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1
Epidemiology of Pediatric Tuberculosis
in the United States, 1993–2006
Surveillance, Epidemiology, and Outbreak Investigations Branch
Division of Tuberculosis EliminationCenters for Disease Control and Prevention (CDC)
2
Pediatric TB—Background
Definition of pediatric tuberculosis (TB):TB disease in a person <15 years old
In 2006, 13,779 TB cases were reported among
all age groups 807 (5.9%) were pediatric
3
TB Case Definition and Verification Incident case of disease Case verification categories:
1) Laboratory confirmed cases-”Gold Standard”- Positive culture, DNA probe, or nucleic
acid amplification test- Positive AFB smear when culture not
attainable2) 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
4
TB Cases, All Ages, by Age Group, 1993–2006
0
2000
4000
6000
8000
10000
12000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
<15 yrs 15-24 yrs 25-44 yrs 45-64 yrs 65+ yrs
Year
TB
Cas
es
5
TB Case Rates, All Ages, by Age Group1993–2006
1
10
100
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Overall US <15 yrs 15-24 yrs 25-44 yrs 45-64 yrs 65+ yrs
Year
TB
Cas
e R
ate
per
100
,000
Note: Rates presented on a logarithmic scale
6
Percent of Pediatric TB Cases by Age Group1993–2006N=15,946
Age 10-1418.2%
Age < 19.2%
Age 1-449.5%
Age 5-923.1%
7
Pediatric TB Cases by Age Group 1993–2006N=15,946
0
100
200
300
400
500
600
700
800
900
1000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
age < 1 Age 1-4 Age 5-9 Age 10-14
Year
TB
Cas
es
8TB Case Rates by Pediatric Age Groups 1993–2006N=15,946
0.1
1
10
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Age < 1 Age 1-4 Age 5-9 Age 10-14
Year
TB
Cas
e R
ate
per
100
,000
Note: Rates presented on a logarithmic scale
9
Pediatric TB Cases by Race/Ethnicity 1993–2006N=15,946
0
100
200
300
400
500
600
700
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
White, non-Hispanic Black, non-HispanicHispanic American Indian/Alaskan NativeAsian/Pacific Islander
Year
Ped
iatr
ic T
B C
ases
10
Pediatric TB Case Rates by Race/Ethnicity 1993–2006N=15,946
0.1
1
10
100
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
YearWhite, non-Hispanic Black, non-Hispanic
Hispanic Asian/Pacific Islander
TB
Cas
e R
ate
per
100
,000
Rates presented on a logarithmic scale. American Indian/Alaska Native rate not shown because of small denominators
11
TB Case Rates by Pediatric Age GroupsU.S.-born and Foreign-born, 1994–2006
N=14,285
0.1
1
10
100
1994 1996 1998 2000 2002 2004 2006
Age < 1, FB Age 1-4, FB Age 5-9, FB Age 10-14, FB
Age < 1, USB Age 1-4, USB Age 5-9, USB Age 10-14, USB
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
Foreign-born
U.S.-born
12
Number and Percent Foreign-born Pediatric TB Cases, 1993–2006
0
200
400
600
800
1000
1200
1400
1600
1800
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
0
10
20
30
40
50
60
70
80
90
100
Pe
rce
nt
of
Ped
iatr
ic T
B C
as
es
Foreign-born U.S.-born Percent foreign-born
Nu
mb
er o
f P
edia
tric
TB
Cas
es
Percent
13
Foreign-born Pediatric TB Cases by Birth Country* and 4-Year Interval, 1995–2006
N=3,231
Mexico (467) Mexico (375) Mexico (323)
Philippines (118) Somalia (79) Somalia (65)
