Basic TB Facts

Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria

usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney,
spine, and brain. Not everyone infected with TB bacteria becomes sick. As a result, two TB-
related conditions exist: latent TB infection (LTBI) and TB disease. If not treated properly,
TB disease can be fatal.

How TB Spreads
TB bacteria are spread through the air from one person to another. The TB bacteria are put
into the air when a person with TB disease of the lungs or throat coughs, speaks, or sings.
People nearby may breathe in these bacteria and become infected.

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TB is NOT spread by

shaking someone's hand

sharing food or drink

touching bed linens or toilet seats

sharing toothbrushes

kissing

When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to grow.
From there, they can move through the blood to other parts of the body, such as the kidney,
spine, and brain.

TB disease in the lungs or throat can be infectious. This means that the bacteria can be spread
to other people. TB in other parts of the body, such as the kidney or spine, is usually not
infectious.

People with TB disease are most likely to spread it to people they spend time with every day.
This includes family members, friends, and coworkers or schoolmates.

Latent TB Infection and TB Disease

Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions
exist: latent TB infection and TB disease.

Latent TB Infection

TB bacteria can live in the body without making you sick. This is called latent TB infection.
In most people who breathe in TB bacteria and become infected, the body is able to fight the
bacteria to stop them from growing. People with latent TB infection:

Have no symptoms

Dont feel sick

Cant spread TB bacteria to others

Usually have a positive TB skin test reaction or positive TB blood test

May develop TB disease if they do not receive treatment for latent TB infection

Many people who have latent TB infection never develop TB disease. In these people, the TB
bacteria remain inactive for a lifetime without causing disease. But in other people, especially
people who have a weak immune system, the bacteria become active, multiply, and cause TB
disease.

TB Disease

TB bacteria become active if the immune system can't stop them from growing. When TB
bacteria are active (multiplying in your body), this is called TB disease. People with TB
disease are sick. They may also be able to spread the bacteria to people they spend time with
every day.

Many people who have latent TB infection never develop TB disease. Some people develop
TB disease soon after becoming infected (within weeks) before their immune system can
fight the TB bacteria. Other people may get sick years later when their immune system
becomes weak for another reason.

For people whose immune systems are weak, especially those with HIV infection, the risk of
developing TB disease is much higher than for people with normal immune systems.

The Difference between Latent TB Infection (LTBI) and TB Disease

A Person with Latent TB Infection A Person with TB Disease

Has symptoms that may include

o a bad cough that lasts 3 weeks

or longer

o pain in the chest

o coughing up blood or sputum

o weakness or fatigue
Has no symptoms
o weight loss

o no appetite

o chills

o fever

o sweating at night

Does not feel sick Usually feels sick

Cannot spread TB bacteria to others May spread TB bacteria to others

Usually has a skin test or blood test Usually has a skin test or blood test
result indicating TB infection result indicating TB infection

Has a normal chest x-ray and a May have an abnormal chest x-ray, or
negative sputum smear positive sputum smear or culture

Needs treatment for latent TB infection Needs treatment to treat TB disease

 A Person with Latent TB Infection A Person with TB Disease

to prevent TB disease

Signs & Symptoms

Symptoms of TB disease depend on where in the body

the TB bacteria are growing. TB bacteria usually grow in the lungs (pulmonary TB). TB
disease in the lungs may cause symptoms such as

a bad cough that lasts 3 weeks or longer

pain in the chest

coughing up blood or sputum (phlegm from deep inside the lungs)

Other symptoms of TB disease are

weakness or fatigue

weight loss

no appetite

chills

fever
 sweating at night

Symptoms of TB disease in other parts of the body depend on the area affected.

People who have latent TB infection do not feel sick, do not have any symptoms, and cannot
spread TB to others.

TB Risk Factors
Some people develop TB disease soon after becoming infected (within weeks) before their
immune system can fight the TB bacteria. Other people may get sick years later, when their
immune system becomes weak for another reason.

