Tuberculosis — United States, 2022

Kimberly R. Schildknecht, MPH; Robert H. Pratt; Pei-Jean I. Feng, MPH; Sandy F. Price; Julie L. Self, PhD

Morbidity and Mortality Weekly Report. 2023;72(12):297-303.

Discussion

U.S. TB incidence increased during 2022, compared with that during 2020 and 2021, but remained lower than incidence during the prepandemic years; after a substantial 20.2% decline in 2020 and partial rebound (9.8% increase) in 2021,^[1] incidence appears to be returning to prepandemic levels among U.S.-born and non–U.S.-born populations.

COVID-19–associated mortality was high among persons aged ≥65 years, which might account, in part, for the lower TB incidence observed among that population.^[3] Even though the decrease in TB incidence was small, reduction of the population aged ≥65 years at risk for TB might have similar effects on TB incidence in future years. The increase in TB incidence among children aged ≤4 years might represent both recent transmission in the United States and infection in countries with higher TB incidence. An analysis of TB incidence among indigenous persons during 2009–2019 found a higher prevalence of underlying chronic medical conditions, and TB incidence was at least 10 times higher among AI/AN and NH/OPI persons than among White persons.^[2] These factors likely contributed to the higher TB incidence in these populations in this report. Among non–U.S.-born persons with TB, the higher proportion reported <1 year after arrival in the United States might reflect greater migration from higher TB incidence areas than what existed at the beginning of the pandemic.^§§§

Although preventing TB transmission in the United States remains a priority, >80% of U.S. TB cases are attributed to reactivation of LTBI.^[1] To achieve TB elimination in the United States, the U.S. Preventive Services Task Force recommends testing and treatment among populations at higher risk for LTBI, including non–U.S.-born persons and persons in congregate living settings.^[4] To treat LTBI, CDC recommends short-course (3- or 4-month), rifamycin-based regimens.^[5] Shorter regimens are also available to treat TB: in 2022, CDC recommended a 4-month treatment regimen for drug-susceptible pulmonary TB as an alternative to the standard 6-month regimen.^[6] Shorter treatment durations improve treatment adherence and completion.^[5,6]

Higher TB incidence among AI/AN and NH/OPI persons represents an ongoing health disparity^[2] in the United States. Alaska reported an increase of TB in 2022 and identified Alaska Native persons as among those at highest risk for TB.^[7] CDC is working to raise awareness about TB and LTBI among communities at risk for TB and their health care providers through the Think. Test. Treat TB campaign,^¶¶¶ which offers resources in multiple languages for general audiences and health care providers.**** CDC also partners with community health clinics and organizations, including the TB Elimination Alliance,^†††† to address TB health disparities through education and innovation.

Higher proportions of TB cases among persons experiencing homelessness or residing in correctional or long-term care facilities might be partially explained by transmission events in congregate settings. For example, gaps in TB infection control practices when resources were diverted to COVID-19 prevention and control efforts likely led to a TB outbreak in at least one state's prison system during 2021–2022.^[8]

The findings in this report are subject to at least two limitations. First, this analysis and case counts are based on provisional 2022 TB surveillance data and might change. Second, rates are calculated with population estimates that are subject to future refinement.

Knowledge of the effects of the COVID-19 pandemic on U.S. TB epidemiology is evolving. As COVID-19 incidence declines, TB remains an important public health challenge characterized by persistent inequities, particularly among AI/AN and NH/OPI populations, persons experiencing homelessness, and persons who are incarcerated. Timely detection and treatment of TB and LTBI among persons at risk are needed to achieve TB elimination in the United States.

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Acknowledgments
State, tribal, local, and territorial health department personnel; Cynthia Adams, Shanita Clemmons, Stacey Parker, Jeanette Roberts, Katrina Williams, Peraton, Herndon, Virginia; Division of Tuberculosis Elimination Surveillance Team, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC; Leeanna Allen, Maryam Haddad, Adam Langer, Noah Schwartz, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC.

^§§§ https://www.census.gov/library/stories/2022/12/net-international-migration-returns-to-pre-pandemic-levels.html
^¶¶¶ https://www.cdc.gov/thinktesttreattb
****https://www.cdc.gov/thinktesttreattb/resources.html
^†††† https://tbeliminationalliance.org/

