Current Trends Tuberculosis -- United States, 1984

In 1984, 22,255 cases of tuberculosis were reported to CDC, for a rate of 9.4 cases per 100,000 population. Compared with 1983, this is a 6.7% decrease in the number of cases reported and a decline of 7.8% in the case rate.

Case rates for the 50 states ranged from 21.0/100,000 in Hawaii to 1.0/100,000 in Wyoming (Table 1). The rate increased in eight states, remained unchanged in two, and decreased in 40.

The case rate for persons living in 57 cities with populations of 250,000 or more was 19.3/100,000--more than twice the national rate (Table 2). Urban rates ranged from 49.9/100,000 in Miami, Florida, to 2.3/100,000 in Omaha, Nebraska. Eight cities had rates at least three times the national rate: Miami, Florida; Newark, New Jersey; Atlanta, Georgia; San Francisco, California; Tampa, Florida; Oakland, California; Honolulu, Hawaii; and Washington, D.C.

In 1984, 1,236 tuberculosis cases were reported among children under 15 years of age, including 759 cases among children under 5 years of age; in 1983, there were 1,360 and 818 such cases, respectively.

Official tuberculosis mortality statistics for the United States are compiled by the National Center for Health Statistics. Final tuberculosis mortality data for 1982 show 1,807 deaths. This is a 6.7% decrease from 1981 in the number of deaths reported. Reported by Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The 6.7% decrease in new reported tuberculosis cases in 1984 continues the downward trend noted for 1982 and 1983. Contributing factors include: (1) the participation of almost all states in a new national case reporting system requiring more accurate verification of cases and (2) a decline in the actual number of indigenous cases. During the past 3 years, health departments have implemented expanded outreach programs in high-incidence areas to ensure complete treatment of diagnosed cases and to strengthen contact investigation and follow-up activities.

When antituberculosis drugs were first introduced over 35 years ago, there was hope that the disease would soon be eliminated in the United States, even though over 100,000 new active cases and about 40,000 deaths from tuberculosis were reported annually. Given the current rate of decline, the elimination of tuberculosis appears unlikely before the year 2100. Over 20,000 new cases and 1,800 deaths still occur each year. Transmission of infection also continues, as evidenced by the continued occurrence of hundreds of cases in young children, most of whom are under 5 years of age. An accelerated rate of decline must be achieved if tuberculosis is to be fully controlled in this century.

Control of tuberculosis has been hampered by a number of factors. Unfortunately, many public and private sector health-care providers do not consider tuberculosis a problem. This perception has been fostered in part by the closing of tuberculosis sanatoriums and the institution of outpatient treatment programs.

Another problem that hampers control efforts for state and local health departments--which have the major responsibility for controlling this disease in the community--is noncompliance with prescribed therapy. Most patients require a minimum of 9 months' treatment, with monthly monitoring for drug toxicity, compliance, and response to therapy. Many patients are unwilling or unable to complete a self-administered course of therapy and may require directly observed therapy or other special assistance from the health department. An estimated 34,000 persons in health department registers are currently under medical supervision for tuberculosis, and each year, an estimated 200,000 persons exposed to new cases must be examined. Many of these persons, as well as other high-risk individuals, are placed on isoniazid preventive treatment for up to 12 months and also require monthly monitoring for drug toxicity and compliance.

A third obstacle to the effective control of tuberculosis is the emergence of tuberculosis organisms that are resistant to antituberculosis drugs, especially isoniazid and streptomycin. Such resistance is relatively more common among persons from Asia, Africa, and Central and South America. However, the problem of drug resistance is not limited to the foreign-born. Community outbreaks of drug-resistant tuberculosis have occurred in Mississippi (1), Montana (2), New York, and more recently, Massachusetts and North Carolina.

Preventing the majority of new tuberculosis cases is difficult to achieve in a short period of time with currently available technology. An estimated 10 million persons in this country are infected with tubercle bacilli and carry a life-long risk of developing tuberculosis. Even if health departments could identify all the infected individuals in the country who are at high risk of developing disease and provide them with preventive therapy, tuberculosis would still continue to occur in some infected individuals over the age of 35 years for whom preventive therapy is not recommended because the risk of isoniazid toxicity outweighs the benefits of therapy.

An acceleration of the decline can be achieved with: (1) full implementation of existing prevention and control methodology; (2) development of new treatment, diagnostic, and prevention technologies; and (3) rapid implementation of these new technologies in all areas of the country as they are developed.

CDC, state and local health departments, and other public agencies and organizations will continue to work together to achieve the first step. In June 1985, a small group of scientists will meet in Pittsfield, Massachusetts, to explore obstacles to tuberculosis elimination and to identify feasible new technologies that could be developed and used to accelerate the elimination of tuberculosis. This effort is sponsored by the U.S. Public Health Service, including CDC and the National Institutes of Health, the American Thoracic Society, and the Pittsfield Antituberculosis Association. Within the next few months, CDC will also identify a group of outside experts who will advise on the further development and implementation of a tuberculosis elimination plan. Successful accomplishment of the three action steps could bring about the elimination of tuberculosis in the United States a century earlier than is now projected.

References

1. Reves R, Blakey D, Snider DE, Jr, Farer LS. Transmission of multiple drug-resistant tuberculosis: report of a school and community outbreak. Am J Epidemiol 1981;113:423-35.

2. CDC. Interstate outbreak of drug-resistant tuberculosis involving children--California, Montana, Nevada, Utah. MMWR 1983;32:516-8.

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