epidemiology of pediatric tuberculosis in the united states, 1993–2012
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Epidemiology of Pediatric Tuberculosis in the United States, 1993–2012. Surveillance, Epidemiology, and Outbreak Investigations Branch Division of Tuberculosis Elimination Centers for Disease Control and Prevention (CDC). - PowerPoint PPT PresentationTRANSCRIPT
Surveillance, Epidemiology, and Outbreak Investigations Branch
Division of Tuberculosis EliminationCenters for Disease Control and Prevention (CDC)
Epidemiology of Pediatric Tuberculosis
in the United States, 1993–2012
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionDivision of Tuberculosis Elimination
Pediatric TB—Background
• Definition of pediatric tuberculosis (TB):TB disease in a person < 15 years old
• In 2012:• 9,945 TB cases were reported among all age
groups – 486 (4.9%) were pediatric
Age Group N Percent out of all age groups
0 – 4 years 260 2.6%5 – 14 years 226 2.3%
2009 TB Case Definition and Verification• Incident case of disease
• Case verification categories:
1) Laboratory confirmed cases– Positive culture or nucleic acid amplification
test– Positive AFB smear when culture not
attainable
2) Clinical case definition– Positive tuberculin skin test or positive
interferon gamma release assay– Signs and symptoms of TB disease– Current treatment for TB disease– Completed diagnostic evaluation
3) Provider diagnosis– Diagnosed by health care provider– Does not fulfill all criteria necessary to meet
laboratory or clinical case definitions
TB Cases, All Ages, by Age Group, 1993–2012
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
0
2,000
4,000
6,000
8,000
10,000
12,000
< 15 yrs 15–24 yrs 25–44 yrs 45–64 yrs 65+ yrs
Year
TB C
ases
TB Case Rates, All Ages, by Age Group,1993–2012
19931994
19951996
19971998
19992000
20012002
20032004
20052006
20072008
20092010
20112012
0.1
1
10
100
Overall US < 15 yrs 15–24 yrs 25–44 yrs 45–64 yrs 65+ yrs
Year
TB C
ase
Rat
e pe
r 100
,000
Note: Rates presented on a logarithmic scale
Percent of Pediatric TB Cases by Age Group,
1993–2012
Age < 1(10.0%)
Age 1– 4(48.9%)
Age 5 – 9(22.5%)
Age 10 – 14(18.6%)
N=19,840
19931995
19971999
20012003
20052007
20092011
0
100
200
300
400
500
600
700
800
900
1,000
Age < 1 Age 1–4 Age 5–9 Age 10–14
Year
TB C
ases
Pediatric TB Cases by Age Group, 1993–2012N=19,840
19931994
19951996
19971998
19992000
20012002
20032004
20052006
20072008
20092010
20112012
0.1
1
10
Age < 1 Age 1–4 Age 5–9 Age 10–14Year
TB C
ase
Rat
e pe
r 100
,000
Note: Rates presented on a logarithmic scale
Pediatric TB Case Rates by Age Groups,
1993–2012N=19,840
19931994
19951996
19971998
19992000
20012002
20032004
20052006
20072008
20092010
20112012
0
100
200
300
400
500
600
700
White, non-Hispanic Black, non-Hispanic Hispanic American Indian/Alaskan Native
Asian
Year
Note: Unknown, multiple race/ethnicity, and Native Hawaiian and Other Pacific Islander not shown
Pediatric TB Cases by Race/Ethnicity, 1993–2012N=19,840
19931994
19951996
19971998
19992000
20012002
20032004
20052006
20072008
20092010
20112012
0.1
1
10
100
White, non-Hispanic Black, non-Hispanic Hispanic Asian
Year
Pediatric TB Case Rates by Race/Ethnicity, 1993–2012N=19,840
TB C
ase
Rat
e pe
r 100
,000
Note: Rates presented on a logarithmic scale. American Indian/Alaska Native and Native Hawaiian and Other Pacific Islander rate not shown because of small denominators
19941995
19961997
19981999
20002001
20022003
20042005
20062007
20082009
20102011
20120.1
1
10
100
1000
Age < 1 Age 1–4 Age 5–9 Age 10–14
Year
TB C
ase
Rat
e pe
r 100
,000
Note: Rates presented on a logarithmic scale. Data not available before 1994.
Pediatric TB Case Rates by Age GroupsU.S.-born, 1994–2012
N=14,780
19941995
19961997
19981999
20002001
20022003
20042005
20062007
20082009
20102011
20120.1
1
10
100
1000
Age < 1 Age 1–4 Age 5–9 Age 10–14Year
TB C
ase
Rat
e pe
r 100
,000
Note: Rates presented on a logarithmic scale. Data not available before 1994.