Overall, about 5 to 10% of infected persons who do not receive treatment for latent TB
infection will develop TB disease at some time in their lives. For persons whose immune
systems are weak, especially those with HIV infection, the risk of developing TB disease is
much higher than for persons with normal immune systems.

Generally, persons at high risk for developing TB disease fall into two categories:

Persons who have been recently infected with TB bacteria

Persons with medical conditions that weaken the immune system

Persons who have been Recently Infected with TB Bacteria

This includes:

Close contacts of a person with infectious TB disease

Persons who have immigrated from areas of the world with high rates of
TB

Children less than 5 years of age who have a positive TB test

Groups with high rates of TB transmission, such as homeless persons,

injection drug users, and persons with HIV infection

Persons who work or reside with people who are at high risk for TB in
facilities or institutions such as hospitals, homeless shelters, correctional
facilities, nursing homes, and residential homes for those with HIV

Persons with Medical Conditions that Weaken the Immune System

Babies and young children often have weak immune systems. Other people can have weak
immune systems, too, especially people with any of these conditions:

HIV infection (the virus that causes AIDS)

Substance abuse

Silicosis
 Diabetes mellitus

Severe kidney disease

Low body weight

Organ transplants

Head and neck cancer

Medical treatments such as corticosteroids or organ transplant

Specialized treatment for rheumatoid arthritis or Crohns disease

Exposure to TB

What to Do If You Have Been Exposed To TB

You may have been exposed to TB bacteria if you

spent time near someone with TB disease. The TB bacteria are put into the air when a person
with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings. You cannot
get TB from

Clothes

Drinking glass

Eating utensils

Handshake

Toilet

Other surfaces
If you think you have been exposed to someone with TB disease, you should contact your
doctor or local health department about getting a TB skin test or a special TB blood test. Be
sure to tell the doctor or nurse when you spent time with the person who has TB disease.

It is important to know that a person who is exposed to TB bacteria is not able to spread the
bacteria to other people right away. Only persons with active TB disease can spread TB
bacteria to others. Before you would be able to spread TB to others, you would have to
breathe in TB bacteria and become infected. Then the active bacteria would have to multiply
in your body and cause active TB disease. At this point, you could possibly spread TB
bacteria to others. People with TB disease are most likely to spread the bacteria to people
they spend time with every day, such as family members, friends, coworkers, or schoolmates.

Some people develop TB disease soon (within weeks) after becoming infected, before their
immune system can fight the TB bacteria. Other people may get sick years later, when their
immune system becomes weak for another reason. Many people with TB infection never
develop TB disease.

TB Prevention
Preventing Latent TB Infection from Progressing to TB Disease

Many people who have latent TB infection never develop TB disease. But some people who
have latent TB infection are more likely to develop TB disease than others. Those at high risk
for developing TB disease include:

People with HIV infection

People who became infected with TB bacteria in the last 2 years

Babies and young children

People who inject illegal drugs

People who are sick with other diseases that weaken the immune system

Elderly people

People who were not treated correctly for TB in the past

If you have latent TB infection and you are in one of these high-risk groups, you should take
medicine to keep from developing TB disease. There are several treatment options for latent
TB infection. You and your health care provider must decide which treatment is best for you.
If you take your medicine as instructed, it can keep you from developing TB disease. Because
there are less bacteria, treatment for latent TB infection is much easier than treatment for TB
disease. A person with TB disease has a large amount of TB bacteria in the body. Several
drugs are needed to treat TB disease.

Learn about TB Risk Factors.

Preventing Exposure to TB Disease While Traveling Abroad

In many countries, TB is much more common than in the United States. Travelers should
avoid close contact or prolonged time with known TB patients in crowded, enclosed
environments (for example, clinics, hospitals, prisons, or homeless shelters).

Although multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB are occurring

globally, they are still rare. HIV-infected travelers are at greatest risk if they come in contact
with a person with MDR or XDR TB.

