Slide Set— Epidemiology of Pediatric Tuberculosis in the United States, 1993–2008

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Slide 1

Epidemiology of Pediatric Tuberculosis in the United States, 1993–2008

Surveillance, Epidemiology, and Outbreak Investigations Branch Division of Tuberculosis Elimination
Centers for Disease Control and Prevention (CDC)
 

Slide 2

Pediatric TB—Background

• Definition of pediatric tuberculosis (TB): TB disease in a person <15 years old
   
• In 2008,
• 12,904 TB cases were reported among all age groups
• 786 (6.1%) were pediatric

Slide 3

1996 TB Case Definition and Verification*

• Incident case of disease
• Case verification categories:
1. Laboratory confirmed cases-“Gold Standard”
• Positive culture or nucleic acid amplification test
• Positive AFB smear when culture not attainable
2. Clinical case definition
• Positive tuberculin skin test
• Signs and symptoms of TB disease
• Current treatment for TB disease
3. Provider diagnosis:
• Diagnosed by health care provider
• Does not fulfill all criteria necessary to meet laboratory or clinical case definitions

*TB Case definition was revised in 2009.  However, previous definition is used because all data precede 2009.

Slide 4

TB Cases, All Ages, by Age Group, 1993–2008

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
<15 yrs	1661	1659	1536	1356	1251	1077	1039	965	929	944	912	954	857	800	777	786
15–24 yrs	1822	1833	1698	1637	1675	1543	1518	1618	1597	1497	1573	1602	1542	1531	1581	1440
25–44 yrs	9588	9043	8201	7564	6884	6335	6063	5576	5609	5288	5072	4938	4736	4691	4316	4242
45–64 yrs	6197	6125	5960	5572	5277	4954	4858	4636	4515	4182	4283	4194	4123	4042	4040	3935
65+ yrs	5820	5539	5328	5076	4663	4377	4020	3514	3293	3141	2993	2811	2809	2662	2573	2500

Slide 5

TB Case Rates, All Ages, by Age Group 1993–2008

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Overall US	9.7	9.3	8.6	8.0	7.4	6.8	6.4	5.8	5.6	5.2	5.1	5.0	4.8	4.6	4.4	4.2
<15 yrs	2.9	2.9	2.7	2.3	2.2	1.9	1.8	1.6	1.5	1.6	1.5	1.6	1.4	1.3	1.3	1.3
15–24 yrs	5.0	5.1	4.7	4.5	4.6	4.1	4.0	4.1	4.0	3.7	3.8	3.9	3.7	3.6	3.7	3.4
25–44 yrs	11.6	10.9	9.8	9.0	8.2	7.6	7.3	6.6	6.6	6.3	6.0	5.9	5.7	5.6	5.2	5.1
45–64 yrs	12.5	12.0	11.4	10.4	9.5	8.7	8.2	7.4	7.0	6.3	6.2	5.9	5.7	5.4	5.3	5.0
65+ yrs	17.7	16.7	15.8	14.9	13.6	12.7	11.6	10.0	9.3	8.8	8.3	7.7	7.6	7.1	6.8	6.4

Note: Rates presented on a logarithmic scale

Slide 6

Percent of Pediatric TB Cases by Age Group 1993–2008
N=17,502

	Age < 1	Age 1-4	Age 5-9	Age 10-14
Pediatric	9.7	49.2	22.8	18.3

Slide 7

Pediatric TB Cases by Age Group 1993–2008
N=17,502

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Age < 1	156	140	120	102	113	105	96	91	97	101	94	82	82	90	114	114
Age 1–4	859	856	774	668	621	533	506	453	446	455	454	469	398	390	352	382
Age 5–9	358	394	393	368	305	243	250	222	208	196	195	203	195	159	160	142
Age 10–14	288	269	249	218	212	196	186	199	178	192	169	200	182	161	151	148

Slide 8

TB Case Rates by Pediatric Age Groups 1993–2008
N=17,502

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Age < 1	4.0	3.6	3.1	2.7	3.0	2.8	2.5	2.4	2.4	2.5	2.3	2.0	2.0	2.2	2.6	2.7
Age 1–4	5.4	5.4	4.9	4.3	4.1	3.5	3.3	3.0	2.9	2.9	2.9	2.9	2.4	2.4	2.1	2.3
Age 5–9	1.9	2.1	2.1	1.9	1.5	1.2	1.3	1.1	1.0	1.0	1.0	1.0	1.0	0.8	0.8	0.7
Age 10–14	1.6	1.4	1.3	1.1	1.1	1.0	1.0	1.0	0.9	0.9	0.8	0.9	0.9	0.8	0.7	0.7

