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Slide 1 (title slide): Tuberculosis in the United States: National Surveillance System, Highlights from 2001. This slide set is from the Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), and provides highlights from the data collected through the national TB surveillance system for 2001. Since 1953, through the cooperation of state and local health departments, CDC has collected information on the numbers of reported TB cases in the United States. The data presented here were primarily collected via the expanded TB case report introduced in 1993. Currently, each individual TB case report (Report of Verified Case of Tuberculosis, or RVCT) is submitted electronically via the Tuberculosis Information Management System (TIMS), a comprehensive CDC software system for TB surveillance, patient management, and program evaluation.
Slide 2: Reported TB Cases, United States, 1981-2001. The resurgence of TB in the mid- 1980s was marked by several years of slightly increasing case counts followed by a substantial rise for several years. The total number of TB cases peaked in 1992. From 1992 until 2001, the total number of TB cases decreased 5%-7% annually, and 2001 marks the ninth year of decline in the total number of TB cases reported in the United States since the peak of the resurgence. In 2001, a total of 15,989 TB cases were reported from the 50 states and the District of Columbia. This represents a 2% decrease from 2000 and a 40% decline from 1992.
Slide 3: TB Morbidity, United States, 1997-2001. This slide provides the total number of reported U.S. TB cases and the associated TB case rates for each of the past 5 years. Rate is defined as cases per 100,000. The number of TB cases decreased from 19,851 in 1997 to 15,989 in 2001, and the TB case rate also decreased from 7.4 in 1997 to 5.6 in 2001.
Slide 4: TB Case Rates, United States, 2001. This map shows TB case rates for 2001. Twenty-three states had a case rate of less than or equal to 3.5 TB cases per 100,000, the interim goal for the year 2000 established by the Advisory Council for the Elimination of Tuberculosis. This group of states has remained fairly constant over the last decade; five states (CT, MI, NM, OR, and PA) joined the group in 2000 and one state (MO) joined the group in 2001 (also in 1998 for one year only). States with a case rate above the national average include the seven states that reported at least 500 cases in 2001: CA, FL, GA, IL, NJ, NY, and TX. These seven states accounted for 60% of the national total and have experienced substantial overall decreases in cases and case rates since 1992.
Slide 5: TB Case Rates by Age Group, United States, 1991-2001. This slide shows the last decade's declining trend in TB case rates by age group. The largest declines occurred in children under 15 years of age (from 3.0 per 100,000 in 1991 to 1.5 in 2001) and in adults aged 25 to 44 years (from 12.5 to 6.6), 45 to 64 years (from 13.5 to 7.2), and 65 years and older (from 19.1 to 9.1), each group having decreased approximately 50%. The case rate declined by approximately 25% in those 15 to 24 years of age (from 5.4 to 4.0), and the rate has remained at 4 per 100,000 for the past 4 years.
Slide 6. Reported TB Cases by Age Group, United States, 2001. This pie chart shows the age distribution of persons reported with TB in 2001. Six percent were children under 15 years of age and 10% were 15- to 24-year-olds, while 35% were 25 to 44 years of age, 28% were 45- to 64-year-olds, and 21% were at least 65 years old.
Slide 7: TB Case Rates by Age Group and Sex, United States, 2001. This slide graphs the TB case rates in 2001 by age group and sex. It shows that rates increase with age, ranging from a low of less than 2 per 100,000 in children to a high of approximately 13 per 100,000 in men over 65 years old. The rates in adult men are approximately twice those in women.
Slide 8: TB Case Rates by Race/Ethnicity, United States, 1991-2001. This slide shows the declining trend in TB case rates by race/ethnicity during the last decade. Asians and Pacific Islanders had the highest TB case rates, which declined from 44 per 100,000 in 1991 to 33 in 2001. Black non-Hispanics had the most substantial decline from 32 in 1991 to 14 in 2001. Case rates declined among Hispanics from 23 in 1991 to 12 in 2001, among American Indians and Alaska Natives from 19 to 11, and among white non-Hispanics from 4 to 2. Several important factors likely contribute to the disproportionate burden of TB in minorities. In foreign-born persons from countries where TB is common, active TB disease may result from infection acquired in the country of origin. In racial and ethnic minorities, unequal distribution of TB risk factors, such as HIV infection, may also contribute to increased exposure to TB or to an increased risk of developing active TB once infected with M. tuberculosis. However, much of the increased risk of TB in minorities has been linked to lower socioeconomic status and the effects of crowding, particularly among U.S.-born persons.
