Tuberculosis — United States, 2020

Molly Deutsch-Feldman, PhD; Robert H. Pratt; Sandy F. Price; Clarisse A. Tsang, MPH; Julie L. Self, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2021;70(12):409-414. 

In This Article

Abstract and Introduction

Introduction

Tuberculosis (TB) disease incidence has decreased steadily since 1993,[1] a result of decades of work by local TB programs to detect, treat, and prevent TB disease and transmission. During 2020, a total of 7,163 TB cases were provisionally reported to CDC's National Tuberculosis Surveillance System (NTSS) by the 50 U.S. states and the District of Columbia (DC), a relative reduction of 20%, compared with the number of cases reported during 2019.* TB incidence per 100,000 persons was 2.2 during 2020, compared with 2.7 during 2019. Since 2010, TB incidence has decreased by an average of 2%–3% annually.[1] Pandemic mitigation efforts and reduced travel might have contributed to the reported decrease. The magnitude and breadth of the decrease suggest potentially missed or delayed TB diagnoses. Health care providers should consider TB disease when evaluating patients with signs and symptoms consistent with TB (e.g., cough of >2 weeks in duration, unintentional weight loss, and hemoptysis), especially when diagnostic tests are negative for SARS-CoV-2, the virus that causes COVID-19. In addition, members of the public should be encouraged to follow up with their health care providers for any respiratory illness that persists or returns after initial treatment. The steep, unexpected decline in TB cases raises concerns of missed cases, and further work is in progress to better understand factors associated with the decline.

Health departments in the 50 U.S. states and DC report cases of TB to CDC based on the Council for State and Territorial Epidemiologists' surveillance definition, which includes both laboratory and clinically verified cases. For each case, health departments electronically submit a report of a verified case of TB to CDC. Although certain jurisdictions reported disruptions to routine TB prevention activities early in the pandemic,[2] all reporting areas provided provisional reporting data to CDC. Among these reports, <5% of the data were missing, providing further confidence that they were reasonably complete. Provisional data were used to calculate national- and state-level TB case counts. Midyear U.S. Census Bureau population estimates§ were used for calculating national- and state-level TB incidence per 100,000 persons. Case reports were grouped on the basis of self-reported race and ethnicity according to federal guidelines. Persons self-reporting Hispanic ethnicity are categorized as Hispanic regardless of self-reported race, persons not reporting Hispanic ethnicity are categorized by self-reported race, and non-Hispanic persons who self-reported more than one race are categorized as "multiple races." Midyear population estimates from the Current Population Survey** were used to calculate incidence by national origin and race/ethnicity.

A total of 7,163 TB cases were reported during 2020 (2.2 cases per 100,000 persons), 20% fewer than during 2019 (2.7 cases per 100,000 persons). Thirty-nine states and DC reported a decrease in cases, eight states reported an increase, and three reported no change. California reported the highest number of cases (1,703), and Alaska reported the highest incidence (7.9 cases per 100,000 persons) (Table 1). The East North Central region experienced the largest decrease in TB incidence (−25%).

During 2020, 71% of TB cases occurred among non–U.S.-born†† persons, the same proportion as in 2019. Incidence decreased among both U.S.-born (0.9 to 0.7 cases per 100,000 persons) and non–U.S.-born persons (14.2 to 11.5 cases per 100,000 persons) (Figure). Among U.S.-born persons reported as having TB disease, 36% identified as Black, 28% as White, 24% as Hispanic, 5% as Asian, 4% as American Indian/Alaska Native (AI/AN), 2% as Native Hawaiian/other Pacific Islander (NH/PI), and 1% as multiple races.§§ TB incidence decreased among all U.S.-born groups, except NH/PI¶¶ (Table 2). Among non–U.S.-born persons with a diagnosis of TB, 48% identified as Asian, 32% as Hispanic, 13% as Black, 4% as White, 1% as NH/PI, 1% as multiple races, and <1% as AI/AN. During both 2019 and 2020, the most frequently reported countries of birth among non–U.S.-born persons were Mexico, the Philippines, India, Vietnam, and China.

Figure.

Tuberculosis disease cases and incidence, by birth origin*,† — United States, 2010–2020
*Numbers of tuberculosis cases among persons with unknown origin are not shown (range = 2–61). Total rate includes cases among persons with unknown national origin.
Rates for non–U.S.-born and U.S.-born persons were calculated by using midyear Current Population Survey estimates. Total rate was calculated by using midyear population estimates from the U.S. Census Bureau.

During 2020, among all non–U.S.-born persons with TB cases, 10% had received a diagnosis ≤1 year after the person's arrival in the United States, compared with an average of 16% during 2015–2019. In addition, the proportion of cases identified among non–U.S.-born persons living in the United States for >20 years increased to 32% from an average of 28% during 2015–2019. The age distribution of persons with TB cases during 2020 was similar to the average distribution during 2015–2019. The largest proportion of cases occurred among persons aged 45–64 years (30%), followed by those aged 25–44 years (29%), ≥65 years (26%), 15–24 years (10%), 5–14 years (2%), and ≤4 years (2%).

*This report is limited to National Tuberculosis Surveillance System data verified as of February 17, 2021. Updated data will be available in CDC's annual TB surveillance report later in 2021.
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/topics/population/race/about.html
**https://www.census.gov/programs-surveys/cps.html
††A person is considered U.S.-born if eligible for U.S. citizenship at birth, regardless of place of birth.
§§Proportions were calculated excluding persons with missing race or ethnicity data.
¶¶Small changes in case numbers or population size can lead to large relative changes because of the small size of this group.

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