Tuberculosis — United States, 2018

Amish Talwar, MD; Clarisse A. Tsang, MPH; Sandy F. Price; Robert H. Pratt; William L. Walker, DVM, PhD; Kristine M. Schmit, MD; Adam J. Langer, DVM

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(11):257-262.

Abstract and Introduction

Introduction

In 2018, a total of 9,029 new tuberculosis (TB) cases were reported in the United States, representing a 0.7% decrease from 2017.* The U.S. TB incidence in 2018 (2.8 per 100,000 persons) represented a 1.3% decrease from 2017; the rate among non–U.S.-born persons was >14 times that in U.S.-born persons. This report summarizes provisional TB surveillance data reported to CDC's National Tuberculosis Surveillance System (NTSS) through 2018. Although the total number of cases and incidence are the lowest ever reported in the United States, a recent model predicted that the U.S. TB elimination goal (annual incidence of <1 case per 1 million persons) will not be attained in the 21st century without greatly increased investment in detection and treatment of latent TB infection (LTBI).^[1] Programs to identify, test, and treat populations at high risk for TB remain important to eliminating TB in the United States.

Health departments in the 50 states and District of Columbia (DC) electronically report provisional case data that meet the national TB surveillance case definition to CDC.^† Data reported include demographic information (e.g., birth date, sex, self-reported race/ethnicity, and country of birth), clinical information (e.g., reason for TB evaluation, anatomic site of disease, test results, and therapy administered), and information on TB risk factors (e.g., human immunodeficiency virus [HIV] infection status, history of homelessness, and residence in a congregate setting). According to U.S. Census Bureau definitions, a "U.S.-born" person is classified as one born in the United States or a U.S. territory or born abroad to a U.S. citizen parent. Race/ethnicity data are collected and reported using federal classification standards; Hispanics/Latinos can be of any race, and all other reported race categories are non-Hispanic/Latino. CDC derived the denominators used to calculate national and state TB incidence from July 2018 U.S. Census Bureau population estimates^[2] and the denominators used to calculate TB incidence by national origin and race/ethnicity from July 2018 Current Population Survey data.^[3] The number of reported TB cases and TB incidence (cases per 100,000 persons) for 2017 and 2018, as well as the percent changes from 2017 to 2018, were calculated for the 50 states and DC and for each U.S. Census Bureau division. The numbers of TB cases and TB incidence per 100,000 persons were calculated by national origin and race/ethnicity for 2015–2018.

TB incidence declined 1.3% from 2017 to 2018 and an average of 1.6% per year during the last 4 years (2014–2018), a slower pace of decline than the 4.7% annual decline during 2010–2014.^§ State-specific TB incidence for 2018 ranged from 0.2 per 100,000 in Wyoming to 8.5 in Alaska, with a median rate of 1.9 (Table 1). Ten states (Alaska, California, Florida, Hawaii, Maryland, Massachusetts, Minnesota, New Jersey, New York, and Texas) and DC reported TB incidence above the national rate. As has been the case for over 2 decades, four states (California, Florida, New York, and Texas) accounted for approximately half of the reported cases of TB in the United States.

Among the 9,029 TB cases reported in the United States in 2018, approximately two thirds (6,276 [69.5%]) occurred in non–U.S.-born persons, whereas 2,662 (29.5%) occurred in U.S.-born persons; 91 (1.0%) cases occurred in persons for whom no national origin was documented (Table 2). This distribution is similar to that in 2017, when 6,392 (70.3%) cases occurred in non–U.S.-born persons, 2,693 (29.6%) occurred in U.S.-born persons, and 9 (0.1%) occurred in persons for whom no national origin was documented. TB incidence among non–U.S.-born persons (14.2 cases per 100,000) decreased by 3.8% from 2017 to 2018, and the incidence among U.S.-born persons (1.0 cases per 100,000) decreased by 1.8% (Figure).^¶

(Enlarge Image)

Figure.

