Progress Toward Tuberculosis Elimination and Tuberculosis Program Performance — National Tuberculosis Indicators Project, 2016–2022

Introduction

Using data to monitor tuberculosis (TB) program performance can provide insights into program functioning and allow for the timely recognition of successes and areas for improvement (1,2). Monitoring and evaluating TB program activities involves a combination of objectives, indicators, and performance targets that allow for continuous tracking of program progress and performance monitoring. Performance indicators are specific, measurable criteria that are chosen based on national TB program objectives and are used to quantitatively assess progress and outcomes (2–4). Each national TB program indicator has an associated performance target. Together, these tools help programs assess the effectiveness of TB control activities and identify areas for improvement, thus improving TB patient outcomes (5,6).

CDC, in collaboration with internal and external partners, developed a set of national TB objectives, associated indicators, and performance targets to evaluate progress toward TB elimination by monitoring the performance of state and city TB program activities (7,8). The national TB indicators are available to TB programs through the National TB Indicators Project (NTIP) application (8).

CDC publishes annual TB surveillance reports (9), which presents national data over time and jurisdiction data for a single year, and state and city TB report (10), which display TB indicator data at a single point at the state and city levels. Neither of these reports provide trend data at the state, city, or local level. The findings in this report can be used by state and city TB programs to assess their TB control efforts and identify areas for improvement.

Methods

To provide programs with a resource to evaluate their performance over time, CDC summarized NTIP data for five key indicators: 1) overall TB incidence in the United States, 2) TB incidence among non–U.S.-born persons, 3) percentage of persons with drug susceptibility results reported, 4) percentage of contacts to sputum acid-fast bacillus (AFB) smear-positive TB patients who received a new diagnosis of latent TB infection (LTBI) and who completed LTBI treatment (among those who started LTBI treatment), and 5) percentage of patients with completion of TB therapy within 12 months (among those who are eligible to complete within 12 months) (9). These indicators are included in a formula to determine the amount of funding provided to TB programs as part of the CDC TB Cooperative Agreement for the prevention and control of TB (11).

Data Sources and Collection

NTIP is a web-based performance-monitoring tool that uses routine data reported to the National TB Surveillance System (NTSS) and the Aggregate Reports for Program Evaluation (ARPE). NTIP was developed to facilitate the use of NTSS data to measure national TB program objectives, indicators, and performance targets, which can help TB programs prioritize activities, monitor progress, and focus program improvement efforts. TB programs have access to their own specific data and national aggregate data in NTIP. However, they are unable to access performance data from other TB programs. As a result, they can only compare their program’s performance trends with national averages.The ability to compare performance among TB programs that report similar numbers of TB cases could be more useful in identifying areas for improvement.

All 50 U.S. states, the District of Columbia, and New York City report each new case of TB to NTSS via the Report of Verified Case of TB (9). U.S. territories and freely associated states also report TB data to NTSS, but these data are not included in this report. Performance measures (rates and percentages) associated with TB incidence in the United States, TB incidence among non–U.S.-born persons, completion of TB therapy within 12 months, and drug susceptibility test results are calculated using NTSS data.

ARPE is a data collection system through which TB programs report information about persons who received a new diagnosis of TB disease or LTBI. ARPE information is submitted through NTIP using a standardized form (12,13). ARPE data are used to calculate the percentage of contacts who received a new diagnosis of LTBI and completed treatment.

The 52 TB programs included in this report correspond to distinct geographic jurisdictions. For the purposes of this report, the term jurisdiction will be used to describe results related to both the TB program and its corresponding geographic area.

National TB Indicators and Performance Targets

The cohort for each national TB indicator is defined as the number of persons reported in the year of interest who are eligible to meet the performance objective for the indicator. For each indicator, inclusion and exclusion criteria are defined for the cohort. National performance targets for these indicators are calculated approximately every 5 years on the basis of historical TB program performance for each indicator (14) (Box).