Air travel itself carries a relatively low risk of infection with TB of any kind. Travelers who
will be working in clinics, hospitals, or other health care settings where TB patients are likely
to be encountered should consult infection control or occupational health experts. They
should ask about administrative and environmental procedures for preventing exposure to
TB. Once those procedures are implemented, additional measures could include using
personal respiratory protective devices.

Travelers who anticipate possible prolonged exposure to people with TB (for example, those
who expect to come in contact routinely with clinic, hospital, prison, or homeless shelter
populations) should have a TB skin test or a TB blood test before leaving the United States.
If the test reaction is negative, they should have a repeat test 8 to 10 weeks after returning to
the United States. Additionally, annual testing may be recommended for those who anticipate
repeated or prolonged exposure or an extended stay over a period of years. Because people
with HIV infection are more likely to have an impaired response to TB tests, travelers who
are HIV positive should tell their physicians about their HIV infection status.

Vaccines
TB Vaccine (BCG)

Bacille Calmette-Gurin (BCG) is a vaccine for tuberculosis (TB) disease. This vaccine is not
widely used in the United States, but it is often given to infants and small children in other
countries where TB is common. BCG does not always protect people from getting TB.

BCG Recommendations

In the United States, BCG should be considered for only very select people who meet specific
criteria and in consultation with a TB expert. Health care providers who are considering BCG
vaccination for their patients are encouraged to discuss this intervention with the TB control
program in their area.

Children
BCG vaccination should only be considered for children who have a negative TB test and
who are continually exposed, and cannot be separated from adults who

Are untreated or ineffectively treated for TB disease, and the child cannot be given
long-term primary preventive treatment for TB infection; or

Have TB disease caused by strains resistant to isoniazid and rifampin.

Health Care Workers

BCG vaccination of health care workers should be considered on an individual basis in

settings in which

A high percentage of TB patients are infected with TB strains resistant to both

isoniazid and rifampin;

There is ongoing transmission of drug-resistant TB strains to health care workers and

subsequent infection is likely; or

Comprehensive TB infection-control precautions have been implemented, but have

not been successful.

Health care workers considered for BCG vaccination should be counseled regarding the risks
and benefits associated with both BCG vaccination and treatment of latent TB infection.

Testing for TB in BCG-Vaccinated People

Many people born outside of the United States have been BCG-vaccinated.

People who were previously vaccinated with BCG may receive a TB skin test to test for TB
infection. Vaccination with BCG may cause a positive reaction to a TB skin test. A positive
reaction to a TB skin test may be due to the BCG vaccine itself or due to infection with TB
bacteria.

TB blood tests (IGRAs), unlike the TB skin test, are not affected by prior BCG vaccination
and are not expected to give a false-positive result in people who have received BCG.

For children under the age of five, the TB skin test is preferred over TB blood tests.

A positive TB skin test or TB blood test only tells that a person has been infected with TB
bacteria. It does not tell whether the person has latent TB infection or has progressed to TB
disease. Other tests, such as a chest x-ray and a sample of sputum, are needed to see whether
the person has TB disease.

TB and HIV Coinfection

Tuberculosis is a serious health threat, especially for people living with HIV. People living
with HIV are more likely than others to become sick with TB. Worldwide, TB is one of the
leading causes of death among people living with HIV.

Without treatment, as with other opportunistic infections, HIV and TB can work together to
shorten lifespan.

Someone with untreated latent TB infection and HIV infection is much more likely to
develop TB disease during his or her lifetime than someone without HIV infection.

Among people with latent TB infection, HIV infection is the strongest known risk
factor for progressing to TB disease.

A person who has both HIV infection and TB disease has an AIDS-defining condition.

People infected with HIV who also have either latent TB infection or TB disease can be
effectively treated. The first step is to ensure that people living with HIV are tested for TB
infection. If found to have TB infection, further tests are needed to rule out TB disease. The
next step is to start treatment for latent TB infection or TB disease based on test results.

