Executive Commentary

Reported Tuberculosis in the United States, 2023

In 2023, the United States reported 9,633 TB disease cases with a corresponding incidence rate of 2.9 cases per 100,000 persons (Table 1). Prior to the COVID-19 pandemic, annual U.S. TB case counts and rates had been steadily declining since 1992 (Table 1). During 2020, the first year of the COVID-19 pandemic, TB cases decreased by 19.4% and the incidence rate decreased by 20.2%. Case counts and incidence rates subsequently rose in 2021 and 2022. In 2023, the number of reported TB cases and incidence rate increased for a third sequential year. Increases in 2023 were widespread. Of the 50 U.S. states, New York City, and the District of Columbia (D.C.), 42 jurisdictions reported an increase in cases and incidence rate (Table 2). As in past years, four U.S. states combined reported half of all U.S. TB cases in 2023: California, Texas, New York (including New York City), and Florida. Of the five U.S. territories and three freely associated states, five jurisdictions reported increases in case counts and six reported increases in incidence rates (Table 2).

The 2023 TB case count and incidence rate exceeded the prepandemic case count and incidence rate of 8,895 and 2.7 per 100,000 persons, respectively, reported in 2019. The case count in 2023 is the highest reported since 2013, and the incidence rate the highest since 2016. The increases in U.S. TB cases and incidence rates represent a setback in progress towards the U.S. TB elimination threshold, defined as <1 case per 1,000,000 population.1 Pandemic-related disruptions to health services and changes in migration and travel patterns are likely contributors to the higher case counts and incidence rates reported in 2023.2345

Origin of birth

Consistent with previous years, origin of birth was a key risk factor for TB disease in 2023. Most TB cases (75.8%) in 2023 occurred among non-U.S.–born persons (Table 9). Compared with 2022, the incidence rate in 2023 among non-U.S.–born persons increased from 13.1 to 15.0 cases per 100,000 persons, a 14.6% increase, while the rate for U.S.-born persons increased by 7.5% when using unrounded numbers. In 2023, the incidence rate for non-U.S.–born persons was 18.5 times greater than for U.S.-born persons.

Similar to recent years, most TB cases among non-U.S.–born persons occurred among people who have resided in the United States for five years or more prior to their diagnoses (Table 11). However, in 2023, there were 1,632 TB cases reported among non-U.S.–born persons who were diagnosed within one year of arrival in the United States. This represents a 56.3% increase compared with 1,044 cases reported in 2022 (Table 11).

The increase in TB cases reported among non-U.S.–born persons is at least partially due to post-pandemic changes in migration and travel.3 Prompt TB diagnoses6 among persons who have recently arrived in the United States could also be contributing to the increase in reported cases in this group.

Racial/ethnic identity

In the United States, TB disease disproportionately impacts persons who identify as members of racial or ethnic minority groups (Table 3). In 2023, persons identifying as Native Hawaiian or Other Pacific Islander had the highest TB incidence rate (22.6 per 100,000 persons) among all racial/ethnic groups followed by persons identifying as Asian (14.0 per 100,000 persons).

Likewise, the U.S.-Affiliated Pacific Islands continued to report some of the highest incidence rates in the world.7 The TB incidence rate in 2023 was 503.7 per 100,000 persons in the Republic of the Marshall Islands and 179.4 per 100,000 persons in the Federated States of Micronesia (Table 2). TB diagnoses during active case finding efforts in the Federated States of Micronesia during 2023 likely contributed to the high incidence rate there, which represents a 300.5% increase compared with 2022 (44.8 per 100,000 persons).

Incidence rates among persons identifying as Hispanic or Latino have steadily increased each year since 2020 (Table 3). In 2023, persons identifying as Hispanic or Latino had an incidence rate of 5.4 per 100,000 persons compared with 3.4 per 100,000 persons in 2020. This increase was most notable among non-U.S.–born Hispanic or Latino persons (13.0 per 100,000 persons in 2023 compared with 8.1 per 100,000 persons in 2020) (Table 5). In 2023, persons identifying as Hispanic or Latino comprised the largest percentage of cases both overall (36.8%) and among non-U.S.–born persons (39.7%), surpassing the percentage among persons identifying as Asian, non-Hispanic (30.0% overall; 37.9% among non-U.S.–born persons). Historically, persons identifying as Asian have comprised the largest percentage of TB cases in the United States, including among non-U.S.–born persons.