The following indicators were selected for this report because of their importance in Federal TB funding allocation and in intensifying efforts to reduce TB incidence:

• TB incidence in the United States: number of new TB cases per 100,000 persons per year
• TB incidence among non–U.S.-born persons: number of TB cases among non–U.S.-born persons per 100,000 non–U.S.-born persons per year
• Drug susceptibility test results: percentage of persons with TB disease with a positive culture result who had initial drug-susceptibility results reported
• Contacts to sputum AFB smear-positive TB patients who received a new diagnosis of LTBI who completed treatment: percentage of contacts to persons with sputum AFB smear-positive TB who received a diagnosis of LTBI and who completed treatment among those patients who started treatment
• Completion of TB therapy within 12 months: percentage of patients who received a new diagnosis of TB disease for whom treatment completion within 12 months is indicated and who completed treatment within 12 months (366 days)

Analysis

Descriptive analyses were performed for the five selected indicators for each of the 52 jurisdictions in the United States. For this report, jurisdictions were categorized into terciles based on the average number of cases during the 5-year reporting period for which the most recent data were available for the analyzed variables. This grouping allowed comparison of jurisdictions with similar numbers of TB cases and allocated an equivalent number of jurisdictions to each category.

The 5-year reporting period was 2018–2022 for overall TB incidence, TB incidence among non–U.S.-born persons, and persons with drug susceptibility results reported. For contacts who received a new diagnosis of LTBI who completed LTBI treatment, the 5-year reporting period was 2017–2021 because of different reporting deadlines associated with data from NTSS and ARPE. TB therapy can take up to 2 years to complete; therefore, 2016–2020 was the 5-year period for completion of TB therapy within 12 months.

The average percentage for each indicator over the 5-year period was calculated using the formula (% from Year 1 + % from Year 2 + % from Year 3 + % from Year 4 + % from Year 5) ÷ 5. The relative change from year 1 to year 5 for each indicator was calculated as [(% from Year 5 − % from Year 1) ÷ % from Year 1] × 100. For indicators based on incidence, the calculations used incidence rather than percentage for each year. The national average was calculated for each indicator (i.e., sum of average percentage or incidence over the 5-year period for all jurisdictions ÷ total number of jurisdictions). Data in the tables are displayed by improved relative change to allow TB programs to assess how they rank in relation to other jurisdictions with similar numbers of reported TB cases. Overall TB incidence and TB incidence among non–U.S.-born persons were calculated using 2015–2019 annual population estimates (the latest population data available) from the Census Bureau’s American Community Survey (15).

Results

For 2018–2022, the terciles for overall TB incidence, TB incidence among non–U.S.-born persons, and percentage of persons with drug susceptibility results reported were jurisdictions with 1–50 TB cases (T1), 51–126 TB cases (T2), and 127 or more TB cases (T3) (Tables 1, 2 and 3). For 2017–2021, the terciles for the percentage of contacts with newly diagnosed LTBI who completed treatment were jurisdictions with 1–49 TB cases (T1), 50–130 TB cases (T2), or ≥131 TB cases (T3) (Table 4). For 2016–2020, the terciles for the percentage of patients with completion of TB therapy within 12 months were jurisdictions with 1–46 TB cases (T1), 47–130 TB cases (T2), or 131 or more TB cases (T3) (Table 5).

TB Incidence in the United States

The incidence of TB decreased in 37 of the 52 (71.2%) jurisdictions from 2018 to 2022 (Table 1). The national 5-year average incidence of TB was 2.5 cases per 100,000 persons. Overall, 15 (28.9%) jurisdictions had a 5-year average incidence that was at or below the national performance target of 1.3 (Figure); 28 jurisdictions (53.9%) had a 5-year average incidence that was at or below the national average of 2.5 but higher than 1.3. Programs in these 28 jurisdictions have not yet met the national performance target. Nearly all jurisdictions in T1 had an average 5-year incidence at or below the national average and performance target (16 of 17 [94.1%] jurisdictions) compared with 16 of 18 (88.9%) jurisdictions in T2 and 11 of 17 (64.7%) jurisdictions in T3.