Number of tuberculosis (TB) cases and TB incidence, by national origin*^,† — United States, 2010–2018
*Number of cases among non–U.S.-born and U.S.-born persons and associated incidence exclude cases with unknown country of origin. Incidence for all U.S. TB cases includes cases with unknown country of origin.
^†Incidence for non–U.S.-born and U.S.-born persons calculated using population estimates from Current Population Survey. Incidence for all persons with TB diagnosed in the United States calculated using population estimates from U.S. Census Bureau.

Among non–U.S.-born persons with TB, incidence in 2018 was highest among Asians, followed by Native Hawaiians/Pacific Islanders, non-Hispanic blacks (blacks), Hispanics, and American Indian/Alaska Natives, and was lowest among non-Hispanic whites (whites) (Table 2). Among TB cases in non–U.S.-born persons, incidence decreased from 2017 to 2018 among Asians, blacks, and whites, but increased in Hispanics. The top five countries of birth of non–U.S.-born persons with TB were Mexico (1,195 cases; 19.0% of all non–U.S.-born cases), Philippines (781; 12.4%), India (616; 9.8%), Vietnam (503; 8.0%), and China (374; 6.0%). Among TB cases in non–U.S.-born persons, 2,905 (46.3%) were diagnosed ≥10 years after the patient first arrived in the United States.

The highest TB incidence for U.S.-born persons occurred among Native Hawaiians/Pacific Islanders, followed by American Indians/Alaska Natives, blacks, Asians, and Hispanics, and was lowest in whites (Table 2). Among U.S.-born persons, TB incidence decreased from 2017 to 2018 among blacks, but remained stable among Asians, Hispanics, and whites.

During 2018, 4.1% of TB cases were reported among persons who experienced homelessness within the year preceding diagnosis, 3.3% among residents of a correctional facility at the time of diagnosis, and 1.6% among residents of a long-term care facility at the time of diagnosis.** Among cases diagnosed in persons who experienced homelessness and among residents of long-term care facilities, 60.8% and 56.8%, respectively, were in persons who were U.S.-born, whereas among residents of a correctional facility, only 33.6% were U.S.-born. HIV status was known for 85.3% of TB cases reported in 2018. Overall, 5.3% of TB patients with known HIV status were coinfected with HIV, including 8.6% among persons aged 25–44 years.

Initial drug-susceptibility testing for at least isoniazid and rifampin was performed for 73.5% of all TB cases (and 93.8% of culture-confirmed cases) in 2017, the most recent year for which complete data are available.^†† Among the 6,684 TB cases reported in 2017 with available drug-susceptibility testing results, 128 (1.9%) were multidrug-resistant TB.^§§ Of these multidrug-resistant TB cases, 110 (85.9%) were in non–U.S.-born persons; 26 (20.3%) multidrug-resistant TB patients reported a previous episode of TB. Three cases of extensively drug-resistant TB^¶¶ were reported, all of which occurred in non–U.S.-born persons.

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Abstract and Introduction
Discussion
References
Sidebar

* This report is limited to National Tuberculosis Surveillance System provisional data as of February 11, 2019. Updated data will be available in CDC's annual TB surveillance report later this year.
^† https://www.cdc.gov/tb/programs/rvct/instructionmanual.pdf.
^§ These calculations are based on unrounded annual TB incidence rates.
^¶ The decrease in overall incidence does not fall within the range of decreases by national origin because, although the denominators used to calculate both rates increased from 2017 to 2018, the denominator used for rates by national origin (according to Current Population Survey data) increased by an additional 705,000 persons, compared with the denominator used to calculate the overall rate (according to U.S. Census Bureau data). This resulted in a larger calculated decrease in rate by national origin, compared with the overall rate.
** Percentages are calculated using cases with complete data for each of these three individual variables.
^†† Because information on initial drug-susceptibility testing for isoniazid and rifampin is only available for 66.5% of all TB cases in 2018 (and 86.1% of culture-confirmed cases), more complete data from 2017 are presented instead. Culture-confirmed cases are defined as cases that were culture-positive on a specimen collected within 2 weeks of start of 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 and rifampin as well as any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin).

