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Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1999American Medical AssociationThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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In 1998, a total of 18,361 tuberculosis (TB) cases were reported from the 50 states and the District of Columbia, a decrease of 8% from 1997 and 31% from 1992, the height of the TB resurgence in the United States.1,2 The 1998 rate of 6.8 per 100,000 population was 35% lower than in 1992 (10.5) but remained above the national goal for 2000 of 3.5.3 This report summarizes national TB surveillance data for 1998 and compares them with similar data from previous years. The findings indicate that the overall number of TB cases continued to decrease, and that trends in the number of reported cases and TB incidence varied by geographic area and population characteristics.
All states reported at least one case in 1998, and 18 states reported <100 cases. Among the states reporting <100 cases in 1998, 17 reported <100 cases in 1992, and 14 had no change or a decrease in the number of reported cases in 1998 compared with 1992. Among all states, the proportion of counties reporting no TB cases increased from 42% in 1992 to 49% in 1998; these counties represented 11% of the total U.S. population in 1998. The 1998 TB rate in 19 states was lower than the 2000 national goal.3
California, Florida, Illinois, New York, and Texas reported the highest number of cases in 1998 and represented 54% of all reported TB cases. During 1992-1998, the five states observed a marked decrease in the number of new cases and together accounted for 68% of the overall decrease. The four cities with the highest number of TB cases were New York (1558), Los Angeles (544), Chicago (473), and Houston (424). The number of reported cases in all four cities decreased between 1992 and 1998: 59% in New York, 51% in Los Angeles, and 41% in Chicago and Houston, and together these cities accounted for 41% of the overall decline in the number of reported TB cases in the United States.
The number of reported TB cases in 1998 compared with 1992 decreased in both sexes and all age groups at varying rates. The largest decrease occurred among children aged <15 years and adults aged 25-44 years. During 1992-1998, the number of cases in U.S.-born persons decreased 44%, and the number of cases in foreign-born persons increased 4%. The proportion of TB cases among foreign-born persons steadily increased, from 27% in 1992 to 42% in 1998. The TB rate in foreign-born persons remained approximately four to six times higher than for U.S.-born persons. In 1998, among the 7591 TB cases in foreign-born persons, the birth countries with the highest number of cases were Mexico with 1757 (23%), Philippines with 968 (13%), and Vietnam with 748 (10%).
In 1993, CDC began to collect drug susceptibility results for initial Mycobacterium tuberculosis isolates on the TB case report. During 1998, results were reported for 91% (13,477 of 14,830 culture-positive cases). Overall, 1086 (8.1%) case-patients had isolates resistant to at least isoniazid, and 150 (1.1%) had isolates resistant to at least isoniazid and rifampin (i.e., multidrug-resistant TB [MDR-TB]); New York (38) and California (36) reported 49% of the MDR-TB cases. During 1993-1998, resistance to isoniazid decreased slightly (from 8.9% in 1993), and MDR-TB decreased markedly (from 2.8% in 1993). The decrease in MDR-TB reflected declines from 2.7% to 0.7% in U.S.-born persons and from 3.0% to 1.6% in foreign-born persons. As a result, the proportion of MDR-TB cases among foreign-born persons increased from 31% in 1993 to 61% in 1998. Forty-five states and the District of Columbia reported at least one MDR-TB case during 1993-1998.
In 1993, CDC began collecting information about human immunodeficiency virus (HIV) status on TB case reports; 48 states submit HIV test results on TB case reports. In 1998, 3509 (55%) of 6365 TB case reports for persons aged 25-44 years included information about HIV status, an increase from 1993 when 33% had HIV status. Among the states with information for ≥75% of the cases in this age group, the proportion of TB cases in HIV-infected persons ranged from 0% (Montana, North Dakota, Vermont, and Wyoming) to 47% (Florida).
Div of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention; and an EIS Officer, CDC.
The decline in the overall number of reported TB cases reflects the apparent strengthening of TB-control programs nationwide, particularly in states and cities with the largest number of cases. Supporting this inference are data indicating that the largest decreases in cases among U.S.-born persons during 1993-1994 occurred in areas that reported the largest increases in measures associated with effective TB control: completion of therapy, conversion of patients' sputum from positive to negative, and number of contacts per case-patient.4 These improvements occurred in the same cities that had the largest increases in cases during the TB resurgence.
The elimination of TB in the United States will depend increasingly on eliminating TB among persons born in countries with high TB rates.5 Because the percentage of reported TB cases among foreign-born persons continues to increase, CDC, in collaboration with local and state health departments, updated recommendations to prevent and control TB among foreign-born persons.5 Priority is placed on case-finding, completion of treatment for active TB, contact tracing, screening, and completion of preventive therapy for high-risk groups. Because rates of TB differ among countries, local TB-control staff should develop epidemiologic profiles to identify groups of foreign-born persons at high risk for TB.
Although the number and proportion of MDR-TB cases decreased markedly during 1993-1998, MDR-TB remains a serious concern. One MDR-TB case can challenge the resources and effectiveness of a TB program, and nearly every state has reported at least one MDR-TB case since 1993. Incidence of MDR-TB is increasing in eastern Europe, Asia, and Africa,6 and will continue to affect the clinical management and contact investigations of foreign-born TB patients who are at risk for resistant TB strains.
Incomplete reporting of HIV to the national TB surveillance system leads to underestimates of the incidence of HIV among TB cases. Incomplete reporting has made it necessary to estimate the proportion of TB cases in HIV-infected persons based on TB and acquired immunodeficiency syndrome registry matching.7-9 Using registry match data to supplement HIV test results submitted on the TB case report, minimum estimates of the proportion of TB cases with HIV infection ranged from 15% during 1993-1994 to 10% in 1997 for persons of all ages and from 29% to 21%, respectively, for persons aged 25-44 years (CDC, unpublished data, 1999). CDC and state and local health departments are collaborating to improve HIV testing and reporting for TB patients.
Although TB rates have been decreasing since 1992, the TB elimination goal of 3.5 cases per 100,000 by 2000 and <1 case per 1,000,000 population by 2010 are unlikely to be achieved at the current rate of decrease.3 The Advisory Council for the Elimination of TB (ACET), which provides advice and recommendations for eliminating TB to the U.S. Department of Health and Human Services and CDC, recently reassessed its 1989 plan and published updated recommendations for TB elimination in the United States.10 To move from TB control to TB elimination, ACET recommends new and improved diagnostic and treatment methods, and prevention efforts that include establishing broad-based partnerships with public health programs, community-based organizations, and managed-care plans. TB elimination in the United States requires global commitment. Dedication to the goal of TB elimination is critical to sustain the progress evidenced by declining TB morbidity in the United States.
Progress Toward the Elimination of Tuberculosis—United States, 1998. JAMA. 1999;282(12):1125–1126. doi:10.1001/jama.282.12.1125-JWR0922-3-1