Treatment

Untreated latent TB infection can quickly progress to TB disease in people living with HIV
since the immune system is already weakened. And without treatment, TB disease can
progress from sickness to death.

Fortunately, there are a number of treatment options for people living with HIV who also
have either latent TB infection or TB disease.

TB Terms
TB disease an illness in which TB bacteria are multiplying and attacking a part of the body,
usually the lungs The symptoms of TB disease include weakness, weight loss, fever, no
appetite, chills, and sweating at night. Other symptoms of TB disease depend on where in the
body the bacteria are growing. If TB disease is in the lungs (pulmonary TB), the symptoms
may include a bad cough, pain in the chest, or coughing up blood. A person with TB disease
may be infectious and spread TB bacteria to others.

BCG a vaccine for TB named after the French scientists who developed it, Calmette and
Gurin. BCG is rarely used in the United States, but it is often given to infants and small
children in other countries where TB is common.

Chest x-ray a picture of the inside of your chest. A chest x-ray is made by exposing a film
to x-rays that pass through the chest. A doctor can look at this film to see whether TB bacteria
have damaged the lungs.

Contact a person who has spent time with a person with infectious TB.

Culture a test to see whether there are TB bacteria in your phlegm or other body fluids.
This test can take 2 to 4 weeks in most laboratories.
Directly observed therapy (DOT) a way of helping patients take their medicine for TB. If
you get DOT, you will meet with a health care worker every day or several times a week. You
will meet at a place you both agree on. This can be the TB clinic, your home or work, or any
other convenient location. You will take your medicine while the health care worker watches.

Extensively drug-resistant TB (XDR TB) - XDR TB is a rare type of TB disease that is

resistant to nearly all medicines used to treat TB.

Extrapulmonary TB TB disease in any part of the body other than the lungs (for example,
the kidney, spine, brain, or lymph nodes).

HIV infection infection with the human immunodeficiency virus, the virus that causes
AIDS (acquired immunodeficiency syndrome). A person with both latent TB infection and
HIV infection is at very high risk for developing TB disease.

Isoniazid (INH) a medicine used to prevent TB disease in people who have latent TB
infection. INH is also one of the four medicines often used to treat TB disease.

Latent TB infection a condition in which TB bacteria are alive, but inactive in the body.
People with latent TB infection have no symptoms, don't feel sick, can't spread TB to others,
and usually have a positive TB skin test or positive TB blood test reaction. But they may
develop TB disease if they do not receive treatment for latent TB infection.

Multidrug-resistant TB (MDR TB) TB disease caused by bacteria resistant to two of the

most important medicines: INH and RIF.

Mycobacterium tuberculosis bacteria that cause latent TB infection and TB disease.

Negative usually refers to a test result. If you have a negative TB skin test reaction or
negative TB blood test reaction, you probably do not have TB infection.

Positive usually refers to a test result. If you have a positive TB skin test reaction or
positive TB blood test reaction, you probably have TB infection.

Pulmonary TB TB disease that occurs in the lungs, usually producing a cough that lasts 3
weeks or longer. Most TB disease is pulmonary.

Resistant bacteria bacteria that can no longer be killed by a certain medicine.

Rifampin (RIF) one of the four medicines often used to treat TB disease. It is considered a
first-line drug.

Rifapentine (RPT) one of two medicines used to treat latent TB infection.

Smear a test to see whether there are TB bacteria in your phlegm. To do this test, lab
workers smear the phlegm on a glass slide, stain the slide with a special stain, and look for
any TB bacteria on the slide. This test usually takes 1 day to get the results.

Sputum phlegm coughed up from deep inside the lungs. Sputum is examined for TB
bacteria using a smear; part of the sputum can also be used to do a culture.
TB blood test a test that uses a blood sample to find out if you are infected with TB
bacteria. The test measures the response to TB proteins when they are mixed with a small
amount of blood. Examples of these TB blood tests include QuantiFERON-TB Gold In-tube
(QFT-GIT) and T-Spot.TB test.

