surveillance, epidemiology, and outbreak investigations branch division of tuberculosis elimination...

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 Prevention

Division 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 definitions 3

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

4

Year

TB

Cas

es

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

5

Year

TB

Cas

e R

ate

per

100

,000

Note: Rates presented on a logarithmic scale

Percent of Pediatric TB Cases by Age Group,

1993–2010N=18,783

6

7

Year

TB

Cas

esPediatric TB Cases by Age Group,

1993–2010N=18,783

8

Year

TB

Cas

e R

ate

per

100

,000

Note: Rates presented on a logarithmic scale

Pediatric TB Case Rates by Age Groups,

1993–2010N=18,783

9

Year

Ped

iatr

ic T

B C

ases

Note: Unknown and multiple race/ethnicity not shown

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

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

10

TB

Cas

e R

ate

per

100

,000

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

11

Year

TB

Cas

e R

ate

per

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

12

Nu

mb

er o

f P

edia

tric

TB

Cas

es

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

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 3.3

Texas 2,277 7.2 2.5

New York 1,563 4.6 2.3

Florida 988 4.5 1.8

Illinois 843 6.3 1.8

Georgia 830 7.7 2.5

All 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 4.9

Rhode Island 89 10.8 2.5

Oklahoma 323 10.3 2.4

Minnesota 332 10.0 1.8

Delaware 57 9.3 2.0

Arizona 448 9.1 2.1

All 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 4.9

D.C.† 62 4.0 3.8

California 4,536 7.3 3.3

Texas 2,277 7.2 2.5

Georgia 830 7.7 2.5

Oklahoma 323 10.3 2.4

All 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]

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,

1993–2010

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.

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

Involvement*, 1993–2010N=9,215

Lymphatic 19.7% 18.5%

Meningeal 4.1% 2.0%

Miliary 1.3% 1.1%

Bone & Joint 1.1% 2.0%

Other 2.7% 2.0%

24

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

Total 28.9% 25.6%

*Any extrapulmonary involvement includes extrapulmonary only and both.

Percent of TB Cases in Children Age 5–9 Years With Any Extrapulmonary

Involvement*, 1993–2010N=4,270

Lymphatic 23.2% 19.8%

Meningeal 1.8% 1.1%

Miliary 0.5% 0.6%

Bone & Joint 1.3% 2.3%

Other 4.4% 4.2%

25

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

Total 31.2% 28.0%

*Any extrapulmonary involvement includes extrapulmonary only and both.

Percent of TB Cases in Children Age 10–14 Years With Any Extrapulmonary

Involvement*, 1993–2010N=3,436

Lymphatic 20.2% 18.7%

Meningeal 1.9% 1.8%

Miliary 1.7% 0.7%

Bone & Joint 2.1% 2.8%

Other 9.4% 7.5%

26

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

Total 35.3% 31.5%

*Any extrapulmonary involvement includes extrapulmonary only and both.

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

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

29

Year

Per

cen

tag

e

*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 95.2

Moved 397 2.3

Lost to follow-up 158 0.9

Died 95 0.5

Other** 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