Date: Fri, 10 May 1996 19:53:47 -0400 From: "Flynn Mclean" Subject: MMWR 05/10/96 MORBIDITY AND MORTALITY WEEKLY REPORT ****************************************** Centers for Disease Control and Prevention May 10, 1996 Vol. 45, No. 18 Tuberculosis Morbidity -- United States, 1995 During 1995, a total of 22,813 cases of tuberculosis (TB) (8.7 cases per 100,000 population) were reported to CDC from the 50 states, the District of Columbia (DC), and New York City--a 6.4% decrease from 1994 (24,361 cases [9.4 per 100,000]) (1); an additional 262 cases were reported from Puerto Rico. This represents the third consecutive year the number of reported TB cases has decreased (Table 1) (2), resulting in the lowest rate for reported TB cases since national surveillance began in 1953. This report summarizes TB surveillance data for 1995 and compares these data with selected data for 1986-1994, and indicates a decreased number of TB cases among U.S.-born persons and increased number among foreign-born persons. During 1995, a total of 32 states and DC reported fewer TB cases than in 1994; in comparison, during 1994, a total of 26 states and DC reported fewer cases than in 1993, and during 1993, a total of 31 states reported fewer cases than in 1992 (Table 1). Nine states (California, Connecticut, Hawaii, Illinois, Michigan, Mississippi, New Jersey, New York, and North Carolina) reported fewer cases each year since 1992, a total of 18 states (36%) reported no change or more cases in 1995 compared with 1994, and two (Iowa and Kansas) reported more cases in each year since 1992 (Table 1). Compared with 1994, the number of reported TB cases in 1995 decreased in each sex and age group and all racial/ethnic groups except Asians/Pacific Islanders, for whom a 2.9% increase was reported (Table 2). During 1995, TB cases reported among persons born outside the United States and its territories (i.e., foreign-born) accounted for 35.7% of total reported cases, compared with 31.3% in 1994 (Table 2). The number and proportion of persons reported with TB who were classified as foreign-born have increased 63.3% since 1986, the first year information on the country of origin was collected for each case (Figure 1). In 1995, the country of origin was known for 7592 (94.4%) cases reported in foreign-born persons; six countries (Haiti, India, Mexico, People's Republic of China, Philippines, and Vietnam) accounted for 63.6% of the cases. Of the 4804 foreign-born persons reported in 1995 whose records contained information about month and year of arrival in the United States, 1441 (30.0%) had TB diagnosed within 1 year and 2567 (53.4%) within 5 years after entering the United States. Compared with 1994, the number of cases reported in U.S.-born persons in 1995 decreased 10.8%, and the number of cases in foreign-born persons increased 5.4% (Table 2). During 1995, the number of cases in U.S.-born persons decreased in all age groups; the decrease was largest (17.0%) among persons aged 25-44 years. In comparison, the number of cases in foreign-born persons reported in 1995 increased in all age groups except for children aged less than 15 years (decreased 7.4%) and persons aged 15-24 years (decreased 5.1%). Human immunodeficiency virus (HIV)-antibody test results were available in 1994 for 3317 (36.4%) of 9106 patients aged 25-44 years (nine states reported this information for greater than or equal to 75% of records) and in 1995 for 2925 (35.6%) of 8227 such patients (eight states reported information for greater than or equal to 75% of records). Information about the prescribed initial drug regimen for each TB case was available for 98.0% of cases reported in both 1994 and 1995. Compared with 1994, in 1995 there was a 5.3% increase in the proportion of cases for which the initial four-drug regimen was prescribed as recommended by the Advisory Council for the Elimination of Tuberculosis, the American Thoracic Society, and CDC (isoniazid [INH], rifampin [RIF], pyrazinamide [PZA], and either ethambutol or streptomycin) (3,4) (Table 2). The proportion of patients for whom drug-susceptibility results for Mycobacterium tuberculosis isolates were reported was larger in 1995 than in 1994 (14,052 [77.3%] of 18,168 patients and 14,509 [74.3%] of 19,537 patients, respectively). In 1995, a total of 37 states reported drug-susceptibility results for isolates from greater than or equal to 75% of cases; of these, 806 (7.6%) of 10,621 isolates were resistant to at least INH, and 145 (1.4%) of 10,611 were resistant to at least INH and RIF. Compared with 1994, when only 23 states reported drug-susceptibility results for isolates from greater than or equal to 75% of cases, the proportion of cases with isolates resistant to at least INH decreased from 8.5%, and resistance to at least INH and RIF decreased from 1.5%. The 37 states reporting drug-susceptibility results accounted for 71% of all culture-positive cases reported in the United States in 1995. Reported by: Div of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention (proposed), CDC. Editorial