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Slide Set— Epidemiology of Pediatric Tuberculosis in the United States, 1993–2006

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Slide 1

Epidemiology of Pediatric Tuberculosis in the United States, 1993–2006

Surveillance, Epidemiology, and Outbreak Investigations Branch Division of Tuberculosis Elimination
Centers for Disease Control and Prevention (CDC)

Slide 2

Pediatric TB—Background

  • Definition of pediatric tuberculosis (TB): TB disease in a person <15 years old
  • In 2006,
    • 13,779 TB cases were reported among all age groups
    • 807 (5.9%) were pediatric

Slide 3

TB Case Definition and Verification

  • Incident case of disease
  • Case verification categories:
    1. Laboratory confirmed cases-”Gold Standard”
    • Positive culture, DNA probe, or nucleic acid amplification test
    • Positive AFB smear when culture not attainable
    1. Clinical case definition
    • Positive tuberculin skin test
    • Signs and symptoms of TB disease
    • Current treatment for TB disease
    1. Provider diagnosis:
    • - Diagnosed by health care provider
    • - Does not fulfill all criteria necessary to meet laboratory or clinical case definitions

Slide 4

TB Cases, All Ages, by Age Group, 1993–2006

  1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
<15 yrs 1661 1659 1536 1356 1251 1077 1039 964 929 944 912 954
15-24 yrs 1823 1833 1698 1637 1675 1542 1518 1617 1597 1497 1573 1602
25-44 yrs 9587 9043 8201 7564 6884 6335 6063 5575 5609 5288 5073 4940
45-64 yrs 6197 6125 5960 5572 5277 4956 4858 4637 4515 4182 4283 4194
65+ yrs 5820 5539 5328 5076 4663 4377 4020 3516 3293 3141 2994 2811

Slide 5

TB Case Rates, All Ages, by Age Group 1993–2006

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Overall US 9.7 9.2 8.5 7.9 7.2 6.6 6.3 5.8 5.6 5.2 5.1 4.9 4.7 4.6
<15 yrs 2.9 2.9 2.6 2.3 2.1 1.8 1.7 1.6 1.5 1.6 1.5 1.6 1.4 1.3
15-24 yrs 5 5 4.6 4.4 4.5 4.1 3.9 4.1 4.0 3.7 3.8 3.8 3.7 3.6
25-44 yrs 11.5 10.7 9.7 8.9 8.0 7.4 7.1 6.6 6.6 6.3 6.0 5.9 5.6 5.6
45-64 yrs 12.4 11.9 11.3 10.2 9.4 8.5 8.0 7.4 7.0 6.3 6.2 5.9 5.7 5.4
65+ yrs 17.7 16.6 15.8 14.9 13.6 12.6 11.6 10.0 9.3 8.8 8.3 7.7 7.7 7.2

Note: Rates presented on a logarithmic scale

Slide 6

Percent of Pediatric TB Cases by Age Group 1993–2006
N=15,946

Age < 1 Age 1-4 Age 5-9 Age 10-14
Pediatric 1471 7884 3691 2900

Slide 7

Pediatric TB Cases by Age Group 1993–2006
N=15,946

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
age < 1 156 140 120 102 113 105 97 91 97 101 94 82 81 92
Age 1-4 859 856 774 668 621 533 506 453 446 455 454 469 397 393
Age 5-9 358 394 393 368 305 243 250 221 208 196 195 203 197 160
Age 10-14 288 269 249 218 212 196 186 199 178 192 169 200 182 162

Slide 8

TB Case Rates by Pediatric Age Groups 1993–2006
N=15,946

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Age < 1 4.0 3.6 3.1 2.7 3.0 2.8 2.5 2.4 2.4 2.5 2.3 2.0 2.0 2.2
Age 1-4 5.4 5.4 4.9 4.3 4.1 3.5 3.3 3 2.9 2.9 2.9 2.9 2.4 2.4
Age 5-9 1.9 2.1 2.1 1.9 1.5 1.2 1.3 1.1 1.0 1.0 1.0 1.0 1.0 0.8
Age 10-14 1.6 1.4 1.3 1.1 1.1 1.0 1.0 1.0 0.9 0.9 0.8 0.9 0.9 0.8

