Epidemiology of Pediatric Tuberculosis in the United States, 1993–2012

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











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

Documents

Epidemiology of Pediatric Tuberculosis in the United States, 1993–2012