log-likelihood ratio (LLR) calculation; clusters with an LLR of 5–10 are classified as a medium alert level, and clusters with an LLR ≥11 are classified as a high alert level. Clustered cases were often part of medium- (22.6%) or high-level alerts (18.6%). At the cluster level, 392 (29.1%) of 1,349 clusters identified nationally were either medium- or high-level alerts.

Slide 44

Nationally, CDC attributed 1,712 (12.6%) of 13,601 genotyped cases reported during 2017–2018 to recent transmission.

Slide 45

National Tuberculosis Surveillance System Highlights from 2018

This slide series was developed as an accompaniment to the document Reported Tuberculosis in the United States, 2018

Page last reviewed: September 6, 2019