Although almost all jurisdictions in T1 had incidences that were below the national average or performance target, these jurisdictions also had the largest range in relative change in TB incidence for the 5-year period (−56.3% to 85.7%), an indication of the instability of data for jurisdictions with few TB cases; small changes in case counts can result in large percentage changes. In comparison, relative change ranged from −31.7% to 51.8% among jurisdictions in T2 and −26.0% to 28.6% in T3.

TB Incidence Among Non–U.S.-Born Persons

Overall, eight of 51 (15.7%) jurisdictions (one state did not report any TB cases among non–U.S.-born persons during the 5-year period) had a 5-year average incidence that was at or below the national performance target of 8.8 cases per 100,000 non–U.S.-born persons (Figure); four of these eight jurisdictions were in T1 (Table 2). The incidence of TB among non–U.S.-born persons decreased in 26 of 51 (51.0%) jurisdictions from 2018 to 2022 (Table 2). Approximately two thirds (12 of 17 [70.6%]) of jurisdictions in T3 had decreases in the relative change in incidence among non–U.S.-born persons compared with approximately one third of jurisdictions in T2 (five of 18 [27.8%]) and over half in T1 (nine of 16 [56.3%]). Among jurisdictions in T3, eight of 17 (47.1%) had an average 5-year incidence at or below the national average of 13.1 compared with six of 18 (33.3%) in T2 and nine of 16 (56.3%) in T1. As with overall TB incidence, the largest range in relative change in TB incidence among non–U.S.-born persons from 2018 to 2022 occurred among jurisdictions in T1(−57.3% to 350.9%) compared with jurisdictions in T2 (−38.1% to 136.5%) and T3 (−33.0% to 21.8%).

Initial Drug Susceptibility Test Results

The 5-year average percentages of persons having initial drug susceptibility test results reported during 2018–2022 in most jurisdictions (28 of 52, [53.9%]) met or exceeded the 5-year national average of 97% (Table 3). The 5-year average percentage could not be calculated for one jurisdiction in T1 because no cases with positive culture results were reported in 2020; therefore, no persons with diagnosed TB disease were eligible to be included in the indicator cohort for that year. The percentage that met or exceeded the national average was highest for jurisdictions in T1 (11 of 17 [64.7%]), followed by T2 (10 of 18 [55.6%]), and T3 (seven of 17 [41.2%]). The 2025 national performance target of 100% has been met in six jurisdictions, all of which were in T1; no jurisdictions in the other two categories met the 2025 national performance target.

Although half of the jurisdictions met or exceeded the national average for initial drug susceptibility results reported, only 12 of 52 (23.1%) had an increase in relative change from 2018 to 2022. In addition, 12 of 52 (23.1%) jurisdictions had no relative change in performance from 2018 to 2022; six of the 12 (50.0%) had a 5-year average performance that had already met the 2025 national performance target for reporting initial drug susceptibility test results.

Contacts to Sputum AFB Smear-Positive TB Patients with a New Diagnosis of LTBI Who Completed Treatment

The relative change in the percentage of contacts who received a new diagnosis of LTBI who completed treatment increased in 29 of 52 (55.8%) jurisdictions from 2017 to 2021, signifying that, for most jurisdictions, steps have been taken to enhance performance for this indicator (Table 4). In addition, the same number of jurisdictions (although not the same jurisdictions) met or exceeded the national average of 81.2% for contacts who received a new diagnosis of LTBI and completed treatment (29 of 52 [55.8%]). However, only two jurisdictions have met or exceeded the 2025 national performance target of 93%. The percentage who met or exceeded the national average was highest among jurisdictions in T2 (12 of 18 [66.7%]), followed by jurisdictions in T3 (nine of 17 [52.9%]) and jurisdictions in T1 (eight of 17 [47.1%]).