Table 1. Tuberculosis (TB) case counts and incidence with annual percent changes, by U.S. Census division and state/district — 50 states and the District of Columbia, 2017 and 2018
Census division/State	No. of reported TB cases*			TB incidence^†
Census division/State	2017	2018	% Change	2017	2018	% Change^§
Division 1: New England
Connecticut	63	51	−19.0	1.8	1.4	−19.0
Maine	14	14	0.0	1.0	1.0	−0.2
Massachusetts	209	200	−4.3	3.0	2.9	−4.8
New Hampshire	19	12	−36.8	1.4	0.9	−37.2
Rhode Island	13	20	53.8	1.2	1.9	53.7
Vermont	3	5	66.7	0.5	0.8	66.2
Total	321	302	−5.9	2.2	2.0	−6.2
Division 2: Middle Atlantic
New Jersey	283	290	2.5	3.2	3.3	2.2
New York	800	750	−6.3	4.1	3.8	−6.0
Pennsylvania	192	212	10.4	1.5	1.7	10.3
Total	1,275	1,252	−1.8	3.1	3.0	−1.8
Division 3: East North Central
Illinois	335	319	−4.8	2.6	2.5	−4.4
Indiana	100	116	16.0	1.5	1.7	15.4
Michigan	133	109	−18.0	1.3	1.1	−18.2
Ohio	149	178	19.5	1.3	1.5	19.2
Wisconsin	49	49	0.0	0.8	0.8	−0.4
Total	766	771	0.7	1.6	1.6	0.5
Division 4: West North Central
Iowa	47	49	4.3	1.5	1.6	3.8
Kansas	29	28	−3.4	1.0	1.0	−3.5
Minnesota	178	172	−3.4	3.2	3.1	−4.1
Missouri	87	82	−5.7	1.4	1.3	−6.0
Nebraska	21	27	28.6	1.1	1.4	27.8
North Dakota	14	13	−7.1	1.9	1.7	−7.7
South Dakota	14	12	−14.3	1.6	1.4	−15.2
Total	390	383	−1.8	1.8	1.8	−2.3
Division 5: South Atlantic
Delaware	15	22	46.7	1.6	2.3	45.1
District of Columbia	36	36	0.0	5.2	5.1	−1.0
Florida	549	591	7.7	2.6	2.8	6.0
Georgia	293	273	−6.8	2.8	2.6	−7.8
Maryland	207	207	0.0	3.4	3.4	−0.3
North Carolina	213	196	−8.0	2.1	1.9	−9.0
South Carolina	101	86	−14.9	2.0	1.7	−15.9
Virginia	204	205	0.5	2.4	2.4	−0.1
West Virginia	16	7	−56.3	0.9	0.4	−56.0
Total	1,634	1,623	−0.7	2.5	2.5	−1.7
Division 6: East South Central
Alabama	120	91	−24.2	2.5	1.9	−24.4
Kentucky	65	65	0.0	1.5	1.5	−0.3
Mississippi	52	80	53.8	1.7	2.7	54.0
Tennessee	127	140	10.2	1.9	2.1	9.2
Total	364	376	3.3	1.9	2.0	2.8
Division 7: West South Central
Arkansas	85	79	−7.1	2.8	2.6	−7.4
Louisiana	141	105	−25.5	3.0	2.3	−25.4
Oklahoma	54	74	37.0	1.4	1.9	36.7
Texas	1,127	1,129	0.2	4.0	3.9	−1.1
Total	1,407	1,387	−1.4	3.5	3.4	−2.4
Division 8: Mountain
Arizona	188	178	−5.3	2.7	2.5	−6.9
Colorado	84	64	−23.8	1.5	1.1	−24.9
Idaho	10	15	50.0	0.6	0.9	47.0
Montana	3	5	66.7	0.3	0.5	65.2
Nevada	80	69	−13.8	2.7	2.3	−15.5
New Mexico	37	41	10.8	1.8	2.0	10.7
Utah	29	18	−37.9	0.9	0.6	−39.1
Wyoming	2	1	−50.0	0.3	0.2	−49.9
Total	433	391	−9.7	1.8	1.6	−11.1
Division 9: Pacific
Alaska	53	63	18.9	7.2	8.5	19.2
California	2,059	2,091	1.6	5.2	5.3	1.1
Hawaii	116	120	3.4	8.1	8.4	3.7
Oregon	69	81	17.4	1.7	1.9	16.2
Washington	207	189	−8.7	2.8	2.5	−10.0
Total	2,504	2,544	1.6	4.7	4.8	1.0
United States	9,094	9,029	−0.7	2.8	2.8	−1.3