Note: The substantial decline in the number of TB cases reported annually in the United States during 1992-1995 (14.5%) reflects at least six factors: 1) improved laboratory methods to allow prompt identification of M. tuberculosis; 2) broader use of drug-susceptibility testing; 3) expanded use of preventive therapy in high-risk groups; 4) decreased transmission of M. tuberculosis in congregative settings (e.g., hospitals and correctional facilities) by implementing infection-control guidelines (5,6); 5) improved follow-up of persons with TB initially reported to the health department, leading to subsequent removal from the surveillance database of cases for which a disease other than TB was diagnosed; and 6) increased federal resources for state and local TB-control efforts. Beginning in 1992, federal resources for assisting state and local TB-control efforts were increased (1,7). Some of the states with the largest decreases (e.g., New York and California) had high rates of HIV infection and acquired immunodeficiency syndrome (AIDS); resources directed to these states also have supported TB-screening efforts and preventive therapy for HIV-infected persons at high risk for TB infection. The increased funding enabled state and local TB-control programs to improve management of TB cases, in part by ensuring that all patients complete an adequate course of therapy and by expanding the use of directly observed therapy (7,8). Preliminary analyses of national surveillance data and TB-control program management reports indicate that the decrease in cases in U.S.-born persons largely reflected improvement in program performance (CDC, unpublished data, 1995). Since 1986, the number and proportion of reported TB cases among foreign-born persons have increased substantially (9). Most of these persons develop TB disease within the first 5 years of arrival in the United States because of reactivation of latent M. tuberculosis infection acquired in their country of origin, inadequate screening for and/or treatment of TB before entering the United States, or inadequate follow-up of those who have entered the United States with noninfectious TB (i.e., abnormal chest radiograph with negative sputum smears). Control of TB among foreign-born persons in the United States can be strengthened through improved screening and services for immigrants and refugees, prompt reporting of immigrants and refugees with suspected TB to public health programs and health-care providers, and early identification and treatment of TB in foreign-born persons from countries with a high prevalence of TB (9). Assessment of the relation between HIV infection and TB has been limited by the incomplete reporting of information on HIV test results for TB cases: during 1994-1995, this information was available for only 36% of reported persons aged 25-44 years. During 1996 and 1997, CDC, in collaboration with selected state and local health departments, will assess HIV-testing and HIV-counseling practices for TB patients, measure the prevalence of testing, and determine barriers to reporting HIV results for patients who are tested. Results of this assessment will be used to develop strategies to improve HIV testing and counseling of TB patients and reporting of HIV results to state and local TB and HIV/AIDS surveillance programs. The recent national decreases in TB morbidity in the United States can be sustained through efforts by federal agencies and state and local health departments to ensure that all persons with TB are promptly identified and treated. These efforts especially must include the identification and treatment of cases in foreign-born persons and persons who are HIV infected. In addition, TB skin tests of high-risk persons will enable identification of persons who could benefit from preventive therapy. References 1. CDC. Tuberculosis morbidity--United States, 1994. MMWR 1995;44:387-9,395. 2. CDC. Reported tuberculosis in the United States, 1993. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994. 3. CDC. Initial therapy for tuberculosis in the era of multidrug resistance: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1993;42(no. RR-7):1-8. 4. American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med 1994;149:1359-74. 5. Stroud LA, Tokars JI, Grieco MH, et al. Evaluation of infection control measures in preventing the nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis in a New York City hospital. Infect Control Hosp Epidemiol 1995;16:141-7. 6. Blumberg HM, Watkins DL, Bersching JD, et al. Preventing the nosocomial transmission of tuberculosis. Ann Intern Med 1995;122:658-63. 7. Frieden TR, Fujiwara PI, Washko RM, Hamburg MA. Tuberculosis in New York City: turning the tide. N Engl J Med 1995;333:229-33. 8. Chaulk CP, Moore-Rice K, Rizzo R, Chaisson RE. Eleven years of community-based directly observed therapy for tuberculosis. JAMA 1995;274:945-51. 9. McKenna MT, McCray E, Onorato I. The epidemiology of tuberculosis among foreign-born persons in the United States, 1986- 1993. N Engl J Med 1995;332:1071-6.