Slide 9: Reported TB Cases by Race/Ethnicity, United States, 2001. In 2001, 79% of all reported TB cases occurred in racial and ethnic minorities (30% in black non-Hispanics, 25% in Hispanics, 22% in Asians and Pacific Islanders, and 1% in American Indians and Alaska Natives), whereas 21% of all reported cases occurred in non-Hispanic whites.
Slide 10: TB Case Rates by Age Group and Race/Ethnicity, United States, 2001. This slide presents TB case rates in 2001 by age group and race/ethnicity. Risk increased with age across racial and ethnic groups, and case rates were consistently higher in minority racial and ethnic groups than in non-Hispanic whites. Case rates were the highest in Asians and Pacific Islanders, particularly in adult age groups. The impact of non-U.S. birth is a consideration in interpreting rate variations by race/ethnicity. For example, approximately 95% of cases in the Asian/Pacific Islander group occurred in foreign-born persons, compared with 74% of cases in Hispanics and 23% of cases in non-Hispanic blacks.
Slide 11: Number of TB Cases in U.S.-born vs. Foreign-born Persons, United States, 1991-2001. This graph plots the number of U.S.-born vs. foreign-born persons reported with TB each year, from 1991 through 2001. It illustrates the sharp increase in the percentage of cases occurring in foreign-born persons during this period which increased from 27% in 1991 to 50% in 2001. Overall, the number of cases in foreign-born persons remained at approximately 7,000-8,000 each year, whereas the number in U.S.-born persons substantially decreased from more than 19,000 in 1991 to less than 8,000 in 2001.
Slide 12: Trends in TB Cases in Foreign-born Persons, United States, 1986-2001. This slide shows trends in TB cases in foreign-born persons in the United States from 1986, when information on country of birth was first reported by all areas submitting reports to CDC, through 2001. The number of TB cases in foreign-born persons increased from nearly 5,000 in 1986 to 7,000-8,000 each year since 1991. The percentage of TB cases accounted for by foreign-born persons increased from more than 25% in 1986 to 50% in 2001.
Slide 13: Percentage of TB Cases Among Foreign-born Persons, United States, 1991 and 2001. The percentage of the total number of TB cases that occurred in foreign-born persons in each state is highlighted for 1991 and 2001 in these two side-by-side maps. The number of states with at least 50% of cases in the foreign born increased from 4 (CA, HI, MA, RI) in 1991 to 23 in 2001, and the number of states with at least 70% increased from one (HI) in 1991 to seven (CA, HI, MA, MN, NH, VT, WA) in 2001.
Slide 14: TB Case Rates in U.S.-born vs. Foreign-born Persons, United States, 1991-2001. TB case rates in foreign-born persons remain substantially higher than those in the U.S.-born population. From 1991 through 2001, the case rates in U.S.-born persons decreased from 8 per 100,000 to 3, whereas the rates in foreign-born persons decreased from 34 per 100,000 to 27.
Slide 15: TB Case Rates in U.S.-born vs. Foreign-born Persons, United States, 1991-2001. This is the same as Slide 14 but the rates are presented on a logarithmic scale to provide a better comparison of the trend in TB case rates among the U.S. born and foreign born. The lines show a marked rate of decline among the U.S. born compared with a minimal decline for the foreign born during the past decade.
Slide 16: Countries of Birth for Foreign-born Persons Reported with TB, United States, 2001. This slide shows the overall distribution of the countries of birth for foreign-born persons reported with TB in 2001. The countries have remained relatively constant since 1986, when information on country of birth was first reported by all areas submitting reports to CDC. Seven countries accounted for more than 60% of the total, with Mexico accounting for 23%; the Philippines, 12%; and Vietnam and India, 8% each. Persons from China accounted for 5%; from Haiti and South Korea, each 3%. Persons from more than 140 other countries each accounted for 2% or less of the total but altogether accounted for 38% of foreign-born persons reported with TB.
Slide 17: Length of U.S. Residence Prior to TB Diagnosis, United States, 2001. The length of U.S. residence among foreign-born persons prior to their TB diagnosis in 2001 is shown in these stacked bars. Overall, approximately 25% had been in the United States for less than 1 year, 25% between 1 and 4 years, and 50% for at least 5 years. The distribution is also shown for the top three countries of birth: the Phillippines, Mexico, and Vietnam. Among persons born in the Philippines, 32% had been in the United States for less than 1 year, 14% between 1 and 4 years, and 54% for at least 5 years. Among persons born in Mexico, 22% had been in the United States for less than 1 year, 25% between 1 and 4 years, and 53% for at least 5 years. Among persons born in Vietnam, 17% had been in the United States for less than 1 year, 13% between 1 and 4 years, and 70% for at least 5 years.