TB disease an illness in which TB bacteria are multiplying and attacking a part of the body,
usually the lungs. The symptoms of TB disease include weakness, weight loss, fever, no
appetite, chills, and sweating at night. Other symptoms of TB disease depend on where in the
body the bacteria are growing. If TB disease is in the lungs (pulmonary TB), the symptoms
may include a bad cough, pain in the chest, and coughing up blood. A person with TB disease
may be infectious and spread TB bacteria to others.

TB skin test a test that is often used to find out if you are infected with TB bacteria. A
liquid called tuberculin is injected under the skin on the lower part of your arm. If you have a
positive reaction to this test, you probably have TB infection. Other tests will be needed to
find out if you have latent TB infection or TB disease.

Tuberculin or PPD a liquid that is injected under the skin on the lower part of your arm
during a TB skin test. If you have latent TB infection, you will probably have a positive
reaction to the tuberculin.

TB Personal Stories
get TB. These stories highlight the personal experiences of several people who were
diagnosed and treated for TB infection or TB disease.

Deos Story

Deo was born in Bhutan and worked as a medical professional before moving to the
United States. A health screening when he arrived in the country revealed he had latent TB
infection. Video

Esteban and Danielles Story

Esteban and Danielle adopted two girls from Ethiopia, one of whom was found to
have multidrug-resistant TB. With the help of a TB nurse, their daughter received the life-
saving treatment she needed.
Kennis Story

Kenni, a mother of two young daughters, became very sick in 2012 with a respiratory
illness. After numerous misdiagnoses, she finally learned she had TB.

Lilianas Story

Liliana was diagnosed with multidrug-resistant (MDR) tuberculosis (TB) in 2009.

She does not recall ever being exposed to anyone with TB disease as a child or as an adult.

Mabrukas Story

At age 18 Mabruka was diagnosed with TB. After successfully completing treatment
for TB, she now serves a peer counselor, educating others about TB.

Marthas Story

Martha is a nurse. In October 2010, she was diagnosed with TB, and later she learned
she had multidrug-resistant TB (MDR TB).

Natalies Story

Natalie contracted multidrug-resistant tuberculosis (MDR TB) while volunteering as

a physical therapist in South Africa. She was treated for 2 years before finally being cured of
the disease.

Rick and Francenes Story

In 2003, Rick and Francene adopted a 13-month-old boy from Russia. Shortly after
returning to the United States, they learned he had TB.
Rosalie and Faith's story

Rosalie's daughter Faith was first diagnosed with TB at the age of 5, although Rosalie
didn't understand the diagnosis. Later, after years of poor health, Faith was diagnosed again
with TB when she was 12.

Santos's Story

When Santoss infant son became ill with TB meningitis, he learned that he himself
had latent TB infection. He started but didnt finish treatment. Years later, he came down with
TB disease. Video

Sarahs Story

When Sarah, a high school student, found an odd lump on her neck in October 2011,
she never imagined it could be TB. She was referred to a surgeon who removed the lump, but
didn't diagnosis it at the time as TB.

Tris Story

Tri found out he had TB shortly after beginning college. After 9 months of treatment
for TB disease, Tri is back doing what he loves-playing basketball. Video

Testing & Diagnosis

Testing

There are two kinds of tests that are used to detect TB

bacteria in the body: the TB skin test (TST) and TB blood tests. A positive TB skin test or
TB blood test only tells that a person has been infected with TB bacteria. It does not tell
whether the person has latent TB infection (LTBI) or has progressed to TB disease. Other
tests, such as a chest x-ray and a sample of sputum, are needed to see whether the person has
TB disease.

Diagnosis

If a person is found to be infected with TB bacteria, other tests are needed to see if the person
has latent TB infection or TB disease.