Viet Nam (73) Philippines (67) Philippines (63)
Somalia (43) Haiti (38) Haiti (45)
Haiti (39) Viet Nam (36) Viet Nam (37)
Russia (38) Sudan (26) India (36)
Other (422) Other (417) Other (424)
1995–1998 (n) 1999–2002 (n) 2003–2006 (n)
*Ranked by counts
14
States with the Greatest Percent of the National Total Pediatric TB Cases, 1993–2006
N=15,946
4.4%
5.0%5.0%
8.8%
11.8%
25.2%
39.8%
California Texas New York Florida
Illinois Georgia All Others
15
States with Greatest Numbers of Pediatric TB Cases, 1993–2006
*Average percent of total state cases that are pediatric, for all years**Time-averaged annual rate per 100,000
California 4,025 7.7 3.7
Texas 1,874 7.3 2.7
New York 1,399 4.8 2.6
Florida 794 4.4 1.9
Illinois 791 6.9 2.1
Georgia 700 7.8 2.8
All Others 6,363 5.9 1.3
State Number Percent* Rate**
Pediatric TB Cases
Overall U.S. 15,946 6.3 1.9
16
States with Greatest Percent of Pediatric TB cases, 1993–2006
*Average percent of total state cases that are pediatric, for all years**Time-averaged rate per 100,000
Alaska 125 13.0 5.7
Rhode Island 72 10.4 2.6
Minnesota 253 9.8 1.7
Oklahoma 262 9.8 2.6
Delaware 52 9.7 2.4
Arizona 361 9.3 2.3
All Others 14,821 6.1 1.9
State Number Percent* Rate**
Pediatric TB Cases
Overall U.S. 15,946 6.3 1.9
17
States with Greatest Rate of Pediatric TB Cases, 1993–2006
*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
Alaska 125 13.0 5.7
D.C.† 54 4.0 4.0
California 4,025 7.7 3.7
Georgia 700 7.8 2.8
Texas 1,874 7.3 2.7
Arkansas 204 8.2 2.6
All Others 8,964 5.5 1.5
State Number Percent* Rate**Pediatric TB Cases
Overall U.S. 15,946 6.3 1.9
18
Pediatric TB Cases by Case Verification Criterion*, 1993–2006
N=15,946
Provider Diagnosis 24%
Clinical Case Definition 51%
Laboratory confirmed 25%
*Based on the public health surveillance definition for TB [MMWR 1997:46(No. RR-10):40-41]
19Pediatric TB Cases by Case Verification Criterion, 1993–2006
N=15,946Age < 1 n=1,471
23%
52%
25%
Age 1-4 n=7,884
54%
26%20%
Age 5-9 n=3,691
15%
59%
26%
Age 10-14 n=2,900
46%
18%36%
Laboratory Confirmed
Clinical Case
Provider Diagnosis
20
Pediatric TB Cases by Site of Disease, 1993–2006
Extrapulmonary
21.9%
Both7.0%
Pulmonary71.1%
Any extrapulmonary involvement*
(totaling 28.9%)
Lymphatic 18.9%
Meningeal 3.1%
Miliary 1.5%
Bone & Joint 1.5%
Other 3.9%
*Any extrapulmonary involvement which includes cases that are extrapulmonary only and bothPatients may have more than one disease site but are counted in mutually exclusive categories for surveillance purposes.
21Percent of Pediatric TB Cases by
Site of Disease*, 1993–2006N=15,946
Age < 1 n=1,471
10.1%
75.2%
14.7%
Age 1-4 n=7,884
20.7%
7.2%
72.1%
Age 5-9 n=3,691
70.1%
25.5%
4.4%
Age 10-14 n=2,900
27.0%
5.9%
67.1%
Pulmonary Extrapulmonary Both
22Percent of Pediatric TB Cases with Any Extrapulmonary Involvement* by Age Group
and Selected Sites of Disease, 1993–2006N=15,946
Lymphatic 8.0 19.3 22.3 19.2
Meningeal 7.5 3.5 1.4 1.8
Miliary 5.6 1.2 0.6 1.2
Bone & Joint 0.3 1.3 1.7 2.4
Other 3.4 2.6 3.9 8.3
Site of Disease
Age < 1(n=1,471)
Age 1-4(n=7,884)
Age 5-9(n=3,691)
Age 10-14 (n=2,900)
Total 24.8 27.9 29.9 32.9
*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.