Slide 18: Primary Anti-TB Drug Resistance, United States, 1993-2001. Primary drug resistance is estimated for the previous 9 years. The graph starts in 1993 because this is the year in which the individual TB case reports submitted to the national surveillance system began collecting information on initial susceptibility test results (for isolates) from patients with culture-positive TB. Data were available for more than 85% of culture-positive cases for each year. Primary resistance was estimated by using data from persons with no reported prior TB episode. Resistance to at least isoniazid remained between 7 and 8%. However, resistance to at least isoniazid and rifampin known as multidrug-resistant TB (MDR TB) decreased from 2.5% in 1993 to 1% in 2001, representing an actual decrease from 410 MDR TB cases to 114 in 2001.
Slide 19: Primary MDR TB, United States, 1993-2001. This graph focuses on trends in primary MDR TB (based on initial isolates from persons with no prior history of TB) in the United States from 1993 through 2001. The number of MDR TB cases, represented by bars, steadily declined from 410 in 1993 to 114 in 2001. The percentage of cases with primary MDR TB, shown by the line, decreased from 2.5% in 1993 to 1.0% in 2001.
Slide 20: Primary Isoniazid Resistance in U.S.-born vs. Foreign-born Persons, United States, 1993-2001. This graph shows primary isoniazid resistance in U.S.-born vs. foreign-born persons. Among foreign-born persons, the percentage of isoniazid resistance (based on initial isolates from persons with no prior history of TB) was approximately two times higher than among U.S.-born persons. The percentage declined from 12.4 in 1993 to 9.6 in 2001 among foreign-born persons, while it decreased from 6.8 in 1993 to 4.5 in 2001 among U.S.-born persons.
Slide 21: Primary MDR TB in U.S.-born vs. Foreign-born Persons, United States, 1993-2001. This graph highlights primary MDR TB in U.S.-born versus foreign-born persons. Although the percentage of MDR TB was more than 2% in each group in 1993, the percentage in the U.S.-born continued to decrease to less than 1% (0.6% in 2001), whereas the percentage in foreign-born persons has remained above 1%. As a result, the proportion of primary MDR TB cases reported in foreign-born persons increased from approximately 25% in 1993 to more than 70% in 2001.
Slide 22: Completeness of HIV Test Results in Persons with TB by Age Group, United States, 1993-2000. This slide shows the completeness of reporting of HIV test results in persons with TB by age group from 1993 through 2000, the latest year with available data. The percentage of those with test results increased from 30% among all ages in 1993 to 49% in 2000. The numerator includes cases with positive, negative, or indeterminate HIV test results and cases from California in persons reported with AIDS (HIV test results are not reported from California). Among adults aged 25-44 years, the percentage increased from 46% to 63% in 2000.
Slide 23: Estimated HIV Coinfection in Persons Reported with TB, United States, 1993-2000. This slide provides minimum estimates of HIV coinfection among persons reported with TB from 1993 through 2000. Since the addition of HIV to the individual TB case report in 1993, incomplete reporting has provided a challenge to calculating reliable estimates. Results from the cross-matching of TB and AIDS registries have been used to supplement reported HIV test results. For all ages, the estimated percentage of HIV coinfection in persons reported with TB decreased from 15% to 9% overall and from 29% to 17% in persons aged 25 to 44 during this period.
Slide 24: Mode of Treatment Administration in Persons Reported with TB, United States, 1993-1999. In 1993, the reporting areas began collecting information about mode of treatment administration on the individual TB case report form. This slide is based on data received at CDC by April 2002. Treatment administered as only directly observed therapy (DOT) increased from approximately 22% in 1993 to 50% in 1999, the latest year with available data. The proportion of patients who received at least some portion of their treatment as DOT (based on combining the percentage of patients who received only DOT and the percentage for whom some portion was self-administered), also increased. In 1999, the proportion of patients who received at least some portion of their treatment as DOT was 77%.
Slide 25: Completion of TB Therapy, United States, 1993-1999. The reporting areas began collecting information on completion of therapy in 1993 through the individual TB case report form. This slide is based on data received at CDC by April 2002. Patients with an initial isolate resistant to rifampin and children with meningeal, bone or joint, or miliary disease were excluded from the calculations. Overall completion remained at approximately 90%; however, completion of therapy in 1 year or less increased from <65% in 1993 to 80% in 1998 and 1999. The current national program goal is completion of therapy in 1 year or less in 90% of patients. CDC is working with state and local health departments to evaluate reasons for apparently delayed completion of therapy, which may vary by jurisdiction. Note: Case rates are based on an extrapolation to the July 2001 population from the U.S. Census July 2000 estimate.