Note: Rates presented on a logarithmic scale

Slide 9

Pediatric TB Cases by Race/Ethnicity 1993–2006
N=15,946

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
White, non-Hispanic 250 230 184 157 136 137 126 104 87 104 82 77 66 67
Black, non-Hispanic 559 572 517 515 469 372 345 334 309 329 257 289 264 252
Hispanic 640 642 624 512 438 423 432 374 413 400 432 456 397 388
American Indian/
Alaskan Native
22 31 34 37 29 15 15 27 8 13 13 13 12 9
Asian/Pacific Islander 184 181 175 133 178 128 116 122 112 95 123 115 108 89


Slide 10

Pediatric TB Case Rates by Race/Ethnicity 1993–2006
N=15,946

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
White, non-Hispanic 0.7 0.6 0.5 0.4 0.4 0.4 0.3 0.3 0.2 0.3 0.2 0.2 0.2 0.2
Black, non-Hispanic 6.5 6.5 5.8 5.7 5.1 4.0 3.7 3.5 3.3 3.5 2.7 3.1 2.8 2.7
Hispanic 8.3 7.9 7.4 5.8 4.7 4.4 4.3 3.5 3.8 3.5 3.7 3.8 3.2 3.1
Asian/Pacific Islander 9.5 9.0 8.4 6.2 8.1 5.7 5.0 5.1 4.6 3.8 4.8 4.4 4.0 3.1

Rates presented on a logarithmic scale.
American Indian/Alaska Native rate not shown because of small denominators

Slide 11

TB Case Rates by Pediatric Age Groups U.S.-born and Foreign-born, 1994–2006
N=14,285

  1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Age < 1, FB 45.7 45.9 65.2 25.8 52.6 72.6 37.4 29.4 12.1 70.3 23.1 11.2 28.2
Age 1-4, FB 43.6 46.1 33.1 33.7 33.8 31.8 30.0 27.0 25.2 29.9 34.0 22.5 21.2
Age 5-9, FB 23.1 16.4 14.4 12.7 10.4 16.5 10.3 14.2 10.2 12.5 11.4 10.5 6.7
Age 10-14, FB 12.2 13.2 11.4 10.7 9.4 9.8 9.5 7.9 9.3 7.8 10.1 8.5 8.5

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Age < 1, USB 3.3 2.9 2.4 2.8 2.3 2.3 2.1 2.2 2.5 2.6 2.1 2.0 2.1
Age 1-4, USB 4.4 4.1 3.6 3.3 2.9 2.7 2.4 2.3 2.4 2.2 2.3 2.0 2.1
Age 5-9, USB 1.3 1.5 1.4 1.1 0.9 0.8 0.8 0.6 0.6 0.6 0.7 0.6 0.6
Age 10-14, USB 0.8 0.7 0.6 0.6 0.6 0.5 0.5 0.5 0.5 0.4 0.5 0.4 0.4

Note: Rates presented on a logarithmic scale. Data not available before 1994.
USB = U.S.-born, FB=Foreign-born

Slide 12

Number and Percent Foreign-born Pediatric TB Cases, 1993–2006

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Foreign-born 413 386 352 312 287 249 265 255 269 249 269 280 243 201
U.S.-born 1232 1252 1179 1030 954 822 763 707 659 690 643 673 613 606
Percent foreign-born 24.9 23.3 22.9 23 22.9 23.1 25.5 26.5 29 26.4 29.5 29.4 28.4 24.9

Slide 13

Foreign-born Pediatric TB Cases by Birth Country* and 4-Year Interval, 1995–2006
N=3,231

1995-1998 (n) 1999-2002 (n) 2003-2006 (n)
Mexico (467) Mexico (375) Mexico (323)
Philippines (118) Somalia (79) Somalia (65)
Viet Nam (73) Philippines (67) Philippines (63)
Somalia (43) Haiti (38) Haiti (45)
Haiti (39) Viet Nam (36) Viet Nam (37)
Russia (38) Sudan (26) India (36)
Other (422) Other (417) Other (424)

*Ranked by counts

Slide 14

States with the Greatest Percent of the National Total Pediatric TB Cases, 1993–2006
N=15,946

California Texas New York Florida Illinois Georgia All Others
U.S. Total 25.2 11.8 8.8 5.0 5.0 4.4 39.8

Slide 15

States with Greatest Numbers of Pediatric TB Cases, 1993–2006

Pediatric TB Cases

State Number Percent* Rate**
California 4,025 7.7 3.7
Texas 1,874 7.3 2.7
New York 1,399 4.8 2.6
Florida  794 4.4 1.9
Illinois 791 6.9 2.1
Georgia 700 7.8 2.8
All Others 6,363 5.9 1.3
Overall U.S. 15,946 6.3 1.9

