Tuberculosis Morbidity -- United States, 1995

During 1995, a total of 22,813 cases of tuberculosis (TB) (8.7 cases per 100,000 population) were reported to CDC from the 50 states, the District of Columbia (DC), and New York City -- a 6.4% decrease from 1994 (24,361 cases {9.4 per 100,000}) (1); an additional 262 cases were reported from Puerto Rico. This represents the third consecutive year the number of reported TB cases has decreased (Table_1) (2), resulting in the lowest rate for reported TB cases since national surveillance began in 1953. This report summarizes TB surveillance data for 1995 and compares these data with selected data for 1986-1994, and indicates a decreased number of TB cases among U.S.-born persons and increased number among foreign-born persons.

During 1995, a total of 32 states and DC reported fewer TB cases than in 1994; in comparison, during 1994, a total of 26 states and DC reported fewer cases than in 1993, and during 1993, a total of 31 states reported fewer cases than in 1992 (Table_1). Nine states (California, Connecticut, Hawaii, Illinois, Michigan, Mississippi, New Jersey, New York, and North Carolina) reported fewer cases each year since 1992, a total of 18 states (36%) reported no change or more cases in 1995 compared with 1994, and two (Iowa and Kansas) reported more cases in each year since 1992 (Table_1). Compared with 1994, the number of reported TB cases in 1995 decreased in each sex and age group and all racial/ethnic groups except Asians/Pacific Islanders, for whom a 2.9% increase was reported (Table_2).

During 1995, TB cases reported among persons born outside the United States and its territories (i.e., foreign-born) accounted for 35.7% of total reported cases, compared with 31.3% in 1994 (Table_2). The number and proportion of persons reported with TB who were classified as foreign-born have increased 63.3% since 1986, the first year information on the country of origin was collected for each case (Figure_1). In 1995, the country of origin was known for 7592 (94.4%) cases reported in foreign-born persons; six countries (Haiti, India, Mexico, People's Republic of China, Philippines, and Vietnam) accounted for 63.6% of the cases. Of the 4804 foreign-born persons reported in 1995 whose records contained information about month and year of arrival in the United States, 1441 (30.0%) had TB diagnosed within 1 year and 2567 (53.4%) within 5 years after entering the United States. Compared with 1994, the number of cases reported in U.S.-born persons in 1995 decreased 10.8%, and the number of cases in foreign-born persons increased 5.4% (Table_2). During 1995, the number of cases in U.S.-born persons decreased in all age groups; the decrease was largest (17.0%) among persons aged 25-44 years. In comparison, the number of cases in foreign-born persons reported in 1995 increased in all age groups except for children aged less than 15 years (decreased 7.4%) and persons aged 15-24 years (decreased 5.1%).

Human immunodeficiency virus (HIV)-antibody test results were available in 1994 for 3317 (36.4%) of 9106 patients aged 25-44 years (nine states reported this information for greater than or equal to 75% of records) and in 1995 for 2925 (35.6%) of 8227 such patients (eight states reported information for greater than or equal to 75% of records). Information about the prescribed initial drug regimen for each TB case was available for 98.0% of cases reported in both 1994 and 1995. Compared with 1994, in 1995 there was a 5.3% increase in the proportion of cases for which the initial four-drug regimen was prescribed as recommended by the Advisory Council for the Elimination of Tuberculosis, the American Thoracic Society, and CDC (isoniazid {INH}, rifampin {RIF}, pyrazinamide {PZA}, and either ethambutol or streptomycin) (3,4) (Table_2).

The proportion of patients for whom drug-susceptibility results for Mycobacterium tuberculosis isolates were reported was larger in 1995 than in 1994 (14,052 {77.3%} of 18,168 patients and 14,509 {74.3%} of 19,537 patients, respectively). In 1995, a total of 37 states reported drug-susceptibility results for isolates from greater than or equal to 75% of cases; of these, 806 (7.6%) of 10,621 isolates were resistant to at least INH, and 145 (1.4%) of 10,611 were resistant to at least INH and RIF. Compared with 1994, when only 23 states reported drug-susceptibility results for isolates from greater than or equal to 75% of cases, the proportion of cases with isolates resistant to at least INH decreased from 8.5%, and resistance to at least INH and RIF decreased from 1.5%. The 37 states reporting drug-susceptibility results accounted for 71% of all culture-positive cases reported in the United States in 1995.

Reported by: Div of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention (proposed), CDC.

Editorial Note

Editorial Note: The substantial decline in the number of TB cases reported annually in the United States during 1992-1995 (14.5%) reflects at least six factors: 1) improved laboratory methods to allow prompt identification of M. tuberculosis; 2) broader use of drug-susceptibility testing; 3) expanded use of preventive therapy in high-risk groups; 4) decreased transmission of M. tuberculosis in congregative settings (e.g., hospitals and correctional facilities) by implementing infection-control guidelines (5,6); 5) improved follow-up of persons with TB initially reported to the health department, leading to subsequent removal from the surveillance database of cases for which a disease other than TB was diagnosed; and 6) increased federal resources for state and local TB-control efforts. Beginning in 1992, federal resources for assisting state and local TB-control efforts were increased (1,7). Some of the states with the largest decreases (e.g., New York and California) had high rates of HIV infection and acquired immunodeficiency syndrome (AIDS); resources directed to these states also have supported TB-screening efforts and preventive therapy for HIV-infected persons at high risk for TB infection. The increased funding enabled state and local TB-control programs to improve management of TB cases, in part by ensuring that all patients complete an adequate course of therapy and by expanding the use of directly observed therapy (7,8).