23
Percent of TB Cases in Children Age < 1 Year With Any Extrapulmonary Involvement, 1993–2006
N=1,471
Lymphatic 7.2% 17.7%
Meningeal 7.8% 3.5%
Miliary 5.8% 3.5%
Bone & Joint 0.3% 0.9%
Other 3.4% 1.8%
Site of disease U.S.-born Foreign-born
Total 24.5%* 27.4%*
*Any extrapulmonary involvement includes extrapulmonary only and both
24
Percent of TB Cases in Children Age 1 - 4 Years With Any Extrapulmonary Involvement, 1993–2006
N=7,884
Lymphatic 19.4% 19.0%
Meningeal 3.8% 2.0%
Miliary 1.3% 1.0%
Bone & Joint 1.1% 2.0%
Other 2.7% 2.0%
Site of disease U.S.-born Foreign-born
Total 28.3%* 26.0%*
*Any Extrapulmonary involvement includes extrapulmonary only and both
25
Percent of TB Cases in Children Age 5 - 9 Years With Any Extrapulmonary Involvement, 1993–2006
N=3,691
Lymphatic 23.1% 20.8%
Meningeal 1.4% 1.0%
Miliary 0.6% 0.6%
Bone & Joint 1.6% 2.1%
Other 4.1% 3.8%
Site of disease U.S.-born Foreign-born
Total 30.8%* 28.3%*
*Any Extrapulmonary involvement includes extrapulmonary only and both
26
Percent of TB Cases in Children Age 10-14 Years With Any Extrapulmonary Involvement, 1993–2006
N=2,900
Lymphatic 20.4% 18.1%
Meningeal 1.6% 1.8%
Miliary 1.5% 0.8%
Bone & Joint 2.0% 2.8%
Other 9.0% 7.3%
Site of disease U.S.-born Foreign-born
Total 34.5%* 30.8%*
*Any Extrapulmonary involvement includes extrapulmonary only and both
27
Pediatric TB Cases by HIV Status, 1993–2005*N=14,990
Information on HIV result is not available for the majority of pediatric TB cases (80.7%)
Percent of pediatric TB cases with HIV-positive test results, minimum estimate** (1.0%)
Percent of pediatric cases with HIV-positive test results of those patients with known results (5.1%)
*California HIV data through 2004 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.”
28
Number and Percent of Culture-confirmed Pediatric TB Cases with Drug Resistance,
1993–2005
First line drugs are Isoniazid, Rifampin, Pyrazinamide and EthambutolMDR TB = resistance to at least Isoniazid and Rifampin
0
10
20
30
40
50
1993 1994 19951996 19971998 1999 20002001 20022003 2004 2005
Year
Nu
mb
er
of
ca
se
s t
ha
ta
re d
rug
re
sis
tan
t
0
5
10
15
20
Pe
rce
nt
of
ca
se
s t
ha
t a
re d
rug
re
sis
tan
t
Resistance to any 1st line drug MDR TB
Percent with resistance to any 1st line drug Percent with MDR TB
29
Pediatric TB Cases by Use of Directly Observed Therapy (DOT), 1993–2004
N=14,233*
0
20
40
60
80
100
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
DOT only Self-Administered only DOT and Self-Administered
Year
Per
cen
tag
e
*Pediatric TB cases with patient alive at diagnosis and started on treatment
30
Pediatric TB Cases by Treatment Outcome 1993–2004N=14,233*
Completed treatment 13,459 94.6
Moved 352 2.5
Lost to follow-up 138 1.0
Died 78 0.6
Other** 206 1.3
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
31
Deaths Occurring Among Pediatric TB Cases, by Age Group, 1993–2004
N=14,282
Note: Cause of death not recorded in TB case reports**Death includes died during therapy or dead at TB diagnosis
Age < 1 1298 26 2.0
Age 1-4 7094 46 0.6
Age 5-9 3334 20 0.6
Age 10-14 2556 20 0.8
Age Group Cases Deaths** % of Cases