Note: Rates presented on a logarithmic scale

Slide 9

Pediatric TB Cases by Race/Ethnicity 1993–2008
N=17,502

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
White, non-Hispanic	250	230	184	157	136	137	125	104	87	103	82	77	66	64	69	48
Black, non-Hispanic	559	572	517	515	469	372	345	335	310	330	257	289	264	249	224	222
Hispanic	640	642	624	512	438	423	432	374	413	401	432	457	397	386	354	357
American Indian/ Alaskan Native	22	31	34	37	29	15	15	27	8	13	13	13	12	9	9	10
Asian/Pacific Islander	184	181	175	134	178	128	116	122	111	94	123	114	108	89	117	138

Note: Unknown and multiple race/ethnicity not shown

Slide 10

Pediatric TB Case Rates by Race/Ethnicity 1993–2008
N=17,502

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
White, non-Hispanic	0.7	0.6	0.5	0.4	0.4	0.4	0.3	0.3	0.2	0.3	0.2	0.2	0.2	0.2	0.2	0.1
Black, non-Hispanic	6.7	6.8	6.1	6.1	5.5	4.4	4.1	3.7	3.4	3.7	2.9	3.3	3.0	2.9	2.6	2.6
Hispanic	8.4	8.1	7.6	6.0	5.0	4.6	4.6	3.5	3.7	3.5	3.7	3.7	3.1	3.0	2.6	2.6
Asian/Pacific Islander	9.3	8.8	8.2	6.1	7.8	5.5	4.8	5.6	4.9	4.1	5.2	4.7	4.3	3.4	4.4	5.1

Rates presented on a logarithmic scale.
American Indian/Alaska Native rate not shown because of small denominators

Slide 11

TB Case Rates by Pediatric Age Groups U.S.-born and Foreign-born, 1994–2008
N=15,759

	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Age < 1, FB	45.7	45.9	65.2	25.8	52.6	72.6	37.4	29.4	12.1	70.3	23.1	11.2	28.2	16.6	43.0
Age 1–4, FB	43.6	46.1	33.1	33.7	33.8	31.8	30.0	27.0	25.2	29.9	33.6	23.1	20.9	20.6	19.5
Age 5–9, FB	23.1	16.4	14.4	12.7	10.4	16.5	10.3	14.2	10.2	12.5	11.6	10.5	6.5	8.5	8.2
Age 10–14, FB	12.2	13.2	11.4	10.7	9.4	9.8	9.5	7.9	9.3	7.7	10.1	8.6	8.5	6.4	7.4

	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Age < 1, USB	3.3	2.9	2.4	2.8	2.3	2.3	2.1	2.2	2.5	2.6	2.1	2.0	2.0	2.7	2.4
Age 1–4, USB	4.4	4.1	3.6	3.3	2.9	2.7	2.4	2.3	2.4	2.2	2.3	2.0	2.0	1.8	2.0
Age 5–9, USB	1.3	1.5	1.4	1.1	0.9	0.8	0.8	0.6	0.6	0.6	0.7	0.6	0.6	0.5	0.4
Age 10–14, USB	0.8	0.7	0.6	0.6	0.6	0.5	0.5	0.5	0.5	0.4	0.5	0.4	0.4	0.4	0.3

Note: Rates presented on a logarithmic scale. Data not available before 1994.
USB = U.S.-born, FB=Foreign-born (unknown excluded from table and counts)

Slide 12

Number and Percent of Pediatric TB Cases by U.S. and Foreign Birth, 1993–2008

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Foreign-born	413	386	352	312	287	249	265	255	269	249	269	280	243	201	205	201
U.S.-born	1232	1252	1179	1030	954	822	763	707	659	690	643	673	613	606	572	580
Percent foreign-born	24.9	23.3	22.9	23.0	22.9	23.1	25.5	26.5	29.0	26.4	29.4	29.4	28.7	24.9	26.4	25.6

Slide 13

Number of Pediatric TB Cases with Foreign Birth by Birth Country*, by 4-Year Intervals, 1997–2008
N=2,973

1997-2000 (n)	2001-2004 (n)	2005-2008 (n)
Mexico (368)	Mexico (380)	Mexico (216)
Philippines (89)	Philippines (74)	Somalia (61)
Somalia (55)	Somalia (72)	Ethiopia (52)
Viet Nam (51)	Haiti (59)	Philippines (52)
Russia (41)	India (35)	Liberia (37)
India (29)	Viet Nam (34)	Haiti (31)
Other (423)	Other (412)	Other (402)

*Ranked by counts

Slide 14

States with the Greatest Percent of the National Total Pediatric TB Cases, 1993–2008
N=17,502

	California	Texas	New York	Florida	Illinois	Georgia	All Others
U.S. Total	24.7	11.8	8.5	5.2	4.7	4.4	40.7