Although the range of relative change in 5-year average performance was highest among jurisdictions in T1 (3,603.7% to −100.0%), these results are unreliable because of multiple jurisdictions with missing or incomplete contact investigation data (or incomplete data reporting), no contact investigation done, or no contacts receiving a diagnosis of LTBI. In contrast, jurisdictions in T2 and T3 had similar ranges in relative change (73.8% to −18.2% and 54.3% to −42.0%, respectively). This observation reinforces the importance of complete and accurate data collection and reporting for a better assessment of LTBI treatment outcomes.

Completion of TB Therapy Within 12 Months

During 2016–2020, approximately two thirds (32 of 52 [61.5%]) of jurisdictions were at or above the national average of 89.7% for patients completing therapy within 12 months (Table 5). The percentage of jurisdictions with performance above the national average varied substantially between terciles: 11 of 17 (64.7%) in T3, 14 of 18 (77.8%) in T2, and seven of 17 (41.2%) in T1. Furthermore, 20 of the 52 jurisdictions (38.5%) had an increase in the percentage of patients completing therapy within 12 months from 2016 to 2020; this percentage is the second lowest performance improvement result among the indicators presented in this report (Figure). Performance improvement was similar between jurisdictions in T3 and T2 (eight of 17 [47.1%] and eight of 18 [44.4%], respectively). Jurisdictions in T1 had a slightly lower performance, with four of 17 (23.5%) jurisdictions with increased performance over the 5-year period. These results indicate that jurisdictions with a higher number of cases demonstrated more improvement for completion of treatment than jurisdictions with fewer cases.

Only one jurisdiction had 5-year average performance that met or exceeded the 2025 national performance target of 99% of patients completing TB therapy within 12 months. This jurisdiction (Wyoming) reported an average of one TB case per year over the 5-year period; therefore, comparing the performance of Wyoming with the performance in most other jurisdictions might not be useful.

Jurisdictions in T1 had the largest range of relative change in 5-year average performance (7.0% to − 66.7%). Jurisdictions in T2 and T3 had similar ranges of relative change (19.5% to −13.9% and 13.2% to −18.4%, respectively).

Discussion

During 2018–2022, most TB programs had improvements in reducing overall TB incidence, and approximately half of programs had improvements in reducing incidence among non–U.S.-born persons. In addition, from 2017 to 2021, most programs increased the percentage of contacts receiving a diagnosis of LTBI who completed treatment. These results suggest that TB programs continue to strengthen activities that help identify persons with TB disease and LTBI and ensure they complete treatment in a timely manner (16). Improvements in reducing TB incidence do not correlate with improved performance across all indicators. Although a lower percentage of TB programs indicated improvement for initial drug susceptibility test results reported, this observation is partly because of the number of TB programs that had no relative change for this indicator because the programs were at 100% for the first and last year of the 5-year period, indicating a high level of performance overall.

TB programs are making progress in reducing TB incidence among non–U.S.-born persons; however, country of birth remains the most important risk factor for TB (17), emphasizing the need for ongoing efforts to reduce incidence of TB among non–U.S.-born persons. Furthermore, reactivation of LTBI is the most common cause of development of TB among non−U.S.-born persons. As a result, the diagnosis and treatment of LTBI play a vital role in TB elimination (17). Although this report provides insight into program performance for completion of therapy among contacts who received a diagnosis of LTBI, TB programs would benefit from additional information (e.g., treatment status and country of birth) about all persons diagnosed with LTBI, not just newly diagnosed contacts.

The low percentage of TB programs indicating improved performance for completion of therapy within 12 months from 2016 to 2020 might be attributed to multiple factors. First, TB treatment is a long and often resource-intensive process that can be affected by various factors (e.g., drug resistance, comorbidities, and socioeconomic factors) (18). Persons with more complicated TB cases, including drug resistance, drug intolerance, severe disease, or other concurrent illnesses or conditions, might require longer and more complex treatment regimens. As a result, the presence of a substantial number of such cases within TB programs might have contributed to the lower overall percentage of improvement. Second, the 5-year reporting period for completion of therapy in this report overlaps with the COVID-19 pandemic, which impacted TB diagnosis and management in a wide range of ways. The implementation of social distancing measures, quarantine protocols, and the diversion of health care resources to manage COVID-19 cases were experienced by most TB programs (19). These disruptions might have affected the ability of staff members in certain TB programs to implement directly observed therapy, which is the standard of care to ensure treatment completion (18).

