Topics in Minority Health Tuberculosis in Minorities -- United States

In 1985, 22,201 cases of tuberculosis were reported to CDC, for a rate of 9.3/100,000 population (1). Of the 22,170 cases of known race, 11,524 (52.0%) were in whites (including 3,032 white Hispanics), and 10,646 (48.0%) were in nonwhites (7,719 blacks, 2,530 Asians/Pacific Islanders, and 397 American Indians/Alaskan Natives). The rate for nonwhites was 5.2 times that for whites (29.6 as compared with 5.7/100,000 population) (Table 1). The ratios of age-specific rates for nonwhites to those for whites ranged from 4.3 for children 5 years of age to 9.0 for adults 25 to 44 years of age.

Excess tuberculosis morbidity in nonwhite minorities was determined by using a methodology similar to that employed by the Department of Health and Human Services Secretary's Task Force on Black and Minority Health (2,3). Excess morbidity was defined as the difference between the number of cases observed in the minority population and the number that would be expected if the minority population had the same age-specific rates as the nonminority population. If nonwhite minorities had experienced the same age-specific morbidity rates as whites, there would have been 1,678 tuberculosis cases among patients for whom race and age were known, instead of the observed 10,640 cases (Table 1). Thus, 8,962 (84.2%) of the tuberculosis cases in nonwhites can be considered as excess cases. The 25- to 44-year age group had the largest number of excess cases (3,646).

In 1984, 1,729 deaths from tuberculosis were reported to the National Center for Health Statistics, for a mortality rate of 0.73/100,000 population. There were 1,047 deaths among whites and 682 among nonwhites. The mortality rate for nonwhites was 3.7 times that for whites (1.94 as compared with 0.52/100,000 population). If nonwhite minorities had experienced the same age-specific mortality rates as whites, the expected number of tuberculosis deaths in which race and age were known would have been 125, instead of the 681 actually reported. Thus, 556 (81.6%) of the tuberculosis deaths in nonwhites can be considered as excess deaths.

An analysis by race and ethnicity of tuberculosis cases reported in 1985 shows that 38.3% (8,453) of 22,060 cases among patients with known race and ethnicity occurred in non-Hispanic whites, and 61.7% (13,607) occurred among all racial and ethnic minorities (blacks, Asians/Pacific Islanders, American Indians/Alaskan Natives, and Hispanics). Figure 1 shows reported tuberculosis cases, by age, among non-Hispanic whites and all racial and ethnic minorities. Patients among minorities in general were much younger than non-Hispanic white patients. Among non-Hispanic whites, the 70- to 74-year age group had the greatest number of reported cases; while in minorities, the number of cases was highest in the 25- to 29-year age group. Members of minority groups accounted for 10,267 (72.8%) of the 14,097 patients who were 60 years of age and for whom age, race, and ethnicity were known. Non-Hispanic whites accounted for 4,616 (58.1%) of the 7,948 patients greater than or equal to 60 years of age.

As shown in Figure 2, the median age for patients with tuberculosis was 62 years for non-Hispanic whites and 41 years for minorities. Fourteen percent (1,209) of non-Hispanic white patients were less than or equal to 35 years of age, compared with 39% (5,266) of patients among racial and ethnic minorities. Reported by Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Over the past three decades, rates of tuberculosis in the United States have been consistently higher among racial minorities than among whites. Furthermore, while the number and rates of tuberculosis cases have decreased in the United States, the rate of decline has been much slower for nonwhites than for whites. As a result, the proportion of cases occurring among nonwhites increased from 23% in 1953 to 48% in 1985. In the United States in 1985, more than three-fifths of all reported cases occurred among racial and ethnic minorities.

Tuberculosis will probably disappear among non-Hispanic whites much sooner than it will among minorities. This is a result of the fact that, among non-Hispanic whites, tuberculosis has become primarily a disease of the elderly; whereas, among minorities, it is found mainly in the young. The older cohort of infected non-Hispanic whites will be replaced by a younger cohort with little or no infection. Furthermore, in most of these older persons tuberculous infection occurred many years ago, and, thus, their risk of developing active tuberculosis is low (4). As a result, transmission from older infected persons is relatively unlikely. In addition, transmission to children by adults beyond child-raising age is also unlikely. This is suggested by the much smaller proportion of childhood cases found among non-Hispanic whites (Figure 2).

In contrast, the number of tuberculosis cases among minorities peaks in the 25- to 34-year age group. These patients come from the much larger pool of persons who are infected with Mycobacterium tuberculosis and who may potentially develop active disease and infect their children. Some of these children may then progress to active tuberculosis, as indicated by the larger proportion of childhood cases among minorities. Each of these childhood tuberculosis cases should be viewed as a sentinel health event reflecting ongoing transmission in the minority population (5-7).

Nevertheless, almost 40% of the cases among minorities occurred among persons 35 years of age and were, therefore, potentially preventable (8). Thus, it remains of particular importance to identify young adults, regardless of race and ethnicity, who are infected with the tubercle bacillus and are eligible for preventive chemotherapy. Preventive therapy is particularly important in protecting contacts of patients with tuberculosis from infection and disease (8).

References

1. CDC. Tuberculosis--United States, 1985. MMWR 1986;35:699-703.

2. US Department of Health and Human Services. Report of the Secretary's task force on black and minority health. Washington, DC: US Department of Health and Human Services, 1985.

3. CDC. Report of the Secretary's task force on black and minority health. MMWR 1986;35:109-12.

4. Comstock GW. Frost revisited: the modern epidemiology of tuberculosis. Am J Epidemiol 1975;101:363-82.

5. Bloch AB, Snider DE Jr. How much tuberculosis in children must we accept? Am J Public Health 1986;76:14-5.

6. Rutstein DD, Berenberg W, Chalmers TC, Child CG 3rd, Fishman AP, Perrin EB. Measuring the quality of medical care: a clinical method. N Engl J Med 1976;294:582-8.

7. Rutstein DD, Mullan RJ, Frazier TM, Halperin WE, Melius JM, Sestito JP. Sentinel health events (occupational): a basis for physician recognition and public health surveillance. Am J Public Health 1983;73:1054-62.

8. American Thoracic Society, CDC. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986;134:355-63.

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