Slide 15

States with Greatest Numbers of Pediatric TB Cases, 1993–2008

Pediatric TB Cases

State	Number	Percent*	Rate**
California	4,313	7.5	3.5
Texas	2,073	7.2	2.6
New York	1,482	4.7	2.5
Florida	902	4.5	1.8
Illinois	821	6.6	1.9
Georgia	778	7.9	2.7
All Others	7,133	6.0	1.3
Overall U.S.	17,502	6.3	1.8

*Average percent of total state cases that are pediatric, for all years
**Time-averaged rate per 100,000

Slide 16

States with Greatest Percent of Pediatric TB cases, 1993–2008

State	Number	Percent*	Rate**
Alaska	133	12.5	5.3
Rhode Island	84	10.9	2.6
Minnesota	306	10.1	1.8
Oklahoma	295	10.1	2.5
Delaware	55	9.5	2.2
Arizona	414	9.4	2.2
All Others	16,215	6.1	1.9
Overall U.S.	17,502	6.3	1.8

*Average percent of total state cases that are pediatric, for all years
**Time-averaged rate per 100,000

Slide 17

States with Greatest Rate of Pediatric TB Cases, 1993–2008

State	Number	Percent*	Rate**
Alaska	133	12.5	5.3
D.C.†	59	4.1	3.9
California	4,313	7.5	3.5
Georgia	778	7.9	2.7
Texas	2,073	7.2	2.6
Arkansas	222	8.3	2.5
All Others	9,924	5.9	1.4
Overall U.S.	17,502	6.3	1.8

*Average percent of total state cases that are pediatric, for all years
**Time-averaged rate per 100,000
†D.C. (District of Columbia) is a distinct reporting jurisdiction

Slide 18

Pediatric TB Cases by Case Verification Criterion*, 1993–2008
N=17,502

Laboratory Confirmed	Clinical Case	Provider Diagnosis
25%	50%	24%

*Based on the public health surveillance definition for TB [MMWR 1997:46(No. RR-10):40-41]

Slide 19

Pediatric TB Cases by Case Verification Criterion, 1993–2008
N=17,502

Age < 1 n=1,697

Laboratory Confirmed	Clinical Case	Provider Diagnosis
51%	25%	24%

Age 1–4 n=8,616

Laboratory Confirmed	Clinical Case	Provider Diagnosis
20%	53%	27%

Age 5–9 n=3,991

Laboratory Confirmed	Clinical Case	Provider Diagnosis
15%	59%	26%

Age 10–14 n=3,198

Laboratory Confirmed	Clinical Case	Provider Diagnosis
37%	45%	18%

Slide 20

Pediatric TB Cases by Site of Disease, 1993–2008

	Both	Extrapulmonary	Pulmonary
Site of Disease	7.1%	22.0%	70.9%

Any extrapulmonary involvement* (totaling 29.1%)
Lymphatic	18.9%
Meningeal	3.1%
Miliary	1.5%
Bone & Joint	1.5%
Other	4.1%

* Any extrapulmonary involvement which includes cases that are extrapulmonary only and both
Patients may have more than one disease site but are counted in mutually exclusive categories for
surveillance purposes.

Slide 21

Percent of Pediatric TB Cases by Site of Disease, 1993–2008
N=17,502

Age <1 n=1,697

	Pulmonary	Extrapulmonary	Both
Site of Disease	75.3%	10.2%	14.5%

Age 1–4 n=8,616

	Pulmonary	Extrapulmonary	Both
Site of Disease	71.9%	20.8%	7.3%

Age 5–9 n=3,991

	Pulmonary	Extrapulmonary	Both
Site of Disease	69.9%	25.5%	4.6%

Age 10–14 n=3,198

	Pulmonary	Extrapulmonary	Both
Site of Disease	66.9%	27.2%	5.9%

Slide 22

Percent of Pediatric TB Cases with Any Extrapulmonary Involvement* by Age Group and Selected Sites of Disease, 1993–2008
N=17,502

Site of Disease	Age < 1 (n=1,697)	Age 1–4 (n=8,616)	Age 5–9 (n=3,991)	Age 10–14 (n=3,198)
Lymphatic	7.8	19.3	22.2	19.4
Meningeal	7.6	3.6	1.5	1.8
Miliary	5.5	1.2	0.6	1.1
Bone & Joint	0.4	1.3	1.6	2.4
Other	3.5	2.7	4.2	8.4
Total	24.8	28.1	30.1	33.1

*Any extrapulmonary involvement includes extrapulmonary only and both
Note: Combine the total extrapulmonary percent shown with the pulmonary percent in slide #21 to obtain 100% for each age group.

