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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