TB Challenge: Partnering to Eliminate TB
in African Americans
TB in African Americans:
Data from the 2003 Surveillance Report
Michael Fraser, Public Health Advisor, DTBE/FSEB
Michael Fraser: What are the current tuberculosis (TB) case
counts and rates for non-Hispanic blacks?
Lori Armstrong: According to the DTBE's national tuberculosis
surveillance system 2004 provisional data, there were 4,006 cases
of TB in non-Hispanic blacks and a rate of 11.1 per 100,000. There
were 4,153 cases of TB in non-Hispanic blacks in 2003 and a rate
of 11.7 per 100,000. This represents a 4.6% decline in the rate
for non-Hispanic blacks from 2003 to 2004.
MF: Looking at the period 1993 to 2003, please discuss some
of the trends in this population. In addition, what is the age
and gender distribution of these cases?
LA: Over the period 1993 to 2003, TB rates in non-Hispanic blacks
have fallen steadily (29.1/100,000 in 1993 to 11.7/ 100,000 in 2003).
This is a 60% decline in the case rate. The percent decline in
case rates for all TB cases during that time was only 48% (9.8/
100,000 in 1993 to 5.1/100,000 in 2003). Although non-Hispanic blacks
still had TB at a rate that was more than 2 times the national case
rate in 2003, the rate has declined tremendously over the past decade.
In 2003, there were more TB cases in male non-Hispanic blacks (n=2531)
than in females (n=1614) and, as one might expect, the rates for
males were much higher (males 14.9/100,000, females 8.7/100,000).
This is the same pattern we see for every other racial/ethnic group
in the United States. The rate of TB also rises with age for all
racial/ethnic groups, including non-Hispanic blacks. The older
the age group, the higher the rate. As in other racial/ethnic groups,
non-Hispanic blacks have their highest rate of TB among those over
age 65 years (21.3/100,000).
MF: Do these data speak to why more non-Hispanic black men
are at a higher risk for developing TB than women? Why blacks in
general versus whites are at a higher risk?
LA: Black non-Hispanic men are more likely than black non-Hispanic
women to have risk factors that put them at greater risk for exposure
for TB, thus at a greater risk for TB disease. In 2003, black non-Hispanic
men with TB were 3.5 times more likely than black non-Hispanic women
with TB to be homeless, 3 times more likely to have used excess
alcohol within the past year, and nearly 4 times more likely to
live in a correctional facility at the time of diagnosis. Homelessness
is a major concern among non-Hispanic black TB patients. Among
all TB patients who were reported in 2003 as being homeless within
the past year, 362 patients (about 40%) were non-Hispanic black,
versus 28% who were white.
MF: For comparing with other populations, do CDC data or
any projects or studies in your branch indicate that non-Hispanic
blacks are more likely to have resided in a correctional facility
or homeless shelter or that this group is less educated, and/or
LA: Homeless status within the past year is collected by
the national surveillance system, but we don't collect information
on whether the person resided in a homeless shelter. There are
several efforts within DTBE to study socioeconomic factors that
may contribute to TB disease, such as educational level or income
level. We don't collect these data in the national TB surveillance
system, but geographically-based socioeconomic factors can be studied
by linking the national surveillance data with U.S. Census data.
These studies examine the SES factors that are collected by the
Census Bureau and are based on where the person lives, such as the
zip code, census tract or block group.
MF: Is CDC collaborating with other governmental and nongovernmental
agencies to address this population that has been described as eight
times more likely than non-Hispanic whites to develop TB disease?
LA: To address the high rate of TB in blacks in the United
States, CDC has funded three demonstration projects in Chicago,
Georgia, and South Carolina in collaboration with state and local
health departments to identify innovative strategies for decreasing
TB rates in African-American communities by improving TB diagnosis,
screening, and treatment adherence in high-risk African-American
communities. CDC is also conducting a formative research and intervention
study in collaboration with the Research Triangle Institute; this
study will 1) examine barriers to health-seeking behaviors and
treatment adherence for blacks with or at risk for TB, 2) determine
barriers to TB guideline adherence among providers who serve this
population, 3) develop and test interventions to overcome identified
barriers, and 4) improve partnerships and collaborations among TB
programs, providers, and organizations serving this population.
Ms. Gail Burns-Grant and Dr. Nick DeLuca, DTBE, serve as the project
officers for these initiatives, respectively. Alongside state and
local health departments, CDC is working to ensure that adequate
local resources are in place in communities with the greatest burden
MF: What was the completion of therapy rate in this group
LA: States have up to 2 years after the diagnosis year
to report completion of therapy on TB cases. Therefore, the most
recent year that data are available is 2001. That year, 81% of
non-Hispanic blacks with TB completed therapy within 1 year of treatment
(among those where 1 year of therapy or less was medically indicated).
This is comparable to 80.5% completion of treatment for all reported
TB cases in the nation that year (among those cases where 1 year
of therapy or less is medically indicated and who received treatment).
The percentage of non-Hispanic blacks who receive directly-observed
therapy is also very high: 83% in 2001, compared to 77% among non-Hispanic
whites and 77% for all cases receiving treatment in 2001.
MF: Can you explain the national estimated HIV coinfection
rates for non-Hispanic blacks and discuss what age groups are most
LA: In a DTBE study published last year, non-Hispanic blacks
with TB reported in Southeastern states from 1991 to 2002 were more
likely than whites to have certain risk factors, such as HIV infection,
incarceration, or excess alcohol or drug use. This suggests that
differences in socioeconomic health status and opportunity for TB
exposure underlie increased risk for TB. For the most recent 5
years of available data, 1999 to 2003, 58% to 65% of all HIV-infected
TB patients were non-Hispanic blacks, the highest percentage of
any other racial/ ethnic group. Among all non-Hispanic black TB
patients, 18% to 19% were HIV-infected throughout that time period
and most cases (29% to 33%) occurred among the 25- to 44-year age
group. We can reduce TB in non-Hispanic blacks by continuing to
work closely and collaboratively with our partners.
MF: Thank you.