*Average percent of total state cases that are pediatric, for all years
**Time-averaged annual rate per 100,000

Slide 16

States with Highest Percent of Pediatric TB cases, 1993–2006

State Number Percent* Rate**
Alaska 125 13.0 5.7
Rhode Island 72 10.4 2.6
Minnesota 253 9.8 1.7
Oklahoma 262 9.8 2.6
Delaware 52 9.7 2.4
Arizona 361 9.3 2.3
All Others 14,821 6.1 1.9
Overall U.S. 15,946 6.3 1.9

*Average percent of total state cases that are pediatric, for all years
**Time-averaged annual rate per 100,000

Slide 17

States with Highest Rate of Pediatric TB Cases, 1993–2006

State Number Percent* Rate**
Alaska 125 13.0 5.7
D.C.† 54 4.0 4.0
California 4,025 7.7 3.7
Georgia 700 7.8 2.8
Texas 1,874 7.3 2.7
Arkansas 204 8.2 2.6
All Others 8,964 5.5 1.5
Overall U.S. 15,946 6.3 1.9

*Average percent of total state cases that are pediatric, for all years
**Time-averaged rate per 100,000
†D.C. (District of Columbia) is a distinct reporting jurisdiction

Slide 18

Pediatric TB Cases by Case Verification Criterion*, 1993–2006
N=15,946

Laboratory Confirmed Clinical Case Provider Diagnosis
25% 51% 24%

Slide 19

Pediatric TB Cases by Case Verification Criterion, 1993–2006
N=15,946

Age < 1 n=1,471

Laboratory Confirmed Clinical Case Provider Diagnosis
52% 25% 23%

Age 1-4 n=7,784

Laboratory Confirmed Clinical Case Provider Diagnosis
20% 54% 26%

Age 5-9 n=3,691

Laboratory Confirmed Clinical Case Provider Diagnosis
15% 59% 26%

Age 10-14 n=2,900

Laboratory Confirmed Clinical Case Provider Diagnosis
36% 46% 18%

Slide 20

Pediatric TB Cases by Site of Disease, 1993–2006

  Both Extrapulmonary Pulmonary
Site of Disease 7.0% 21.9% 71.1%

Any extrapulmonary involvement*
(totaling 28.9%)
Lymphatic 18.9%
Meningeal 3.1%
Miliary 1.5%
Bone & Joint 1.5%
Other 3.9%

* Any extrapulmonary involvement which includes cases that are extrapulmonary only and both
Patients may have more than one disease site but are counted in mutually exclusive categories for
surveillance purposes.

Slide 21

Percent of Pediatric TB Cases by Site of Disease*, 1993–2006
N=15,946

Age <1 n=1,471

  Pulmonary Extrapulmonary Both
Site of Disease 75.2% 10.1% 14.7%

Age 1-4 n=7,884

  Pulmonary Extrapulmonary Both
Site of Disease 72.1% 20.7% 7.2%

Age 5-9 n=3,691

  Pulmonary Extrapulmonary Both
Site of Disease 70.1% 25.5% 4.4%

Age 10-14 n=2,900

  Pulmonary Extrapulmonary Both
Site of Disease 67.1% 27.0% 5.9%

Slide 22

Percent of Pediatric TB Cases with Any Extrapulmonary Involvement* by Age Group and Selected Sites of Disease, 1993–2006
N=15,946

Site of Disease Age < 1
(n=1,471)
Age 1-4
(n=7,884)
Age 5-9
(n=3,691)
Age 10-14
(n=2,900)
Lymphatic 8.0 19.3 22.3 19.2
Meningeal 7.5 3.5 1.4 1.8
Miliary 5.6 1.2 0.6 1.2
Bone & Joint 0.3 1.3 1.7 2.4
Other 3.4 2.6 3.9 8.3
Total 24.8 27.9 29.9 32.9

*Any extrapulmonary involvement includes extrapulmonary only and both
Note: Combine the total extrapulmonary percent shown with the pulmonary percent in slide #21 to obtain 100% for each age group.