Table 1. Number of tuberculosis disease cases and tuberculosis incidence, by jurisdiction — National Tuberculosis Surveillance System, United States, 2019–2022
Jurisdiction	No. of cases*				Incidence^†
Jurisdiction	2019	2020	2021	2022	2019	2020	2021	2022
Alabama	87	72	91	66	1.8	1.4	1.8	1.3
Alaska	58	58	58	96	7.9	7.9	7.9	13.1
Arizona	183	136	129	154	2.5	1.9	1.8	2.1
Arkansas	64	59	69	69	2.1	2.0	2.3	2.3
California	2,110	1,703	1,749	1,843	5.4	4.3	4.5	4.7
Colorado	66	52	58	57	1.1	0.9	1.0	1.0
Connecticut	67	54	54	67	1.9	1.5	1.5	1.8
Delaware	19	17	41	13	1.9	1.7	4.1	1.3
District of Columbia	24	19	18	15	3.4	2.8	2.7	2.2
Florida	558	412	500	536	2.6	1.9	2.3	2.4
Georgia	302	220	222	256	2.8	2.1	2.1	2.3
Hawaii	99	92	106	101	7.0	6.3	7.3	7.0
Idaho	7	8	5	11	0.4	0.4	0.3	0.6
Illinois	326	216	254	298	2.6	1.7	2.0	2.4
Indiana	108	92	127	99	1.6	1.4	1.9	1.4
Iowa	52	39	49	60	1.6	1.2	1.5	1.9
Kansas	37	37	43	52	1.3	1.3	1.5	1.8
Kentucky	65	66	57	70	1.5	1.5	1.3	1.6
Louisiana	88	99	86	89	1.9	2.1	1.9	1.9
Maine	18	17	14	20	1.3	1.2	1.0	1.4
Maryland	209	149	197	152	3.5	2.4	3.2	2.5
Massachusetts	178	142	151	153	2.6	2.0	2.2	2.2
Michigan	131	101	137	120	1.3	1.0	1.4	1.2
Minnesota	148	117	134	132	2.6	2.0	2.3	2.3
Mississippi	57	43	46	54	1.9	1.5	1.6	1.8
Missouri	70	79	77	69	1.1	1.3	1.2	1.1
Montana	2	4	3	6	0.2	0.4	0.3	0.5
Nebraska	17	33	22	28	0.9	1.7	1.1	1.4
Nevada	53	57	61	62	1.7	1.8	1.9	2.0
New Hampshire	6	12	12	11	0.4	0.9	0.9	0.8
New Jersey	309	245	289	286	3.5	2.6	3.1	3.1
New Mexico	41	29	24	30	2.0	1.4	1.1	1.4
New York	746	605	683	714	3.8	3.0	3.4	3.6
North Carolina	185	159	178	163	1.8	1.5	1.7	1.5
North Dakota	18	10	15	5	2.4	1.3	1.9	0.6
Ohio	149	132	151	148	1.3	1.1	1.3	1.3
Oklahoma	73	67	69	80	1.8	1.7	1.7	2.0
Oregon	70	67	79	70	1.7	1.6	1.9	1.7
Pennsylvania	198	157	166	173	1.5	1.2	1.3	1.3
Rhode Island	14	7	17	17	1.3	0.6	1.5	1.6
South Carolina	80	67	87	101	1.6	1.3	1.7	1.9
South Dakota	16	16	12	10	1.8	1.8	1.3	1.1
Tennessee	129	113	84	107	1.9	1.6	1.2	1.5
Texas	1,154	879	996	1,089	4.0	3.0	3.4	3.6
Utah	27	29	17	33	0.8	0.9	0.5	1.0
Vermont	4	3	3	3	0.6	0.5	0.5	0.5
Virginia	191	169	160	195	2.2	2.0	1.8	2.2
Washington	221	163	199	253	2.9	2.1	2.6	3.2
West Virginia	9	13	6	11	0.5	0.7	0.3	0.6
Wisconsin	51	35	66	52	0.9	0.6	1.1	0.9
Wyoming	1	0	3	1	0.2	0	0.5	0.2
Total	8,895	7,170	7,874	8,300	2.7	2.2	2.4	2.5

*Case counts are based on data reported to the National Tuberculosis Surveillance System as of March 6, 2023.
^†Incidence is calculated as cases per 100,000 persons using midyear population estimates from the U.S. Census Bureau. Short-term projections from the monthly population estimates by age, sex, race, and Hispanic origin were used for 2022 population, 2021 vintage population estimates were used for 2021 and 2020, and 2010 vintage population estimates were used for 2019. https://www.census.gov/programs-surveys/popest/data/tables.html; https://www.census.gov/programs-surveys/popest/data/tables.2019.List_58029271.html#list-tab-List_58029271