Preliminary analyses of national surveillance data and TB-control program management reports indicate that the decrease in cases in U.S.-born persons largely reflected improvement in program performance (CDC, unpublished data, 1995). Since 1986, the number and proportion of reported TB cases among foreign-born persons have increased substantially (9). Most of these persons develop TB disease within the first 5 years of arrival in the United States because of reactivation of latent M. tuberculosis infection acquired in their country of origin, inadequate screening for and/or treatment of TB before entering the United States, or inadequate follow-up of those who have entered the United States with noninfectious TB (i.e., abnormal chest radiograph with negative sputum smears). Control of TB among foreign-born persons in the United States can be strengthened through improved screening and services for immigrants and refugees, prompt reporting of immigrants and refugees with suspected TB to public health programs and health-care providers, and early identification and treatment of TB in foreign-born persons from countries with a high prevalence of TB (9).

Assessment of the relation between HIV infection and TB has been limited by the incomplete reporting of information on HIV test results for TB cases: during 1994-1995, this information was available for only 36% of reported persons aged 25-44 years. During 1996 and 1997, CDC, in collaboration with selected state and local health departments, will assess HIV-testing and HIV-counseling practices for TB patients, measure the prevalence of testing, and determine barriers to reporting HIV results for patients who are tested. Results of this assessment will be used to develop strategies to improve HIV testing and counseling of TB patients and reporting of HIV results to state and local TB and HIV/AIDS surveillance programs.

The recent national decreases in TB morbidity in the United States can be sustained through efforts by federal agencies and state and local health departments to ensure that all persons with TB are promptly identified and treated. These efforts especially must include the identification and treatment of cases in foreign-born persons and persons who are HIV infected. In addition, TB skin tests of high-risk persons will enable identification of persons who could benefit from preventive therapy.

References

1. CDC. Tuberculosis morbidity -- United States, 1994. MMWR 1995;44:387-9,395.

2. CDC. Reported tuberculosis in the United States, 1993. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994.

3. CDC. Initial therapy for tuberculosis in the era of multidrug resistance: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1993;42(no. RR-7):1-8.

4. American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med 1994;149:1359-74.

5. Stroud LA, Tokars JI, Grieco MH, et al. Evaluation of infection control measures in preventing the nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis in a New York City hospital. Infect Control Hosp Epidemiol 1995;16:141-7.

6. Blumberg HM, Watkins DL, Bersching JD, et al. Preventing the nosocomial transmission of tuberculosis. Ann Intern Med 1995;122:658-63.

7. Frieden TR, Fujiwara PI, Washko RM, Hamburg MA. Tuberculosis in New York City: turning the tide. N Engl J Med 1995;333:229-33.

8. Chaulk CP, Moore-Rice K, Rizzo R, Chaisson RE. Eleven years of community-based directly observed therapy for tuberculosis. JAMA 1995;274:945-51.

9. McKenna MT, McCray E, Onorato I. The epidemiology of tuberculosis among foreign-born persons in the United States, 1986- 1993. N Engl J Med 1995;332:1071-6.

