epidemiology of pediatric tuberculosis in the united states, 1993–2010

Surveillance, Epidemiology, and Outbreak Investigations Branch

Division of Tuberculosis EliminationCenters for Disease Control and Prevention (CDC)

Epidemiology of Pediatric Tuberculosis

in the United States, 1993–2010

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 2010:• 11,182 TB cases were reported among all age

groups – 637 (5.7%) were pediatric

» 365 (3.3%) in ages 0 – 4» 272 (2.4%) in ages 5 – 14

2

2009 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 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 definitions3

TB Cases, All Ages, by Age Group, 1993–2010

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

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 4

Year

TB C

ases

TB Case Rates, All Ages, by Age Group,1993–2010

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20101

10

100

Overall US < 15 yrs 15–24 yrs 25–44 yrs 45–64 yrs 65+ yrs

5

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,

1993–2010N=18,783Age < 1

9.9%

Age 1–449.1%

Age 5–922.7%

Age 10–1418.3%

6

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

100

200

300

400

500

600

700

800

900

1,000

Age < 1 Age 1–4 Age 5–9 Age 10–14 7

Year

TB C

ases

Pediatric TB Cases by Age Group, 1993–2010N=18,783

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100.1

1

10

Age < 1 Age 1–4 Age 5–9 Age 10–148

Year

TB C

ase

Rat

e pe

r 100

,000

Note: Rates presented on a logarithmic scale

Pediatric TB Case Rates by Age Groups,

1993–2010N=18,783

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

100

200

300

400

500

600

700

White, non-Hispanic Black, non-Hispanic Hispanic

American Indian/Alaskan Native Asian/Pacific Islander

9

Year

Pedi

atric

TB

Cas

es

Note: Unknown and multiple race/ethnicity not shown

Pediatric TB Cases by Race/Ethnicity, 1993–2010N=18,783

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100.1

1

10

100

White, non-Hispanic Black, non-Hispanic HispanicAsian/Pacific Islander

Year

Pediatric TB Case Rates by Race/Ethnicity, 1993–2010N=18,783

10

TB C

ase

Rat

e pe

r 100

,000

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

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100.1

1

10

100

Age < 1, FB Age 1–4, FB Age 5–9, FB Age 10–14, FBAge < 1, USB Age 1–4, USB Age 5–9, USB Age 10–14, USB

11

Year

TB C

ase

Rat

e pe

r 100

,000

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)

Foreign-born

U.S.-born

Pediatric TB Case Rates by Age GroupsU.S.-born and Foreign-born, 1994–2010,

N=17,054

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

1993–2010

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

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

12

Num

ber o

f Ped

iatr

ic T

B C

ases

Percent

Number of Pediatric TB Cases with Foreign Birth by Birth Country*, by 4-

Year Intervals, 1997–2010N=2,725

Mexico (375) Mexico (324) Mexico (125)Somalia (79) Somalia (65) Ethiopia (68)Philippines (67) Philippines (63) Philippines (57)Haiti (38) Haiti (45) Haiti (42)Vietnam (36) India (36) Somalia (39)Sudan (26) Vietnam (36) Myanmar (36)Other (417) Other (424) Other (327)

13

1999–2002 (n) 2003–2006 (n) 2007–2010 (n)

*Ranked by counts

24.2%

12.1%

8.3%

5.3%4.5%4.4%

41.2%

California Texas New York Florida Illinois Georgia All others 14

States with the Greatest Percent of the U.S. Total Pediatric TB Cases, 1993–

2010N=18,783

States with Greatest Numbers of Pediatric TB Cases, 1993–2010

California 4,536 7.3 3.3Texas 2,277 7.2 2.5New York 1,563 4.6 2.3Florida 988 4.5 1.8

Illinois 843 6.3 1.8Georgia 830 7.7 2.5All others 7,746 6.0 1.2

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

State Number Percent* Rate**

Pediatric TB Cases

Overall U.S. 18,783 6.2 1.8

States with Greatest Percent of Pediatric TB Cases, 1993–2010

Alaska 138 11.9 4.9Rhode Island 89 10.8 2.5Oklahoma 323 10.3 2.4Minnesota 332 10.0 1.8Delaware 57 9.3 2.0Arizona 448 9.1 2.1All others 17,396 6.0 1.7

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

State Number Percent* Rate**

Pediatric TB Cases

Overall U.S. 18,783 6.2 1.8

States with Greatest Rate of Pediatric TB Cases, 1993–2010

Alaska 138 11.9 4.9D.C.† 62 4.0 3.8California 4,536 7.3 3.3Texas 2,277 7.2 2.5Georgia 830 7.7 2.5Oklahoma 323 10.3 2.4All others 10,617 5.5 1.3