TB programs whose jurisdictions were in T1 over a 5-year period tended to have higher performance improvement (measured by a decrease in relative change for incidence [e.g., TB incidence] and an increase in relative change for indicators measured by percentages [e.g., initial drug susceptibility test results]) than TB programs whose jurisdictions were in T2 or T3 with higher numbers of TB cases. This performance is likely because of small absolute changes associated with a lower number of TB cases leading to larger percentage changes.

The results presented in this report use the 2025 national performance targets as a measure of TB program effectiveness. Although certain TB programs have already achieved the 2025 performance target for specific indicators, these targets are designed to be aspirational and are not mandatory benchmarks for all TB programs (14). The targets should be interpreted as long-term objectives and should be used alongside other metrics (e.g., the national average) to provide a more comprehensive assessment of TB program performance.

Although this report provides a comparison of TB program performance on these five indicators, the report is not intended to penalize or negatively affect any TB programs or staff members or be used in a competitive manner. Rather, TB programs can use this report to monitor progress of TB prevention and control activities and determine where improvements can be made. Because this is the only report that allows TB programs to review the trend performance of other programs, it can provide context for where to focus improvement efforts based on successes of other TB programs or, conversely, for TB programs to understand where they have been successful compared with other programs. In addition, this report can facilitate communication between TB programs and generate ideas for sharing and learning in regional or national meetings, conferences, and trainings.

Limitations

The findings in this report are subject to at least five limitations. First, TB program performance involves programmatic and contextual factors (e.g., population demographics and complexity of TB cases) that are not measured by indicator data. Second, TB programs vary in size and resources and, although these differences were accounted for by grouping based on the number of TB cases reported, the variability of case counts within each group is still large; therefore, not all TB programs within each group are comparable. Third, other ways exist to assess TB programs with similar characteristics (e.g., by age, race, or other demographic characteristics of persons with TB disease; by the cohort or denominator of persons who meet specific indicator criteria; or by geography) and differences that affect program performance are not only based on the number of persons with TB in the associated jurisdiction. However, this study does not examine alternative methods for grouping TB programs. Fourth, the relative change calculation is subject to the first and last year of the 5-year period and does not account for variability within that period. Finally, for TB programs that report few cases, a small absolute change can lead to a large percentage change that can be misleading and difficult to interpret. Therefore, results for TB programs with 1–50 cases should be interpreted with caution.

Future Direction

To sustain progress toward TB elimination, maintaining strong evaluation and performance monitoring systems is important. Continued support for NTIP and regular assessment and improvement of indicators are essential to adapt to evolving TB trends and challenges. In addition, TB programs might benefit from a greater exchange of information and best practices, enabling them to learn from each other’s successes and challenges. Data from NTIP can also play an important role in resource allocation and garnering support for TB control; TB programs can use this information to guide public health policy decisions at both the state and Federal levels. Finally, implementing comprehensive LTBI surveillance that includes data on the country of birth would enable establishment of specific objectives, performance indicators, and targets stratified by U.S.-born and non–U.S.-born persons. This approach would provide TB programs with the means to effectively monitor performance in diagnosing and treating persons with LTBI.

Conclusion

The findings in this report indicate that most TB programs have indicated improvement in reducing TB incidence and increasing the percentage of contacts with LTBI who complete treatment. These activities are critical in preventing the spread of TB. Continuous monitoring and evaluation, along with subsequent programmatic actions aimed at enhancing performance in identified areas, will be essential for improving strategies to decrease the incidence of TB.