Current Trends Tuberculosis -- United States, 1985

In 1985, 22,201 cases of tuberculosis were reported to CDC (a rate of 9.3/100,000 population). The number of cases reported in 1985 was 54 less than the 22,255 reported in 1984--a marked change from the average annual decrease of 1,706 cases observed from 1981 to 1984. Compared with 1984, this is a 0.2% decrease in the number of reported cases and a decline of 1.1% in the case rate.

Table 1 shows the observed cases for 1984 and 1985 by state and the expected cases for 1985, based upon the average annual decline of 6.7% observed for the entire nation from 1981 to 1984. Overall, there were 1,437 more cases than expected (excess) in 1985. The five states with the greatest number of excess cases were: California (+407 cases), New York (+385), Texas (+247), Florida (+179), and Massachusetts (+106). The five large cities ( greater than or equal to 250,000 population) with the greatest number of excess cases were: New York City (+322), Los Angeles (+108), Miami (+97), Dallas (+79), and San Francisco (+54).

Table 2 shows observed cases for 1984 and 1985 by age, sex, race, and ethnicity. There were 1,261 reported cases in children under 15 years of age, including 789 in children under 5. Compared with 1984, reported cases increased in two age groups in 1985--children under 5 years of age (+4.0%) and adults from 25 to 44 years of age (+5.5%). Reported cases increased 0.4% among males and declined 1.4% among females. Reported cases among whites decreased 1.6% while increases occurred in blacks (+0.7%), Asians/Pacific Islanders (+2.4%), and American Indians/Alaskan Natives (+5.9%). Reported tuberculosis cases among Hispanics increased 14.0%, but among non-Hispanics they decreased 2.2%.

Table 2 also shows the expected number of cases for 1985, based upon the average age-, sex-, race-, and ethnicity-specific declines observed from 1981 to 1984. Comparing observed with expected cases for 1985, the age groups with the greatest number of excess cases in 1985 were: 25-44 years (+663), 65+ years (+244), 45-64 years (+211), and 15-24 years (+146). There were 1,011 excess cases among males and 419 excess cases among females. Excess cases by race were: white (+747), black (+294), Asian/Pacific Islander (+294), and American Indian/Alaskan Native (+58). There were 640 excess cases among Hispanics and 791 excess cases among non-Hispanics.

Final morbidity data reported to CDC for 1985 indicate that 1,276 (5.7%) of the total 22,201 reported cases were found at time of death. In addition, program evaluation data reported to CDC from 95 reporting areas indicate that 9.3% of patients who began chemotherapy in 1984 died of various causes (including tuberculosis) within 1 year. Final tuberculosis mortality data from the National Centers for Health Statistics indicate that there were 1,729 tuberculosis deaths in 1984--a decline of 2.8% from the 1,779 deaths reported in 1983. Reported by Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The observed decline of only 0.2% in 1985 is substantially smaller than the average annual decline of 6.7% observed from 1981 to 1984. As reported previously (1-3), available evidence from some areas suggests that human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) infection of persons infected with the tubercle bacillus may be responsible for increased tuberculosis morbidity, but the full impact of HTLV-III/LAV on national tuberculosis morbidity is unknown. Health departments are encouraged to undertake surveillance activities to determine the degree to which tuberculosis morbidity is associated with AIDS and HTLV-III/LAV infection (1,4).

Of the five states (New York, California, Florida, New Jersey, and Texas) with the largest number of AIDS cases reported through 1985, four (New York, California, Florida, and Texas) had the greatest number of excess tuberculosis cases in 1985 (Table 1). New Jersey began participating in the national tuberculosis individual case reporting system in 1985, and the decrease in its reported tuberculosis cases (Table 1) may reflect a reporting artifact sometimes encountered during the first year that a state reports to this system.

Of the five metropolitan areas (New York City, San Francisco, Miami, Newark, and Los Angeles) with the largest number of reported AIDS cases through 1985, four (New York City, Los Angeles, Miami, and San Francisco) had the greatest number of excess tuberculosis cases in 1985. As with the total number of cases reported for New Jersey, tuberculosis morbidity reported for Newark in 1985 may be artifactually low.

In addition to the probable impact of HTLV-III/LAV infection, there are undoubtedly other reasons for the excess tuberculosis morbidity in 1985. Excess morbidity occurred in all age groups, both sexes, and all four races (Table 2), whereas AIDS patients who have had tuberculosis (as reported from Florida, New York City, San Francisco, and Newark) are predominantly black or white males from 25 to 44 years of age (1,2,5,6). This suggests that there are other factors contributing to the excess morbidity that need to be examined.

The continued occurrence of tuberculosis in children is clear evidence of ongoing transmission of infection in the United States. Health departments are encouraged to analyze childhood tuberculosis cases as a "sentinel health event" (7-9) to determine how and why they occurred and what program changes are needed to prevent future cases.

Reported tuberculosis deaths have failed to show an appreciable decline in recent years. From 1980 to 1984, the average annual decline in mortality was only 2.9%. Five to ten percent of persons who develop tuberculosis die from this disease, yet tuberculosis is considered preventable and curable by the medical community. Health departments are encouraged to identify and correct breakdowns or gaps in surveillance and health care systems that contribute to tuberculosis mortality.

It should be possible to accelerate the decline of tuberculosis by: (1) fully implementing existing methods of prevention; (2) developing new treatment, diagnostic, and prevention technologies (10); and (3) rapidly implementing these new technologies in all areas of the country.

References

1. CDC. Tuberculosis and acquired immunodeficiency syndrome--Florida. MMWR 1986;35:587-90.

2. Stoneburner RL, Kristal A. Increasing tuberculosis incidence and its relationship to acquired immunodeficiency syndrome in New York City. Presented at the International Conference on the Acquired Immunodeficiency Syndrome (AIDS), Atlanta, Georgia, April 1985.

3. CDC. Tuberculosis--United States, 1985, and the possible impact of human T-lymphotropic virus type III/lymphadenopathy-associated virus infection. MMWR 1986;35:74-6.

4. CDC. Diagnosis and management of mycobacterial infection and disease in persons with human T-lymphotropic virus type III/lymphadenopathy-associated virus infection. MMWR 1986;35:448-52.

5. Chaisson RE, Theuer CP, Schecter GF, Rutherford GW, Echenberg DF, Hopewell PC. Clinical aspects of tuberculosis in AIDS patients: a population based study. Presented at the Second International Conference on the Acquired Immunodeficiency Syndrome (AIDS), Paris, France, June 1986.

6. Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB. Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS). JAMA 1986;256:362-6.

7. Rutstein DD, Berenberg W, Chalmers TC, Child CG, Fishman AP, Perrin EB. Measuring the quality of medical care. A clinical method. N Engl J Med 1976;294:582-8.

8. Rutstein DD, Mullan RJ, Frazier TM, Halperin WE, Melius JM, Sestito JP. Sentinel health events (occupational): a basis for physician recognition and public health surveillance. Am J Public Health 1983;73:1054-62.

9. Bloch AB, Snider DE. How much tuberculosis in children must we accept? Am J Public Health 1986;76:14-5.

10. American Thoracic Society, Centers for Disease Control, National Institutes of Health, Pittsfield Antituberculosis Association. Supplement on future research in tuberculosis. Am Rev Respir Dis 1986;134:401-23.

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