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