TABLE 1. Number of reported tuberculosis cases and percentage change, by state and
year -- United States, 1992-1995
=================================================================================================
                                No. cases                                 % Change
                   -------------------------------------     ----------------------------------
State               1992     1993       1994       1995      1992-1993    1993-1994   1994-1995
-----------------------------------------------------------------------------------------------
Alabama               418      487        433        420       +16.5        -11.1       - 3.0
Alaska                 57       57         93         81           0        +63.2       -12.9
Arizona               259      231        249        319       -10.8        + 7.8       +28.1
Arkansas              257      209        264        271       -18.7        +26.3       + 2.7
California          5,382    5,170      4,859      4,622       - 3.9        - 6.0       - 4.9
Colorado              104      104         94         95           0        - 9.6       + 1.1
Connecticut           156      155        148        140       - 0.6        - 4.5       - 5.4
Delaware               55       66         57         56       +20.0        -13.6       - 1.8
District of
 Columbia             146      161        121        102       +10.3        -24.8       -15.7
Florida             1,707    1,655      1,762      1,557       - 3.0        + 6.5       -11.6
Georgia               893      812        740        746       - 9.1        - 8.9       + 0.8
Hawaii                273      251        247        193       - 8.1        - 1.6       -21.9
Idaho                  26       11         13         14       -57.7        +18.2       + 7.7
Illinois            1,270    1,237      1,117      1,024       - 2.6        - 9.7       - 8.3
Indiana               247      248        211        199       + 0.4        -14.9       - 5.7
Iowa                   49       59         66         72       +20.4        +11.8       + 9.1
Kansas                 56       80         84         89       +42.9        + 5.0       + 6.0
Kentucky              402      404        347        327       + 0.5        -14.1       - 5.8
Louisiana             373      367        433        476       - 1.6        +18.0       + 9.9
Maine                  24       28         35         28       +16.7        +25.0       -20.0
Maryland              442      417        363        370       - 5.7        -13.0       + 1.9
Massachusetts         428      370        329        330       -13.6        -11.1       + 0.3
Michigan              495      480        462        424       - 3.0        - 3.8       - 8.2
Minnesota             165      144        140        156       -12.7        - 2.8       +11.4
Mississippi           281      279        278        271       - 0.7        - 0.4       - 2.5
Missouri              245      257        260        245       + 4.9        + 1.2       - 5.8
Montana                16       22         24         21       +37.5        + 9.1       -12.5
Nebraska               28       23         22         24       -17.9        - 4.4       + 9.1
Nevada                 99       99        126        115           0        +27.3       - 8.7
New Hampshire          18       26         17         23       +44.4        -34.6       +35.3
New Jersey            984      912        855        848       - 7.3        - 6.3       - 0.8
New Mexico             88       74         81         84       -15.9        + 9.5       + 3.7
New York*           4,574    3,953      3,636      3,066       -13.6        - 8.0       -15.7
North Carolina        604      594        566        519       - 1.7        - 4.7       - 8.3
North Dakota           11        7         10          5       -36.4        +42.9       -50.0
Ohio                  358      315        337        280       -12.0        + 7.0       -16.9
Oklahoma              216      209        261        237       - 3.2        +24.9       - 9.2
Oregon                145      154        165        156       + 6.2        + 7.1       - 5.5
Pennsylvania          758      749        621        680       - 1.2        -17.1       + 9.5
Rhode Island           54       64         56         50       +18.5        -12.5       -10.7
South Carolina        387      401        387        334       + 3.6        - 3.5       -13.7
South Dakota           32       16         28         28       -50.0        +75.0           0
Tennessee             527      556        520        465       + 5.5        - 6.5       -10.6
Texas               2,510    2,396      2,542      2,369       - 4.5        + 6.1       - 6.8
Utah                   78       46         55         48       -41.0        +19.6       -12.7
Vermont                 7        7         10          4           0        +42.9       -60.0
Virginia              457      458        372        359       + 0.2        -18.8       - 3.5
Washington            306      285        264        278       - 6.9        - 7.4       + 5.3
West Virginia          92       75         80         71       -18.5        + 6.7       -11.3
Wisconsin             106      100        109        117       - 5.7        + 9.0       + 7.3
Wyoming                 8        7         12          5       -12.5        +71.4       -58.3

Total              26,673   25,287     24,361     22,813       - 5.2        - 3.7       - 6.4
-----------------------------------------------------------------------------------------------
*Includes New York City.
=================================================================================================

TABLE 2. Number of persons with reported cases of tuberculosis, by selected
characteristics and year -- United States, 1994-1995
======================================================================================
                                        No. reported cases
                                       --------------------        % Change,
Characteristic                          1994          1995         1994-1995
----------------------------------------------------------------------------
Sex *
 Male                                  15,833        14,482          - 8.5
 Female                                 8,517         8,301          - 4.9

Age group (yrs) +
  0-14                                  1,695         1,551          - 8.5
 15-24                                  1,825         1,700          - 6.9
 25-44                                  9,106         8,227          - 9.7
 45-64                                  6,141         5,985          - 2.5
  >=65                                  5,546         5,332          - 3.9

Race/Ethnicity &
 White, non-Hispanic                    6,494         5,950
 Black, non-Hispanic                    8,345         7,521
 Hispanic                               5,074         4,808          - 5.2
 Asian/Pacific Islander                 3,821         3,932          + 2.9
 American Indian/
  Alaskan Native                          332           323          - 2.7

Country of origin @
 United States                         16,278        14,515          -10.8
 Other                                  7,627         8,042          + 5.4

Initial drug regimen **
 Isoniazid and rifampin                 1,626         1,083          -33.4
 Isoniazid, rifampin, and
  pyrazinamide                          5,332         4,325          -18.9
 Isoniazid, rifampin,
  pyrazinamide, and ethambutol
  or streptomycin                      12,768        13,439          + 5.3
 Other                                  3,019         2,373          -21.4

Total                                  24,361        22,813          - 6.4
----------------------------------------------------------------------------
 * Excludes persons for whom sex was unknown (11 in 1994 and 30 in 1995).
 + Excludes persons with unknown or missing age (48 in 1994 and 18 in 1995).
 & Excludes persons with unknown race/ethnicity (295 in 1994 and 279 in 1995).
 @ Excludes persons with unknown country of origin (456 in 1994 and 256 in 1995).
** Excludes persons with unknown or no drug regimen (1616 in 1994 and 1593 in 1995).
======================================================================================

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