Abstract and Introduction
Incidence of reported tuberculosis (TB) decreased gradually in the United States during 1993–2019, reaching 2.7 cases per 100,000 persons in 2019. Incidence substantially declined in 2020 to 2.2, coinciding with the COVID-19 pandemic. Proposed explanations for the decline include delayed or missed TB diagnoses, changes in migration and travel, and mortality among persons susceptible to TB reactivation. Disparities (e.g., by race and ethnicity) in TB incidence have been described. During 2021, TB incidence partially rebounded (to 2.4) but remained substantially below that during prepandemic years, raising concerns about ongoing delayed diagnoses. During 2022, the 50 U.S. states and the District of Columbia (DC) provisionally reported 8,300 TB cases to the National Tuberculosis Surveillance System. TB incidence was calculated using midyear population estimates and stratified by birth origin and by race and ethnicity. During 2022, TB incidence increased slightly to 2.5 although it remained lower than during prepandemic years.* Compared with that in 2021, TB epidemiology in 2022 was characterized by more cases among non–U.S.-born persons newly arrived in the United States; higher TB incidence among non-Hispanic American Indian or Alaska Native (AI/AN) and non-Hispanic Native Hawaiian or other Pacific Islander (NH/OPI) persons and persons aged ≤4 and 15–24 years; and slightly lower incidence among persons aged ≥65 years. TB incidence appears to be returning to prepandemic levels. TB disparities persist; addressing these disparities requires timely TB diagnosis and treatment to interrupt transmission and prevention of TB through treatment of latent TB infection (LTBI).
Health departments in the 50 U.S. states and DC electronically report verified TB cases to CDC based on the Council of State and Territorial Epidemiologists' surveillance case definition.† Midyear U.S. Census Bureau population estimates§ are used to calculate national, state-level, and age-stratified TB incidence. Persons with TB are grouped by self-reported race and ethnicity according to federal guidelines.¶ Persons reporting Hispanic ethnicity are categorized as Hispanic or Latino (Hispanic) irrespective of race. Non-Hispanic persons are categorized by race; non-Hispanic persons who reported more than one race are categorized as "multiple race." Midyear population estimates from the Current Population Survey** are used to calculate incidence by U.S. birth origin (U.S.-born versus non–U.S.-born)†† and by race and ethnicity. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§§
During 2022, 8,300 TB cases were reported in the United States, compared with 7,874 during 2021. TB incidence during 2022 increased slightly to 2.5 per 100,000 persons, compared with 2.4 during 2021. Consistent with previous years, in 2022, California reported the highest number of TB cases (1,843) and Alaska reported the highest TB incidence (13.1) (Table 1).
In 2022, 73% (6,009 of 8,248 TB cases in persons for whom birth origin was known) of TB cases occurred among non–U.S.-born persons,¶¶ compared with 72% in 2021. Among U.S.-born persons, TB incidence was 0.8 during both 2021 and 2022; among non–U.S.-born persons, incidence increased slightly from 12.6 in 2021 to 12.8 in 2022 (Figure) (Table 2). Among 2,239 U.S.-born persons with TB in 2022, 673 (30%) identified as non-Hispanic Black or African American (Black), 578 (26%) as Hispanic, 568 (25%) as non-Hispanic White (White), 182 (8%) as non-Hispanic Asian (Asian), 110 (5%) as AI/AN, and 52 (2%) as NH/OPI; 76 (3%) identified as multiple race or had unknown race and ethnicity. Among these groups, incidence was highest among NH/OPI persons (6.6), followed by AI/AN (4.4), Asian (2.2), and Black persons (1.9) and was lowest among White persons (0.3). Compared with that in 2021, incidence in 2022 increased 63% among Asian persons, 26% among NH/OPI persons, 16% among AI/AN persons, and 7% among Hispanic persons. Incidence declined 9% among Black persons, and 10% among White persons.***
Tuberculosis disease cases* and incidence,† by patient U.S. birth origin status§,¶ — National Tuberculosis Surveillance System, United States, 2012–2022
*Case counts are based on data from the National Tuberculosis Surveillance System as of March 6, 2023.
†Cases per 100,000 persons. The Current Population Survey provides the population denominators used to calculate tuberculosis incidence according to national origin and racial and ethnic group. https://www.census.gov/programs-surveys/cps.html (Accessed February 3, 2023).
§A person is considered U.S.-born if eligible for U.S. citizenship at birth, regardless of place of birth. Birth origin was missing or unknown for 232 (2.8%) cases during 2022. Among those, 180 (77.6%) had country of birth reported, and birth origin was defined as U.S.-born for persons reporting birth in the United States or U.S. territories and as non–U.S.-born for persons born outside the United States and its territories.
¶Persons for whom birth origin was unknown (range = 2  to 52 ) were excluded.
In 2022, 6,009 TB cases occurred among non–U.S.-born persons; >80% of these cases were among Asian (2,632; 44%) or Hispanic (2,194; 37%) persons. The remaining cases occurred among Black (625; 10%), White (276; 5%), and NH/OPI (103; 2%) persons, and multiple race persons or persons whose race and ethnicity were unknown (177; 3%). In 2022, similar to that among U.S.-born persons, the highest TB incidence among non–U.S.-born persons (27.8) was among NH/OPI persons. The next highest incidence (22.0) occurred among Asian persons, followed by Black (13.7), Hispanic (10.1), AI/AN (4.3) and White (3.4) persons. Among these groups, the largest increase in incidence from 2021 to 2022 (221%) occurred among AI/AN persons, followed by NH/OPI (20%), Hispanic (13%), and White (7%) persons. Incidence declined 12% among Black persons and 7% among Asian persons in 2022.
Among non–U.S.-born persons with TB in 2022, 16.5% (992) received a diagnosis <1 year after their initial arrival in the United States, compared with 9.8% (553) during 2021. A slightly lower number and percentage of persons with newly diagnosed TB were living in the United States for >10 years in 2022 (2,821; 46.9%) compared with 2021 (2,845; 50.2%).
By age group, TB incidence in 2022 was highest among persons aged ≥65 years (3.9), followed by persons aged 45–64 (2.9), 25–44 (2.7), 15–24 (1.9), ≤4 (1.1), and 5–14 years (0.4). Compared with 2021, 2022 had the largest increase in incidence among persons aged ≤4 (28.8%) and 15–24 years (23.7%); persons aged ≥65 years were the only group that experienced a decrease (1.8%). Among 84.7% of persons with TB that had a known HIV status, 4.7% were coinfected in 2022 compared with 4.3% in 2021. Among persons with TB, increased percentages reported experiencing homelessness within 12 months preceding diagnosis (4.8%) and residing in a correctional facility (3.5%) or long-term care facility (1.7%) at the time of diagnosis in 2022, compared with 2021 (Table 2).†††
Morbidity and Mortality Weekly Report. 2023;72(12):297-303. © 2023 Centers for Disease Control and Prevention (CDC)