Topics in Minority Health Tuberculosis in Blacks -- United States

In 1985, 22,201 tuberculosis cases were reported to CDC, for a crude morbidity rate of 9.3/100,000 population. Of the 22,170 tuberculosis cases among persons of known race, 11,524 (52.0%) occurred among whites, and 7,719 (34.8%) occurred among blacks, for morbidity rates of 5.7 and 26.7 cases per 100,000 population, respectively. In 1984, the National Center for Health Statistics received reports of 1,729 deaths from tuberculosis, for a crude mortality rate of 0.73/100,000 population. Of these, 1,047 (60.6%) occurred among whites, and 619 (35.8%) occurred among blacks, for mortality rates of 0.52 and 2.17 deaths per 100,000 population, respectively.

Using a methodology similar to that employed by the Secretary's Task Force on Black and Minority Health (1), age- and sex-specific relative risks and excess morbidity and mortality were determined for the black population, as compared with the white population. Relative risk was defined as the ratio of age- and sex-specific tuberculosis morbidity and mortality rates in the black population compared with the white population. Excess cases and excess deaths were defined as the difference between the number of cases or deaths observed in the black population and the number that would have been expected if the black population had had the same age- and sex-specific morbidity or mortality rates as the white population. This method quantifies the number of cases and deaths that would not have occurred had morbidity or mortality rates for blacks equalled those for whites.

In 1985, the overall age-adjusted relative risk of tuberculosis among persons of known age, race, and sex was 6.2 for black males and 5.1 for black females (Table 2, Table 3). The largest relative risks were among 25- to 44-year-old blacks and were 9.1 for males and 7.3 for females. This was also the age group with the largest number of excess cases. Overall, 82.7% (6,382) of the 7,714 reported tuberculosis cases among blacks of known age and sex were excess cases.

In 1984, the overall age-adjusted relative risk of death from tuberculosis among persons of known age, race, and sex was 6.3 for black males and 5.4 for black females (Table 4, Table 5). The largest relative risks occurred among 25- to 44-year-old blacks and were 16.2 for males and 14.2 for females. The largest number of excess deaths occurred in the 45- to 64-year-old age group. Overall, 83.0% (513) of the 618 tuberculosis deaths among blacks of known age and sex were excess deaths.

In an analysis by 5-year age groups, the largest number of cases occurred in the 30- to 34-year-old age group for blacks, in the 60- to 64-year-old age group for all whites, and in the 70- to 74-year-old age group for non-Hispanic whites. The median age for blacks was 44 years, compared with 57 years for all whites and 62 years for non-Hispanic whites. Of the total 7,714 tuberculosis cases among blacks of known age, 33.1% (2,553) were 35 years of age, as compared with 23.2% (2,675) among the 11,515 whites and 14.3% (1,209) among the 8,446 non-Hispanic whites.

The majority of U.S. counties reporting tuberculosis in blacks were in the southeastern and eastern seaboard states and in California (Figure 1). The 10 states with the largest number of tuberculosis cases among blacks were: New York, 1,215; Florida, 714; Georgia, 509; Illinois, 509; Texas, 468; South Carolina, 435; North Carolina, 401; California, 399; New Jersey, 283; and Alabama, 276. These states reported 67.5% (5,209) of the 7,719 cases in blacks. Reported by: Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: 1985 was the first year in which all states reported detailed information on individual cases of tuberculosis, thus allowing for more precise identification of groups at risk for tuberculosis. Two indices were used to summarize tuberculosis morbidity and mortality differentials among blacks as compared with whites. They were 1) relative risk and 2) excess tuberculosis cases and deaths. The relative risks for both morbidity and mortality are disturbingly high among blacks. Age-specific rates of tuberculosis were four- to ninefold higher among blacks than among whites, while mortality rates were 4- to 16-fold higher. Eighty-three percent of all reported tuberculosis cases among blacks in 1985 represented excess morbidity. Similarly, 83% of all deaths from tuberculosis occurring among blacks in 1984, represented excess mortality.

The Secretary's Task Force on Black and Minority Health examined more than 40 specific causes of death among blacks 45 years of age; tuberculosis had the highest relative risk (1). While tuberculosis is becoming more and more a disease of the elderly among whites, particularly non-Hispanic whites (2), it is still a threat to black adults at much younger ages. The finding that 33% of black tuberculosis patients were 35 years of age suggests that many of these cases were potentially preventable (3). The finding that 10 states reported two-thirds of all tuberculosis cases among blacks indicates that the geographic distribution of tuberculosis cases among blacks is largely focal.

Morbidity rates of tuberculosis have progressively declined among both whites and non-whites over the past three decades; however, it is noteworthy that the ratio of morbidity rates for non-whites compared with those for whites has steadily increased--from 2.9 in 1953 to 5.2 in 1985. This disparity in the burden of tuberculosis experienced by blacks as well as other minority Americans calls for an intensified effort to close this gap and thereby prevent unnecessary disease and death.

In several areas of the nation where both tuberculosis and acquired immunodeficiency syndrome (TB/AIDS) have been investigated, the majority of TB/AIDS patients have been black (Newark, 93%; Florida, 79%; Connecticut, 61%; and New York City, 56%), while, in San Francisco, blacks comprised a smaller proportion (16%) (4-8). The degree to which AIDS or human immunodeficiency virus (HIV) infection contributes to tuberculosis morbidity in blacks and other racial/ethnic groups in the nation is currently unknown. It will thus be important for health departments to determine the proportion of tuberculosis patients who are seropositive for HIV, as recommended in recently published guidelines (9,10). Furthermore, the identification of the specific demographic characteristics and geographic distribution of TB/AIDS patients should result in program activities to prevent tuberculosis in persons at increased risk for AIDS (9,10).

While an earlier MMWR article provided an overview of the health impact of tuberculosis in minorities in the United States (2), this is the first in a subsequent series of articles that will provide more detailed information on tuberculosis in blacks, Asians/Pacific Islanders, American Indians/Alaskan Natives, and Hispanics. Such information indicates that tuberculosis patients in each minority group have specific age/sex characteristics and are located in particular areas within the nation. Such detailed information will allow the development of more precisely targeted programs to prevent and treat tuberculosis in minorities.

References

1. US Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health--volume I: executive summary. Washington, DC: U.S. Department of Health and Human Services, 1985:63-86.

2. CDC. Tuberculosis in minorities--United States. MMWR 1987;36:77-80.

3. American Thoracic Society, CDC. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986;134:355-63.

4. 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.

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

6. CDC. Tuberculosis and AIDS--Connecticut. MMWR 1987;36:133-5.

7. 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.

8. 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.

9. 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.

10. CDC. Diagnosis and management of mycobacterial infection and disease in persons with human immunodeficiency virus infection. Ann Intern Med 1987;106:254-6.

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