1 Epidemiology of Pediatric Tuberculosis in the United States, 1993–2006 Surveillance, Epidemiology, and Outbreak Investigations Branch Division of Tuberculosis Elimination Centers 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 attainable 2) 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 Year TB Cases

5 TB Case Rates, All Ages, by Age Group 1993–2006 Year TB Case Rate per 100,000 Note: Rates presented on a logarithmic scale

6 Percent of Pediatric TB Cases by Age Group 1993–2006 N=15,946

7 Pediatric TB Cases by Age Group 1993–2006 N=15,946 Year TB Cases

8 TB Case Rates by Pediatric Age Groups 1993–2006 N=15,946 Year TB Case Rate per 100,000 Note: Rates presented on a logarithmic scale

9 Pediatric TB Cases by Race/Ethnicity 1993–2006 N=15,946 Year Pediatric TB Cases

10 Pediatric TB Case Rates by Race/Ethnicity 1993–2006 N=15,946 TB Case Rate 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 Groups U.S.-born and Foreign-born, 1994–2006 N=14,285 Year TB Case Rate per 100,000 Note: Rates presented on a logarithmic scale. Data not available before USB = U.S.-born, FB=Foreign-born Foreign-born U.S.-born

12 Number and Percent Foreign-born Pediatric TB Cases, 1993–2006 Number of Pediatric TB Cases 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

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, Texas 1, New York 1, Florida Illinois Georgia All Others 6, StateNumberPercent*Rate** Pediatric TB Cases Overall U.S.15,

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 Rhode Island Minnesota Oklahoma Delaware Arizona All Others 14, StateNumberPercent*Rate** Pediatric TB Cases Overall U.S.15,

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 D.C. † California 4, Georgia Texas 1, Arkansas All Others 8, StateNumberPercent*Rate** Pediatric TB Cases Overall U.S.15,

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]

19 Pediatric TB Cases by Case Verification Criterion, 1993–2006 N=15,946 Laboratory Confirmed Clinical Case Provider Diagnosis

20 Pediatric TB Cases by Site of Disease, 1993–2006 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 both Patients may have more than one disease site but are counted in mutually exclusive categories for surveillance purposes.

21 Percent of Pediatric TB Cases by Site of Disease*, 1993–2006 N=15,946 PulmonaryExtrapulmonaryBoth

22 Percent of Pediatric TB Cases with Any Extrapulmonary Involvement* by Age Group and Selected Sites of Disease, 1993–2006 N=15,946 Lymphatic Meningeal Miliary Bone & Joint Other Site of Disease Age < 1 (n=1,471) Age 1-4 (n=7,884) Age 5-9 (n=3,691) Age (n=2,900) Total *Any extrapulmonary involvement includes extrapulmonary only and both Note: 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 Lymphatic7.2%17.7% Meningeal7.8%3.5% Miliary5.8%3.5% Bone & Joint0.3%0.9% Other3.4%1.8% Site of diseaseU.S.-bornForeign-born Total24.5%*27.4%* *Any extrapulmonary involvement includes extrapulmonary only and both

24 Percent of TB Cases in Children Age Years With Any Extrapulmonary Involvement, 1993–2006 N=7,884 Lymphatic19.4%19.0% Meningeal3.8%2.0% Miliary1.3%1.0% Bone & Joint1.1%2.0% Other2.7%2.0% Site of diseaseU.S.-bornForeign-born Total28.3%*26.0%* *Any Extrapulmonary involvement includes extrapulmonary only and both

25 Percent of TB Cases in Children Age Years With Any Extrapulmonary Involvement, 1993–2006 N=3,691 Lymphatic23.1%20.8% Meningeal1.4%1.0% Miliary0.6% Bone & Joint1.6%2.1% Other4.1%3.8% Site of diseaseU.S.-bornForeign-born Total30.8%*28.3%* *Any Extrapulmonary involvement includes extrapulmonary only and both

26 Percent of TB Cases in Children Age Years With Any Extrapulmonary Involvement, 1993–2006 N=2,900 Lymphatic20.4%18.1% Meningeal1.6%1.8% Miliary1.5%0.8% Bone & Joint2.0%2.8% Other9.0%7.3% Site of diseaseU.S.-bornForeign-born Total34.5%*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 Ethambutol MDR TB = resistance to at least Isoniazid and Rifampin

29 Pediatric TB Cases by Use of Directly Observed Therapy (DOT), 1993–2004 N=14,233* Year Percentage *Pediatric TB cases with patient alive at diagnosis and started on treatment

30 Pediatric TB Cases by Treatment Outcome 1993–2004 N=14,233* Completed treatment 13, Moved Lost to follow-up Died Other** 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 < Age Age Age Age Group Cases Deaths** % of Cases