Table 2. Demographic and risk characteristics of persons with tuberculosis and number and incidence of tuberculosis cases — National Tuberculosis Surveillance System, United States, 2021–2022
Characteristic	No. of TB cases* (%)^†			TB incidence^§
Characteristic	2021	2022	% Change 2021 to 2022	2021	2022	% Change 2021 to 2022
Total	7,874	8,300	5.4	2.4	2.5	5.0
Age group, yrs
≤4	160 (2.0)	202 (2.4)	26.3	0.8	1.1	28.8
5–14	156 (2.0)	161 (1.9)	3.2	0.4	0.4	4.4
15–24	676 (8.6)	840 (10.1)	24.3	1.6	1.9	23.7
25–44	2,265 (28.8)	2,431 (29.3)	7.3	2.5	2.7	7.1
45–64	2,409 (30.6)	2,419 (29.2)	0.4	2.9	2.9	1.1
≥65	2,208 (28.0)	2,244 (27.0)	1.6	4.0	3.9	−1.8
Birth origin, ^¶ race and ethnicity
U.S.-born
AI/AN, non-Hispanic	86 (3.9)	110 (4.9)	27.9	3.8	4.4	15.8
Asian, non-Hispanic	112 (5.1)	182 (8.1)	62.5	1.4	2.2	63.2
Black or African American, non-Hispanic	743 (34.1)	673 (30.1)	−9.4	2.0	1.9	−9.1
NH/OPI, non-Hispanic	40 (1.8)	52 (2.3)	30.0	5.2	6.6	26.2
White, non-Hispanic	634 (29.1)	568 (25.4)	−10.4	0.3	0.3	−10.4
Hispanic or Latino	539 (24.7)	578 (25.8)	7.2	1.3	1.4	6.6
Unknown race and ethnicity or multiple races	28 (1.3)	76 (3.4)	NA	NA	NA	NA
Subtotal	2,182 (100.0)	2,239 (100.0)	2.6	0.8	0.8	2.4
Non–U.S.-born
AI/AN, non-Hispanic	1 (0)	2 (0)	100.0	1.3	4.3	221.3
Asian, non-Hispanic	2,709 (47.8)	2,632 (43.8)	−2.8	23.8	22.0	−7.5
Black or African American, non-Hispanic	674 (11.9)	625 (10.4)	−7.3	15.5	13.7	−11.6
NH/OPI, non-Hispanic	75 (1.3)	103 (1.7)	37.3	23.3	27.8	19.5
White, non-Hispanic	249 (4.4)	276 (4.6)	10.8	3.2	3.4	7.4
Hispanic or Latino	1,847 (32.6)	2,194 (36.5)	18.8	8.9	10.1	12.6
Unknown race and ethnicity or multiple races	109 (1.9)	177 (2.9)	NA	NA	NA	NA
Subtotal	5,664 (100.0)	6,009 (100.0)	6.1	12.6	12.8	1.1
Unknown birth origin**	28 (0.4)	52 (0.6)	NA	NA	NA	NA
Interval from initial U.S. arrival to TB diagnosis, yrs
<1	553 (9.8)	992 (16.5)	79.4	NA	NA	NA
1–10	1,642 (29.0)	1,528 (25.4)	−6.9	NA	NA	NA
>10	2,845 (50.2)	2,821 (46.9)	−0.8	NA	NA	NA
Unknown	624 (11.0)	668 (11.1)	7.1	NA	NA	NA
HIV-positive at time of diagnosis	302 (4.3)	327 (4.7)	8.3	NA	NA	NA
Experienced homelessness during previous year	352 (4.5)	380 (4.8)	8.0	NA	NA	NA
Correctional facility resident at diagnosis	178 (2.3)	286 (3.5)	60.7	NA	NA	NA
Long-term care facility resident at diagnosis	109 (1.4)	139 (1.7)	27.5	NA	NA	NA

Abbreviations: AI/AN = American Indian or Alaska Native; NA = not applicable; NH/OPI = Native Hawaiian or other Pacific Islander; TB = tuberculosis.
*Case counts are based on data reported to the National Tuberculosis Surveillance System as of March 6, 2023.
^†Percentages are calculated only among patients with available data, except for the years after U.S. arrival. Age was missing or unknown for zero cases in 2021 and three cases in 2022; origin of birth remained missing or unknown for 28 cases in 2021 and 52 cases in 2022; race and ethnicity was missing or unknown for 56 cases in 2021 and 175 cases in 2022; HIV testing results were missing or unknown for 842 cases in 2021 and 1,270 cases in 2022; whether a person was experiencing homelessness was missing or unknown for 60 cases in 2021 and 301 cases in 2022; whether a person was residing in a correctional facility was missing or unknown for 92 cases in 2021 and 215 cases in 2022; and whether a person was residing in a long-term care facility was missing or unknown for 81 cases in 2021 and 215 cases in 2022.
^§Incidence is calculated as cases per 100,000 persons using midyear population estimates from the U.S. Census Bureau. Short-term projections from the monthly population estimates by age, sex, race, and Hispanic origin were used for 2022 population, 2021 vintage population estimates were used for 2021 and 2020, and 2010 vintage population estimates were used for 2019. https://www.census.gov/programs-surveys/popest/data/tables.html; https://www.census.gov/programs-surveys/popest/data/tables.2019.List_58029271.html#list-tab-List_58029271
^¶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.
**Excluded from race and ethnicity subtotals.

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Tuberculosis — United States, 2022

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