Tuberculosis — United States, 2019

Noah G. Schwartz, MD; Sandy F. Price; Robert H. Pratt; Adam J. Langer, DVM

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(11):286-289. 

In This Article

Abstract and Introduction

Introduction

Since 1989, the United States has pursued a goal of eliminating tuberculosis (TB) through a strategy of rapidly identifying and treating cases and evaluating exposed contacts to limit secondary cases resulting from recent TB transmission.[1] This strategy has been highly effective in reducing U.S. TB incidence,[2] but the pace of decline has significantly slowed in recent years (2.2% average annual decline during 2012–2017 compared with 6.7% during 2007–2012).[3] For this report, provisional 2019 data reported to CDC's National Tuberculosis Surveillance System were analyzed to determine TB incidence overall and for selected subpopulations and these results were compared with those from previous years. During 2019, a total of 8,920 new cases were provisionally reported in the United States, representing a 1.1% decrease from 2018.* TB incidence decreased to 2.7 cases per 100,000 persons, a 1.6% decrease from 2018. Non–U.S.-born persons had a TB rate 15.5 times greater than the rate among U.S.-born persons. The U.S. TB case count and rate are the lowest ever reported, but the pace of decline remains slow. In recent years, approximately 80% of U.S. TB cases have been attributed to reactivation of latent TB infection (LTBI) acquired years in the past, often outside the United States.[2] An expanded TB elimination strategy for this new decade should leverage existing health care resources, including primary care providers, to identify and treat persons with LTBI, without diverting public health resources from the continued need to limit TB transmission within the United States. Partnerships with health care providers, including private providers, are essential for this strategy's success.

Health departments in the 50 U.S. states and the District of Columbia (DC) report all TB cases that meet the Council of State and Territorial Epidemiologists' surveillance case definition to CDC. Reports include patient demographics, clinical features, and medical and social risk factors. Self-reported race/ethnicity data are collected and reported following federal standards; Hispanics/Latinos can be of any race, and all other reported race categories are non-Hispanic/Latino. The U.S. Census Bureau defines a U.S.-born person as one born in the United States or a U.S. territory or born abroad to a U.S. citizen parent. Rates (cases per 100,000 persons) were calculated for the United States and administrative divisions (i.e., the 50 states, DC, and census divisions) using midyear U.S. Census Bureau population estimates.§ Rates by national origin and race/ethnicity were calculated using midyear Current Population Survey estimates. Average annual percentage changes (APC) in incidence were calculated for 2007–2012 and 2012–2019; these years were selected based on previous research demonstrating a statistically significant change in incidence trends during 2007 and 2012.[3] Data regarding drug-resistant TB cases are reported for 2018, the most recent year for which complete drug-resistance data are available.

U.S. TB incidence decreased an average of 2.1% per year during 2012–2019, a slower rate of decline than the average 6.4% per year during 2007–2012. The overall U.S. TB rate for 2019 was 2.7 cases per 100,000 persons, while state-specific 2019 TB rates ranged from 0.2 (Wyoming) to 8.1 (Alaska) (Table 1). Nine states (Alaska, California, Georgia, Hawaii, Maryland, New Jersey, New York, Texas, and Washington) and DC reported TB rates higher than the national rate. Four states (California, Florida, New York, and Texas) continued to account for approximately half of all reported TB cases.

Among 8,920 TB cases reported during 2019, a total of 6,322 (70.9%) occurred among non–U.S.-born persons (Table 2). From 2018 to 2019, the rate among U.S.-born persons declined 4.2% (to 0.9 cases per 100,000 persons), while the rate among non–U.S.-born persons declined 1.5% (to 14.1) (Table 2) (Figure).

Figure.

Tuberculosis (TB) case counts and rates, by national origin*,† — United States, 2007–2019
*Number of cases with unknown national origin not shown (range = 2–60 per year; median = 7). Total rate includes cases with unknown national origin.
Rates for non–U.S.-born and U.S.-born persons were calculated using Current Population Survey estimates. Total rate was calculated using U.S. Census Bureau population estimates.

Among non–U.S.-born persons residing in the United States, TB rates during 2019 were highest among Asians (25.7 per 100,000), followed by Native Hawaiians/Pacific Islanders (25.1), blacks/African Americans (19.5), Hispanics/Latinos (10.2), and American Indians/Alaska Natives (5.3) and were lowest among whites (3.1) (Table 2). Rates decreased from 2018 to 2019 for all non–U.S.-born groups except American Indians/Alaska Natives and Native Hawaiians/Pacific Islanders. The top five countries of birth among non–U.S.-born persons with incident TB in 2019 were Mexico (1,165 cases; 18.4% of non–U.S.-born cases), the Philippines (790; 12.5%), India (573; 9.1%), Vietnam (503; 8.0%), and China (387; 6.1%).

Among U.S.-born persons, 2019 rates were highest for Native Hawaiians/Pacific Islanders (3.5), followed by American Indians/Alaska Natives (3.4), blacks/African Americans (2.5), Hispanics/Latinos (1.6), and Asians (1.6) and were lowest among whites (0.4). TB incidence decreased from 2018 to 2019 for all U.S.-born groups except Hispanics.

Human immunodeficiency virus (HIV) status was known for 87.3% of reported 2019 TB cases; 4.9% of those patients were coinfected with HIV, including 7.8% of persons aged 25–44 years. Initial drug-susceptibility testing results for at least isoniazid and rifampin were reported for 94.9% of culture-confirmed cases during 2018, the most recent year for which complete data are available.** Among the 6,746 cases during 2018 with available drug-susceptibility test data, 102 (1.5%) were multidrug-resistant††; 88 (86.3%) of these cases were among non–U.S.-born persons; 83 (81.4%) reported no previous TB episode. One case of extensively drug-resistant TB§§ was reported during 2018; this case occurred in a non–U.S.-born person with a reported previous episode of TB disease.

*This report is limited to National Tuberculosis Surveillance System case reports verified as of March 3, 2020. Updated data will be available in CDC's annual TB surveillance report later this year.
https://www.cdc.gov/tb/programs/rvct/instructionmanual.pdf.
§ https://www.census.gov/data/tables/time-series/demo/popest/2010s-national-total.html.
https://www.census.gov/programs-surveys/cps/data/data-tools.html.
**Because initial drug-susceptibility test results for isoniazid and rifampin were only available for 86.4% of culture-confirmed cases during 2019, more complete data from 2018 are presented. Culture-confirmed cases are defined as cases that were culture-positive on a specimen collected ≤2 weeks after starting TB treatment.
††A case of TB caused by a strain of Mycobacterium tuberculosis that is resistant to at least isoniazid and rifampin.
§§A case of TB caused by a strain of Mycobacterium tuberculosis that is resistant to isoniazid, rifampin, any fluoroquinolone, and at least one injectable second-line drug (i.e., amikacin, kanamycin, or capreomycin).

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