Pediatric TB Case Rates by Age GroupsForeign-born, 1994–2012
N=4,986
Number and Percent of Pediatric TB Cases by U.S. and Foreign Birth,
1993–2012
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
0
10
20
30
40
50
60
70
80
90
100
Foreign-born U.S.-born Percent foreign-born
Year
Perc
ent o
f Ped
iatr
ic T
B C
ases
Num
ber o
f Ped
iatr
ic T
B C
ases
(%)
Number of Pediatric TB Cases with Foreign Birth by Birth Country*, by 6-
Year Intervals, 1995–2012N=4,187
* Ranked by counts
1995–2000 2001–2006 2007–2012
Country (n) Country (n) Country (n)
Mexico (651) Mexico (515) Mexico (159)Philippines (154) Somalia (109) Ethiopia (86)Vietnam (94) Philippines (94) Philippines (78)Somalia (78) Haiti (70) Haiti (53)Russia (54) Vietnam (52) Somalia (53)Haiti (52) India (48) Myanmar (53)
Other (639) Other (621) Other (474)
California23.9%
Texas12.4%
New York8.2%Florida
5.3%Georgia
4.4%
Illinois4.4%
All others41.3%
States with the Greatest Percent of the U.S. Total Pediatric TB Cases, 1993–
2012N=19,840
States with Greatest Numbers of Pediatric TB Cases, 1993–2012
Pediatric TB CasesState Number Percent* Rate**California 4,751 7.1 3.1Texas 2,453 7.2 2.4New York 1,617 4.6 2.2Florida 1,060 4.6 1.7Georgia 879 7.7 2.4Illinois 877 6.3 1.7All others 8,203 5.9 1.2Overall U.S. 19,840 6.2 1.7
*Average percent of total state cases that are pediatric, for all years**Time-averaged annual rate per 100,000
States with Greatest Percent of Pediatric TB Cases, 1993–2012
*Average percent of total state cases that are pediatric, for all years**Time-averaged rate per 100,000
Pediatric TB CasesState Number Percent* Rate**Alaska 153 11.9 4.9Rhode Island 93 10.7 2.4Oklahoma 347 10.5 2.3Minnesota 365 10.1 1.7South Dakota 32 9.1 1.0Colorado 177 9.0 1.0All others 18,673 6.0 1.7Overall U.S. 19,840 6.2 1.7
States with Greatest Rate of Pediatric TB Cases, 1993–2012
Pediatric TB CasesState Number Percent* Rate**Alaska 153 11.9 4.9D.C.† 66 4.0 3.6California 4,751 7.1 3.1Texas 2,453 7.2 2.4Rhode Island 93 10.7 2.4Georgia 879 7.7 2.4All others 11,445 5.5 1.2Overall U.S. 19,840 6.2 1.7
*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
Pediatric TB Cases by Case Verification Criterion*, 1993–
2012N=19,840
ProviderDiagnosis
23%
Clinical Case 51%
Laboratory Confirmed
26%
*Based on the public health surveillance definition for TB [MMWR 1997:46(No. RR-10):40-41]
51%26%
23%
Age < 1 n=1,992
20%
54%
25%
Age 1–4 n=9,692
16%
60%
24%
Age 5–9 n=4,474
37%
46%
16%
Age 10–14 n=3,682
Laboratory Confirmed
Clinical Case
Provider Diagnosis
Pediatric TB Cases by Case Verification Criterion by Age Group,
1993–2012N=19,840
Pediatric TB Cases by Site of Disease,
1993–2012Both7.2%
Extra-pulmonary
22.2%
Pulmonary70.6%
*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 categoriesfor surveillance purposes.
Any extrapulmonary involvement* (totaling
29.4%)Extrapulmonary site
(%)
Lymphatic 18.8%Meningeal 3.4%Miliary 1.4%Bone & Joint 1.5%Other 4.3%
75.3%
10.4%
14.3%
Age < 1 n=1,992
71.8%
20.9%
7.3%
Age 1–4 n=9,692
69.6%
25.6%
4.7%
Age 5–9 n=4,474
66.1%
27.8%
6.0%
Age 10–14 n=3,682
Pulmonary Extrapulmonary Both
Pediatric TB Cases by Site of Disease by Age Group, 1993–2012
N=19,840
Pediatric TB Cases with Any Extrapulmonary Involvement* by Age Group and Selected Sites of Disease,
1993–2012N=19,840
Site of Disease
Age <1(n =
1,992)Age 1–4(n=9,69
2)Age 5–9(n=4,47
4)
Age 10–14
(n=3,682)
Lymphatic 7.9% 19.4% 22.0% 19.5%Meningeal 8.2% 3.8% 1.6% 2.0%Miliary 4.7% 1.1% 0.5% 1.2%Bone & Joint 0.4% 1.3% 1.7% 2.4%Other 3.5% 2.6% 4.5% 8.7%Total 24.7% 28.2% 30.3% 33.8%
* “Any extrapulmonary involvement” includes: 1.) extrapulmonary only, and 2.) both extrapulmonary and pulmonary.Note: Combine the total extrapulmonary percent shown with the pulmonary percent in slide #21 to obtain 100% for each age group.