Slide 23

Percent of TB Cases in Children Age < 1 Year With Any Extrapulmonary Involvement, 1993–2006
N=1,471

Site of Disease U.S.-born Foreign-born
Lymphatic 7.2% 17.7%
Meningeal 7.8% 3.5%
Miliary 5.8% 3.5%
Bone & Joint 0.3% 0.9%
Other 3.4% 1.8%
Total 24.5% 27.4%*

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 24

Percent of TB Cases in Children Age 1 - 4 Years With Any Extrapulmonary Involvement, 1993–2006
N=7,884

Site of Disease U.S.-born Foreign-born
Lymphatic 19.4% 19.0%
Meningeal 3.8% 2.0%
Miliary 1.3% 1.0%
Bone & Joint 1.1% 2.0%
Other 2.7% 2.0%
Total 28.3%* 26.0%*

*Any Extrapulmonary involvement includes extrapulmonary only and both

Slide 25

Percent of TB Cases in Children Age 5 - 9 Years With Any Extrapulmonary Involvement, 1993–2006
N=3,691

Site of Disease U.S.-born Foreign-born
Lymphatic 23.1% 20.8%
Meningeal 1.4% 1.0%
Miliary 0.6% 0.6%
Bone & Joint 1.6% 2.1%
Other 4.1% 3.8%
Total 30.8%* 28.3%*

*Any Extrapulmonary involvement includes extrapulmonary only and both

Slide 26

Percent of TB Cases in Children Age 10-14 Years With Any Extrapulmonary Involvement, 1993–2006
N=2,900

Site of Disease U.S.-born Foreign-born
Lymphatic 20.4% 18.1%
Meningeal 1.6% 1.8%
Miliary 1.5% 0.8%
Bone & Joint 2.0% 2.8%
Other 9.0% 7.3%
Total 34.5%* 30.8%*

*Any Extrapulmonary involvement includes extrapulmonary only and both

Slide 27

Pediatric TB Cases by HIV Status, 1993–2005*
N=14,990

  • Information on HIV result is not available for the majority of pediatric TB cases (80.7%)
     
  • Percent of pediatric TB cases with HIV-positive test results, minimum estimate** (1.0%)
     
  • Percent of pediatric cases with HIV-positive test results of those patients with known results (5.1%)

*California HIV data through 2004 only
**Pediatric TB cases with positive HIV test results divided by all pediatric TB cases .
California only reports positive HIV test results based on TB and AIDS registry matching; all other California TB
cases are classified as “Unknown.”

Slide 28

Number and Percent of Culture-confirmed Pediatric TB Cases with Drug Resistance, 1993–2005

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Resistance to any 1st line drug 31.0 43.0 31 38 38 28 28 27 38 33 30 39 38
Percent with resistance to any 1st line drug 9.7 13.3 10.3 12.7 13.4 12.2 12.3 11.3 15 14.7 14.6 17 18.1
MDR TB 6 6 4 6 4 6 5 1 4 4 3 1 5
Percent with MDR TB 1.9 1.9 1.3 2.0 1.4 2.7 2.2 0.4 1.6 1.8 1.5 0.4 2.4

First line drugs are Isoniazid, Rifampin, Pyrazinamide and Ethambutol
MDR TB = resistance to at least Isoniazid and Rifampin

Slide 29

Pediatric TB Cases by Use of Directly Observed Therapy (DOT), 1993–2004
N=14,233*

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
DOT only 22.1 26.9 40.9 47.4 55.3 58.3 56.5 61.5 61.5 64.4 62.9 65
Self-Administered only 64.3 51.0 34.5 28.2 20.0 17.1 15.2 13.4 11.3 7.6 6.4 6.3
DOT and Self-Administered 12.1 19.1 22.3 22.1 22.5 23.4 26 24 25.3 26.1 29.3 25.5

*Pediatric TB cases with patient alive at diagnosis and started on treatment

Slide 30

Pediatric TB Cases by Treatment Outcome 1993–2004
N=14,233*

Outcome Cases %
Completed treatment 13,459 94.6
Moved 352 2.5
Lost to follow-up 138 1.0
Died 78 0.6
Other** 206 1.3

Note: Cause of death not recorded in TB case reports
*Pediatric TB cases with patient alive at diagnosis and started on treatment
**Other includes refused, other, unknown and missing


Slide 31

Deaths Occurring Among Pediatric TB Cases, by Age Group, 1993–2004
N=14,282

Age Group Cases Deaths** % of Cases
Age<1 1298 26 2.0
Age 1-4 7094 46 0.6
Age 5-9 3334 20 0.6
Age 10-14 2556 20 0.8

Note: Cause of death not recorded in TB case reports
**Death includes died during therapy or dead at TB diagnosis

 

 


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