Risk factors

New risk factor variables

In 2023, all jurisdictions fully implemented the revised TB case report form (2020 Report of Verified Case of Tuberculosis [RVCT]). The new variables on the revised form provide additional understanding of characteristics and risk factors among persons with TB disease. This year's annual report includes select data from new variables from the 2020 RVCT, including pregnancy, smoking, and history of experiencing homelessness.

Pregnancy

TB disease in pregnancy poses a substantial risk of morbidity to both the pregnant person and the fetus if not diagnosed and treated in a timely manner.8 Among people reported to be female in the 15–44 year old age group, the United States reported 55 TB cases among pregnant persons, representing 1% of female persons in the 15–24 year old age group and 3.1% of female persons in the 25–44 year old age group (Table 24).

Smoking

Smoking is associated with increased risk of TB disease.9 In 2023, 2,834 (31.2%) persons with TB disease reported currently or formerly smoking or vaping tobacco or nicotine products (Table 35).

History of experiencing homelessness

Living or working in congregate settings, including homeless shelters, is a risk factor for TB because shared airspace can facilitate TB exposure and transmission. In 2023, 695 (8.3%) persons ≥15 years of age with TB disease reported ever experiencing homelessness during their lifetime (Table 35). Of those, 536 (77.1%) reported experiencing homelessness within 12 months prior to TB diagnostic evaluation.

Other risk factors

For other risk factors, 23.4% of TB cases occurred in persons reported to have diabetes and 4.9% occurred in persons with HIV. Among persons with TB who were at least 15 years of age, social risk factors included excess alcohol use (7.9%), noninjecting drug use (7.8%), and residence within a correctional facility (3.6%) at the time of diagnosis.

Evaluation and treatment

All persons with signs or symptoms of TB disease should have chest imaging.10 Persons with presumed pulmonary TB disease should have bacteriologic examination of their sputum including smear microscopy and a rapid nucleic acid amplification test as part of a complete diagnostic evaluation.1011 Health care providers should treat all persons diagnosed with TB disease with an effective anti-TB drug regimen and monitor their treatment closely to prevent emergence of drug-resistant TB. Among persons diagnosed with TB disease in 2023:

• More than 90% received a chest radiograph
  • Of those, 24.8% had cavitary disease (Table 22)
• Almost 90% had a sputum sample collected
  • Of those, 46.4% had a sputum sample that was positive for the presence of acid-fast bacilli (Table 22)
• Almost 95% began treatment regimens of either four months of high-dose daily rifapentine with moxifloxacin, isoniazid, and pyrazinamide; rifampin, isoniazid, pyrazinamide, and ethambutol; or another regimen with at least four anti-TB drugs. This percentage has been consistent since 2012 (Table 15).

TB case outcome data are available after a two-year lag. In 2021, 94.0% of persons diagnosed with TB disease received at least part of their treatment through directly observed therapy (DOT) (Table 16). The use of video DOT might have facilitated consistently high use of this critical case management strategy even during the COVID-19 pandemic.12

TB-related deaths

The National Vital Statistics System reported 565 TB-related deaths in 2022, the most recent year for which data are available (Table 1). The TB mortality rate was 0.2 deaths per 100,000 persons. Using unrounded numbers, this represents a 6.1% decrease in the number of TB-related deaths and 6.5% decrease in the mortality rate compared with 2021.

Conclusion

The COVID-19 pandemic disrupted access to health care and impacted the public health workforce, migration and travel patterns, and social mixing behaviors. The continued increase in reported cases of TB disease and incidence rates in 2023 underscores the need to regain the momentum lost toward the United States' goal of eliminating TB. Despite the increases, which have been reported globally, the United States continues to maintain one of the lowest TB incidence rates in the world.7

This report highlights the services public health programs provided for persons with TB disease even with the challenges associated with the COVID-19 pandemic.2 Public health programs facilitated prompt TB diagnoses, initiated evidence-based drug treatment regimens, and collaborated with persons with TB through directly observed therapy to ensure treatment completion. These efforts reduce TB-associated morbidity for individuals and protect communities from transmission of TB bacteria. To reverse recent increases in TB, enhanced strategies to diagnose and treat latent TB infection and TB disease are needed. These strategies include establishing and strengthening partnerships between health care providers, people affected by TB, communities with high risk of TB, and public health programs.