Percent of TB Cases in Children Age < 1 Year With Any Extrapulmonary
Involvement*, 1993–2012N=1,992
Site of disease U.S.-born Foreign-born
Lymphatic 7.2% 17.7%Meningeal 8.6% 2.8%Miliary 4.9% 3.6%Bone & Joint 0.3% 0.7%Other 3.4% 3.6%Total 24.4% 28.4%
* “Any extrapulmonary involvement” includes: 1.) extrapulmonary only, and 2.) both extrapulmonary and pulmonary.
Percent of TB Cases in Children Age 1–4 Years With Any Extrapulmonary
Involvement*, 1993–2012N=9,692Site of disease U.S.-born Foreign-born
Lymphatic 19.5% 18.6%Meningeal 4.2% 2.0%Miliary 1.2% 0.9%Bone & Joint 1.1% 2.2%Other 2.7% 2.0%Total 28.7% 25.7%
* “Any extrapulmonary involvement” includes: 1.) extrapulmonary only, and 2.) both extrapulmonary and pulmonary.
Percent of TB Cases in Children Age 5–9 Years With Any Extrapulmonary
Involvement*, 1993–2012N=4,474Site of disease U.S.-born Foreign-born
Lymphatic 23.3% 19.7%Meningeal 2.0% 1.0%Miliary 0.5% 0.6%Bone & Joint 1.3% 2.4%Other 4.6% 4.3%Total 31.7% 28.0%
* “Any extrapulmonary involvement” includes: 1.) extrapulmonary only, and 2.) both extrapulmonary and pulmonary.
Percent of TB Cases in Children Age 10–14 Years With Any Extrapulmonary
Involvement*, 1993–2012N=3,682Site of disease U.S.-born Foreign-born
Lymphatic 20.3% 18.7%Meningeal 2.0% 2.0%Miliary 1.5% 0.7%Bone & Joint 2.1% 2.7%Other 9.8% 7.4%Total 35.7% 31.5%
* “Any extrapulmonary involvement” includes: 1.) extrapulmonary only, and 2.) both extrapulmonary and pulmonary.
Pediatric TB Cases by HIV Status, 1993–2011*
N=19,354Information on HIV results are not
available for the majority of pediatric TB cases (75.9%)
*California HIV data missing from 2005 - 2010; Vermont HIV data through 2006 only.**Pediatric TB cases with positive HIV test results divided by all pediatric TB cases. Note: Through 2004, California only reported positive HIV test results based on TB and AIDS registry matching; all other California TB cases were classified as “Unknown.”
Pediatric TB cases with HIV-positive test results, minimum estimate** 0.9%
Pediatric cases with HIV-positive test results of those patients with known results
3.7%
Number and Percent of Culture-Confirmed Pediatric TB Cases with
Drug Resistance, 1993–2011
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
05
101520253035404550
0
5
10
15
20
25
Resistance to any 1st line drug MDR TB Percent with resistance to any 1st line drugPercent with MDR TB
Year
Num
ber o
f cas
es th
atar
e dr
ug re
sist
ant
Perc
ent o
f cas
es th
at
are
drug
resi
stan
t
First line drugs are isoniazid, rifampin, pyrazinamide and ethambutolMDR TB = resistance to at least isoniazid and rifampin
19931994
19951996
19971998
19992000
20012002
20032004
20052006
20072008
20092010
0
20
40
60
80
100
DOT only Self-Administered only DOT and Self-Administered
Year
Perc
enta
ge
*Pediatric TB cases with patient alive at diagnosis and started on treatment
Pediatric TB Cases by Use of Directly Observed Therapy (DOT), 1993–
2010N=18,719*
Pediatric TB Cases by Treatment Outcome
1993–2010N=18,719*
Outcome Cases %Completed treatment 17,858 95.4
Moved 397 2.1Lost to follow-up 160 0.9Died 102 0.5
Other** 202 1.1Note: Cause of death not recorded in TB case reports until 2009; “Moved” no longer a valid response *Pediatric TB cases with patient alive at diagnosis and started on treatment**Other includes refused, other, unknown, and missing
Deaths Occurring Among Pediatric TB Cases, by Age Group, 1993–2010
N=18,777
Age Group Cases Deaths* % of
Cases Age < 1 1,862 34 1.8
Age 1–4 9,211 61 0.7
Age 5–9 4,269 27 0.6 Age 10–14 3,435 24 0.7
Note: Cause of death not recorded in TB case reports*Death includes died during therapy or dead at TB diagnosis