17

*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

State Number Percent* Rate**Pediatric TB Cases

Overall U.S. 18,783 6.2 1.8

Pediatric TB Cases by Case Verification Criterion*, 1993–

2010N=18,783

18

ProviderDiagnosis

24%

Clinical Case 51%

Laboratory Confirmed

25%

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

51%25%

24%

Age < 1 n=1,862

20%

53%

27%

Age 1–4 n=9,215

15%

60%

25%

Age 5–9 n=4,270

37%

46%

17%

Age 10–14 n=3,436

19Laboratory Confirmed

Clinical Case

Provider Diagnosis

Pediatric TB Cases by Case Verification Criterion by Age Group,

1993–2010N=18,783

Pediatric TB Cases by Site of Disease,

1993–2010Both7.1%

Extra-pulmonary

22.2%

Pulmonary70.7%

20

Any extrapulmonary involvement* (totaling 29.3%) Lymphatic 18.9% Meningeal 3.3% Miliary 1.5% Bone & Joint 1.4% Other 4.2%

*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.

75.0%

10.5%

14.5%

Age < 1 n=1,862

71.7%

20.9%

7.4%

Age 1–4 n=9,215

69.9%

25.5%

4.6%

Age 5–9 n=4,270

66.4%

27.6%

6.0%

Age 10–14 n=3,436

21Pulmonary Extrapulmonary Both

Pediatric TB Cases by Site of Disease by Age Group, 1993–2010

N=18,783

Pediatric TB Cases with Any Extrapulmonary Involvement* by Age Group and Selected Sites of Disease,

1993–2010N=18,783

Lymphatic 8.0% 19.4% 22.0% 19.5%Meningeal 8.0% 3.7% 1.6% 1.8%

Miliary 5.3% 1.3% 0.5% 1.2%

Bone & Joint 0.4% 1.3% 1.6% 2.4%

Other 3.3% 2.6% 4.3% 8.6%

22

Site of Disease Age < 1(n=1,862)

Age 1–4(n=9,215)

Age 5–9(n=4,270)

Age 10–14 (n=3,436)

Total 25.0% 28.3%*Any extrapulmonary involvement includes extrapulmonary only and bothNote: Combine the total extrapulmonary percent shown with the pulmonary percent in slide #21 to obtain 100% for each age group.

30.0% 33.5%

Percent of TB Cases in Children Age < 1 Year With Any Extrapulmonary

Involvement*, 1993–2010N=1,862

Lymphatic 7.3% 17.2%

Meningeal 8.4% 3.0%

Miliary 5.5% 3.7%

Bone & Joint 0.3% 0.8%

Other 3.3% 2.2%

23

Site of disease U.S.-born Foreign-born

Total 24.9% 26.9%

*Any extrapulmonary involvement includes extrapulmonary only and both.

Percent of TB Cases in Children Age 1–4 Years With Any Extrapulmonary



Meningeal 4.1% 2.0%

Miliary 1.3% 1.1%


Other 2.7% 2.0%

24


Total 28.9% 25.6%





Meningeal 1.8% 1.1%

Miliary 0.5% 0.6%


Other 4.4% 4.2%

25


Total 31.2% 28.0%





Meningeal 1.9% 1.8%

Miliary 1.7% 0.7%


Other 9.4% 7.5%

26


Total 35.3% 31.5%


Pediatric TB Cases by HIV Status, 1993–2009*

N=18,146• Information on HIV result is not available

for the majority of pediatric TB cases (77.6%)

• 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 (4.2%)

27

*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.”

Number and Percent of Culture-Confirmed Pediatric TB Cases with

Drug Resistance, 1993–2009

1993 1995 1997 1999 2001 2003 2005 2007 200905

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

28First line drugs are isoniazid, rifampin, pyrazinamide and ethambutolMDR TB = resistance to at least isoniazid and rifampin

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080

20

40

60

80

100

DOT only Self-Administered only DOT and Self-Administered

29

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–

2008N=17,445*

Pediatric TB Cases by Treatment Outcome

1993–2008N=17,445*

Completed treatment 16,601 95.2Moved 397 2.3Lost to follow-up 158 0.9Died 95 0.5Other** 194 1.1

30

Outcome %

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

Cases

Deaths Occurring Among Pediatric TB Cases, by Age Group, 1993–2008

N=17,499

Age < 1 1,691 32 1.9

Age 1–4 8,618 58 0.7

Age 5–9 3,991 22 0.6

Age 10–14 3,199 24 0.8

31

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

Age Group Cases Deaths* % of Cases

epidemiology of pediatric tuberculosis in the united states, 1993–2010

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