Surveillance, Epidemiology, and Outbreak Investigations Branch Division of Tuberculosis Elimination Centers 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:  Laboratory confirmed cases (Gold Standard): –Positive culture or nucleic acid amplification test –Positive AFB smear when culture not attainable  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  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– Year TB Cases

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

Percent of Pediatric TB Cases by Age Group, 1993–2010 N=18,783 6

7 Year TB Cases Pediatric TB Cases by Age Group, 1993–2010 N=18,783

8 Year TB Case Rate per 100,000 Note: Rates presented on a logarithmic scale Pediatric TB Case Rates by Age Groups, 1993–2010 N=18,783

9 Year Pediatric TB Cases Note: Unknown and multiple race/ethnicity not shown Pediatric TB Cases by Race/Ethnicity, 1993–2010 N=18,783

Pediatric TB Case Rates by Race/Ethnicity, 1993–2010 N=18, TB Case Rate per 100,000 Note: Rates presented on a logarithmic scale. American Indian/Alaska Native rate not shown because of small denominators

11 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 (unknown excluded from table and counts) Foreign-born U.S.-born Pediatric TB Case Rates by Age Groups U.S.-born and Foreign-born, 1994–2010, N=17,054

Number and Percent of Pediatric TB Cases by U.S. and Foreign Birth, 1993– Number of Pediatric TB Cases Percent

Number of Pediatric TB Cases with Foreign Birth by Birth Country*, by 4-Year Intervals, 1997–2010 N=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) –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, 1993–2010 N=18,783

States with Greatest Numbers of Pediatric TB Cases, 1993–2010 California 4, Texas 2, New York 1, Florida Illinois Georgia All others 7, *Average percent of total state cases that are pediatric, for all years **Time-averaged annual rate per 100,000 State NumberPercent*Rate** Pediatric TB Cases Overall U.S.18,

States with Greatest Percent of Pediatric TB Cases, 1993–2010 Alaska Rhode Island Oklahoma Minnesota Delaware Arizona All others 17, *Average percent of total state cases that are pediatric, for all years **Time-averaged rate per 100,000 StateNumberPercent*Rate** Pediatric TB Cases Overall U.S. 18,

States with Greatest Rate of Pediatric TB Cases, 1993–2010 Alaska D.C. † California 4, Texas 2, Georgia Oklahoma All others 10, *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 StateNumberPercent*Rate** Pediatric TB Cases Overall U.S.18,

Pediatric TB Cases by Case Verification Criterion*, 1993–2010 N=18, Provider Diagnosis 24% Clinical Case 51% Laboratory Confirmed 25% *Based on the public health surveillance definition for TB [MMWR 1997:46(No. RR-10):40-41]

19 Laboratory Confirmed Clinical Case Provider Diagnosis Pediatric TB Cases by Case Verification Criterion by Age Group, 1993–2010 N=18,783

Pediatric TB Cases by Site of Disease, 1993– 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 categories for surveillance purposes.

21 PulmonaryExtrapulmonaryBoth 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, 1993–2010 N=18,783 Lymphatic8.0%19.4%22.0%19.5% Meningeal8.0%3.7%1.6%1.8% Miliary5.3%1.3%0.5%1.2% Bone & Joint0.4%1.3%1.6%2.4% Other3.3%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) Total25.0% 28.3% *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. 30.0%33.5%

Percent of TB Cases in Children Age < 1 Year With Any Extrapulmonary Involvement*, 1993–2010 N=1,862 Lymphatic7.3%17.2% Meningeal8.4%3.0% Miliary5.5%3.7% Bone & Joint0.3%0.8% Other3.3%2.2% 23 Site of diseaseU.S.-bornForeign-born Total24.9%26.9% *Any extrapulmonary involvement includes extrapulmonary only and both.

Percent of TB Cases in Children Age 1–4 Years With Any Extrapulmonary Involvement*, 1993–2010 N=9,215 Lymphatic19.7%18.5% Meningeal4.1%2.0% Miliary1.3%1.1% Bone & Joint1.1%2.0% Other2.7%2.0% 24 Site of diseaseU.S.-bornForeign-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*, 1993–2010 N=4,270 Lymphatic23.2%19.8% Meningeal1.8%1.1% Miliary0.5%0.6% Bone & Joint1.3%2.3% Other4.4%4.2% 25 Site of diseaseU.S.-bornForeign-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*, 1993–2010 N=3,436 Lymphatic20.2%18.7% Meningeal1.9%1.8% Miliary1.7%0.7% Bone & Joint2.1%2.8% Other9.4%7.5% 26 Site of diseaseU.S.-bornForeign-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– First line drugs are isoniazid, rifampin, pyrazinamide and ethambutol MDR TB = resistance to at least isoniazid and rifampin

29 Year Percentage *Pediatric TB cases with patient alive at diagnosis and started on treatment Pediatric TB Cases by Use of Directly Observed Therapy (DOT), 1993–2008 N=17,445*

Pediatric TB Cases by Treatment Outcome 1993–2008 N=17,445* Completed treatment 16, 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

Deaths Occurring Among Pediatric TB Cases, by Age Group, 1993–2008 N=17,499 Age < 11, Age 1–48, Age 5–93, Age 10–143, 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