Current Trends Update: Tuberculosis Elimination -- United States

In April 1989, CDC's Advisory Committee for the Elimination of Tuberculosis (ACET) published A Strategic Plan for the Elimination of Tuberculosis in the United States (1). This plan established the goal of tuberculosis (TB) elimination (i.e., a case rate of 0.1 per 100,000 persons) by the year 2010, with an interim goal of a case rate of 3.5 per 100,000 population by the year 2000.

CDC, in collaboration with state and local health departments, uses three sources to monitor progress toward these goals: 1) an individual-case surveillance system, 2) TB mortality data from CDC's National Center for Health Statistics (NCHS), and 3) program performance data collected on cases, contact follow-up, bacteriologic conversion of sputum, continuity of drug therapy, completion of therapy, and preventive therapy. This report updates TB elimination efforts based on the most recent data from these three sources. Case Surveillance

In 1988, the last year for which individual-case data are available, 22,436 TB cases (9.1 per 100,000 U.S. population) were reported, a 0.4% decrease from the 22,517 cases reported in 1987. If the 6.7% average annual decline between 1981 and 1984 had continued through 1988, an estimated 14,768 fewer cases would have been expected during 1985-1988 (Figure 1).

When compared with 1985, the number of reported TB cases in the 25-44-year age group in 1988 increased by 961 cases; however, in other age groups, cases declined (Table 1). In all age groups, reported cases increased among non-Hispanic blacks and Hispanics but decreased among non-Hispanic whites, Asians/Pacific Islanders, and American Indians/Alaskan Natives (Table 1). In the 25-44-year age group, cases among non-Hispanic blacks increased by 22.6% (from 2898 in 1985 to 3552 in 1988);Hispanics, by 34.5% (from 1153 to 1551); and non-Hispanic whites, by 2.3% (from 1520 to 1555). Increases in cases occurred among both males and females. In 1988, TB case rates for racial/ethnic minorities were approximately fourfold to ninefold higher than for non-Hispanic whites (Table 1). NCHS Data

Final TB mortality data from NCHS for 1987 indicate that 1755 persons died from TB in the United States--a 1.5% decrease from the 1782 deaths reported in 1986. Program Performance Data

Case register and contact follow-up reports contained information on approximately 75% of cases reported during 1988. As of December 31, 1988, 76% of the patients receiving two or more TB drugs were current with their chemotherapy regimen. Up-to-date bacteriologic information was available for 57% of patients; for 84% of these patients, contacts were identified, and 93% of these were examined. Of contacts who were examined, 23% were infected. Preventive therapy was prescribed for 89% of infected contacts less than 15 years of age and for 59% of those greater than or equal to 15 years of age. Approximately 1% of the contacts examined had clinically apparent TB.

Data on the bacteriologic conversion of sputum were known for 17,868 (79%) of the 22,517 cases reported during 1987. Sixty-one percent of patients with positive sputum were known to have become negative (bacteriologic conversion) within 3 months after starting chemotherapy; 20% remained positive beyond the third month of chemotherapy; and 7% died within 3 months of being reported. No information was available on the remaining patients. Data on drug therapy were known for 14,072 (63%) of the cases reported during 1987. Medication was taken continuously during the first 6 months of therapy by 86% of patients. Six percent interrupted their therapy; 2% stopped taking their medication; and 9% died within the first 6 months of treatment. Approximately 75% of patients for whom reports were available completed therapy within 12 months: 9%, within 6 months; 27%, within 7-9 months; and 39%, within 10-12 months. Approximately 11% of patients died within 1 year of diagnosis.

More than 95,000 persons with tuberculous infection at risk for clinical disease were reported to have begun preventive therapy during 1987; 66% completed 6 continuous months of treatment. Contacts of TB patients had a 72% completion rate. Recent converters and other infected persons had completion rates of 70% and 64%, respectively. Reported by: State and local health departments. Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The number of newly reported TB patients meeting the CDC case definition (2) represents greater than 90% of patients under treatment supervision by state and local health departments (CDC, unpublished data), and this percentage has remained stable since 1984. However, the public health burden of TB is only partially reflected by the number of new cases reported annually. In 1987, this burden included the more than 115,000 persons under treatment for TB ( greater than 20,000 new patients plus greater than 95,000 high-risk persons who began preventive therapy). In addition, 1755 persons died from this curable disease.

The trends for race/ethnicity primarily reflect the increasing occurrence of TB in persons infected with human immunodeficiency virus (HIV) (3). Because the HIV-infection status of TB patients is not collected on the TB case report form, the precise impact of HIV infection on TB morbidity trends in the United States cannot be determined. Nevertheless, HIV infection is an important risk factor for developing clinically apparent TB among persons already infected with the tubercle bacillus (4). Accordingly, CDC recommends that all HIV-infected persons be screened for TB and latent tuberculous infection and, if infected, offered curative or preventive therapy (5). Similarly, persons with TB and known tuberculin-positive persons should be evaluated for HIV infection so that appropriate counseling and treatment can be undertaken (5).

Approximately 1% of the estimated 10 million persons in the United States who are infected with the tubercle bacillus (CDC, unpublished data) were identified and treated in 1988. Identification and treatment of all 10 million infected persons is not necessary to substantially reduce the burden of TB. Instead, ACET has emphasized focusing on high-risk populations (1). The proportion of infected persons represented in high-risk groups is unknown. However, the percentage of infected persons who are screened and treated for TB annually must increase substantially beyond 1% if TB is to be eliminated by the year 2010. These patients must also be carefully monitored for compliance and adverse drug reactions (6).

Use of program performance reports allows state and local health departments to measure their progress toward TB elimination. The reports indicate that noncompliance with prescribed therapy is the greatest remaining obstacle to elimination (7). Ideally, 90% of patients should complete therapy within 12 months. Program and research strategies that may be effective in addressing noncompliance include the use of outreach workers to administer and directly observe therapy and provide incentives to enhance compliance (8); education programs for health professionals; studies of compliance predictors and enhancers; and research targeted toward reducing the duration of therapy and number of drug doses required. Careful monitoring of all patients for compliance and the more widespread use of compliance-enhancing strategies is essential for eliminating TB.

References

1. CDC. A strategic plan for the elimination of tuberculosis in the United States. MMWR 1989; 38(no. S-3).

2. CDC. Public Health Service recommendations for counting reports of tuberculosis cases: procedural guide. Atlanta: US Department of Health, Education, and Welfare, Public Health Service, 1977.

3. Bloch AB, Rieder HL, Kelly GD, Cauthen GM, Hayden CH, Snider DE. The epidemiology of tuberculosis in the United States. Semin Respir Infect 1989;4:157-70.

4. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med 1989; 320:545-50.

5. CDC. Tuberculosis and human immunodeficiency virus infection: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR 1989;38:236-8, 243-50.

6. Bass JB, Farer LS, Hopewell PC, Jacobs RF. Treatment of tuberculosis and tuberculosis infection. Am Rev Respir Dis 1986;134:355-63.

7. Addington WW. Patient compliance: the most serious remaining problem in the control of tuberculosis in the United States. Chest 1979;76(suppl):741-3.

8. Division of Tuberculosis Control, South Carolina Department of Health and Environmental Control/American Lung Association of South Carolina. Enablers and incentives. Columbia, South Carolina: American Lung Association of South Carolina, 1989.

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