Slide 23

Percent of TB Cases in Children Age < 1 Year With Any Extrapulmonary Involvement, 1993–2008
N=1,697

Site of Disease	U.S.-born	Foreign-born
Lymphatic	7.2%	16.0%
Meningeal	7.9%	3.1%
Miliary	5.6%	3.8%
Bone & Joint	0.4%	0.8%
Other	3.5%	2.3%
Total	24.6%	26.0%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 24

Percent of TB Cases in Children Age 1–4 Years With Any Extrapulmonary Involvement, 1993–2008
N=8,616

Site of Disease	U.S.-born	Foreign-born
Lymphatic	19.5%	18.7%
Meningeal	3.9%	2.0%
Miliary	1.3%	1.0%
Bone & Joint	1.1%	2.2%
Other	2.7%	2.0%
Total	28.5%	25.9%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 25

Percent of TB Cases in Children Age 5–9 Years With Any Extrapulmonary Involvement*, 1993–2008
N=3,991

Site of Disease	U.S.-born	Foreign-born
Lymphatic	23.2%	20.3%
Meningeal	1.8%	1.0%
Miliary	0.5%	0.6%
Bone & Joint	1.3%	2.2%
Other	4.4%	4.0%
Total	31.2%*	28.1%*

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 26

Percent of TB Cases in Children Age 10-14 Years With Any Extrapulmonary Involvement*, 1993–2008
N=3,198

Site of Disease	U.S.-born	Foreign-born
Lymphatic	20.4%	18.5%
Meningeal	1.8%	1.7%
Miliary	1.6%	0.7%
Bone & Joint	1.8%	2.9%
Other	9.3%	7.2%
Total	34.9%	31.0%

*Any extrapulmonary involvement includes extrapulmonary only and both

Slide 27

Pediatric TB Cases by HIV Status, 1993–2007*
N=16,716

• Information on HIV result is not available for the majority of pediatric TB cases (79.2%)
   
• Percent of pediatric TB cases with HIV-positive test results, minimum estimate** (0.9%)
   
• Percent of pediatric cases with HIV-positive test results of those patients with known results (4.5%)

*California HIV data through 2004 only; Vermont HIV data through 2006 only.
**Pediatric TB cases with positive HIV test results divided by all pediatric TB cases.
California only reports positive HIV test results based on TB and AIDS registry matching; all other California TB cases are classified as "Unknown."

Slide 28

Number and Percent of Culture-confirmed Pediatric TB Cases with Drug Resistance, 1993–2007

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007
Resistance to any 1st line drug	31.0	43.0	31.0	38.0	38.0	28.0	28.0	27.0	38.0	33.0	30.0	40.0	38.0	27.0	23.0
Percent with resistance to any 1st line drug	9.7	13.3	10.3	12.8	13.4	12.2	12.5	11.5	15.0	15.0	14.6	17.5	18.1	13.4	11.0
MDR TB	6.0	6.0	4.0	6.0	4.0	6.0	5.0	1.0	3.0	4.0	3.0	1.0	5.0	4.0	4.0
Percent with MDR TB	1.9	1.9	1.3	2.0	1.4	2.7	2.2	0.4	1.2	1.8	1.5	0.4	2.4	2.0	1.9

First line drugs are isoniazid, rifampin, pyrazinamide and ethambutol
MDR TB = resistance to at least isoniazid and rifampin

Slide 29

Pediatric TB Cases by Use of Directly Observed Therapy (DOT), 1993–2006
N=15,887*

	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006
DOT only	22.1	26.9	40.9	47.4	55.3	58.3	56.5	61.6	61.6	64.4	63.1	65.2	64.6	65.1
Self-Administered only	64.3	51.0	34.5	28.2	20.0	17.1	15.1	13.4	11.3	7.6	6.3	6.3	6.4	4.8
DOT and Self-Administered	12.1	19.1	22.3	22.1	22.5	23.4	26.0	24.0	25.3	26.1	29.3	25.8	28.1	30.2

*Pediatric TB cases with patient alive at diagnosis and started on treatment

Slide 30

Pediatric TB Cases by Treatment Outcome 1993–2006
N=15,887*

Outcome	Cases	%
Completed treatment	15,069	94.9
Moved	376	2.4
Lost to follow-up	143	0.9
Died	86	0.5
Other**	213	1.3

Note: Cause of death not recorded in TB case reports
*Pediatric TB cases with patient alive at diagnosis and started on treatment
**Other includes refused, other, unknown and missing


Slide 31

Deaths Occurring Among Pediatric TB Cases, by Age Group, 1993–2006
N=15,939

Age Group	Cases	Deaths**	% of Cases
Age<1	1,469	28	1.9
Age 1–4	7,882	52	0.7
Age 5–9	3,689	20	0.5
Age 10–14	2,899	23	0.8

Note: Cause of death not recorded in TB case reports
**Death includes died during therapy or dead at TB diagnosis