*Case counts were based on data from the National Tuberculosis Surveillance System as of February 11, 2019.
^†Cases per 100,000 persons. TB incidence was calculated using denominators from U.S. Census Bureau midyear population estimates.
^§Percentage change in incidence was calculated using unrounded rate for 2017 and 2018.

Table 2. Newly diagnosed tuberculosis (TB) case counts and incidence,* by national origin and race/ethnicity — United States, 2015–2018 ^†
U.S. population group	No. of cases (incidence)
U.S. population group	2015	2016	2017	2018
U.S.-born^§
Hispanic	660 (1.8)	603 (1.6)	591 (1.5)	582 (1.5)
White, non-Hispanic	984 (0.5)	910 (0.5)	797 (0.4)	801 (0.4)
Black, non-Hispanic	1,142 (3.3)	1,066 (3.0)	1,008 (2.9)	938 (2.6)
Asian	138 (2.1)	146 (2.1)	134 (1.9)	139 (1.9)
American Indian/Alaska Native	144 (7.0)	110 (5.1)	92 (3.8)	102 (4.0)
Native Hawaiian/Pacific Islander	42 (6.1)	31 (4.3)	46 (6.7)	42 (5.6)
Multiple or unknown race/Ethnicity	25 (—^¶)	23 (—^¶)	25 (—^¶)	58 (—^¶)
Total U.S.-born	3,135 (1.1)	2,889 (1.0)	2,693 (1.0)	2,662 (1.0)
Non–U.S.-born
Hispanic	2,036 (10.4)	1,990 (10.1)	1,973 (10.0)	2,006 (10.1)
White, non-Hispanic	258 (3.4)	286 (3.8)	268 (3.5)	251 (3.1)
Black, non-Hispanic	858 (23.2)	914 (22.7)	901 (22.2)	829 (19.9)
Asian	3,157 (29.7)	3,051 (27.2)	3,126 (27.3)	2,993 (25.4)
American Indian/Alaska Native	1 (1.9)	1 (2.9)	2 (2.9)	3 (5.2)
Native Hawaiian/Pacific Islander	60 (18.6)	47 (13.0)	66 (22.4)	74 (25.0)
Multiple or unknown race/Ethnicity	37 (—^¶)	68 (—^¶)	56 (—^¶)	120 (—^¶)
Total non–U.S.-born	6,407 (15.3)	6,357 (14.7)	6,392 (14.7)	6,276 (14.2)
Unknown national origin	5 (—^¶)	7 (—^¶)	9 (—^¶)	91 (—^¶)
Overall total	9,547 (3.0)	9,253 (2.9)	9,094 (2.8)	9,029 (2.8)

*Incidence was calculated as cases per 100,000 persons.
^†Case counts were based on data from the National Tuberculosis Surveillance System as of February 11, 2019. The Current Population Survey (https://www.census.gov/programs-surveys/cps.html) provides the population denominators used to calculate TB incidence according to national origin and racial/ethnic group.
^§U.S.-born persons were born in the United States or U.S. territories (American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and U.S. Virgin Islands) or born elsewhere to a U.S. citizen. Non–U.S.-born persons were born outside the United States (or the U.S. territories), and include those born in the sovereign freely associated states (Federated States of Micronesia, Marshall Islands, and Palau) (unless one or both parents were U.S. citizens).
^¶Incidence was not calculated for these categories.