Who Should be Tested

Certain people should be tested for TB infection because they are at higher risk for
being infected with TB bacteria, including:

People who have spent time with someone who has TB disease

People from a country where TB disease is common (most countries in Latin

America, the Caribbean, Africa, Asia, Eastern Europe, and Russia)

People who live or work in high-risk settings (for example: correctional facilities,
long-term care facilities or nursing homes, and homeless shelters)

Health-care workers who care for patients at increased risk for TB disease

Infants, children and adolescents exposed to adults who are at increased risk for latent
tuberculosis infection or TB disease

Many people who have latent TB infection never develop TB disease. But some people who
have latent TB infection are more likely to develop TB disease than others. Those at high risk
for developing TB disease include:

People with HIV infection

People who became infected with TB bacteria in the last 2 years

Babies and young children

People who inject illegal drugs

People who are sick with other diseases that weaken the immune system

Elderly people

People who were not treated correctly for TB in the past

TB tests are generally not needed for people with a low risk of infection with TB bacteria.
Testing for TB Infection
There are two types of tests for TB infection: the TB skin test and the TB blood test. A
persons health care provider should choose which TB test to use. Factors in selecting which
test to use include the reason for testing, test availability, and cost. Generally, it is not
recommended to test a person with both a TB skin test and a TB blood test.

Types of TB tests

TB Skin Test

TB Blood Test

Administering the TB skin test

The TB skin test is also called the Mantoux tuberculin skin test (TST). A TB skin test
requires two visits with a health care provider. On the first visit the test is placed; on the
second visit the health care provider reads the test.

The TB skin test is performed by injecting a small amount of fluid (called

tuberculin) into the skin on the lower part of the arm.

A person given the tuberculin skin test must return within 48 to 72 hours
to have a trained health care worker look for a reaction on the arm.

The result depends on the size of the raised, hard area or swelling.

o Positive skin test: This means the persons body was infected
with TB bacteria.

Reading the result of a TB skin test

 Additional tests are needed to determine if the person has latent TB
infection or TB disease.

o Negative skin test: This means the persons body did not react to
the test, and that latent TB infection or TB disease is not likely.

There is no problem in repeating a TB skin test. If repeated, the additional test should be
placed in a different location on the body (e.g., other arm).

The TB skin test is the preferred TB test for children under the age of five.

Testing in BCG-Vaccinated Persons

Many people born outside of the United States have been given a vaccine called BCG.

People who were previously vaccinated with BCG may receive a TB skin test to test for TB
infection. Vaccination with BCG may cause a false positive reaction to a TB skin test. A
positive reaction to a TB skin test may be due to the BCG vaccine itself or due to infection
with TB bacteria.

TB blood tests (IGRAs), unlike the TB skin test, are not affected by prior BCG vaccination
and are not expected to give a false-positive result in people who have received BCG. TB
blood tests are the preferred method of TB testing for people who have received the BCG
vaccine.

Testing Health Care Workers

Tuberculosis (TB) transmission has been documented

in health care settings where workers and patients come in contact with people who have TB
disease. Periodic testing of health care workers is recommended as part of a TB Infection
Control Plan and may be required by state regulations.

TB testing programs should include anyone working or volunteering in health-care settings.

Persons (health care workers and non- health care workers) who have face to face contact or
potential exposure to TB through shared air or space with infectious patient(s) should be part
of a TB testing program.

There are two types of testing for TB in health care workers.

Initial baseline testing upon hire: Two-step testing with a TB skin test or a TB blood
test

Annual or serial screening: determined by state regulations or risk assessment

outcomes.

Testing During Pregnancy

There is a greater risk to a pregnant woman and her

baby if TB disease is not diagnosed and treated.

TB skin testing is considered both valid and safe throughout pregnancy. TB blood tests also
are safe to use during pregnancy, but have not been evaluated for diagnosing TB infection in
pregnant women. Other tests are needed to show if a person has TB disease.

Diagnosing latent TB infection and TB

disease
Most persons, but not everyone, with TB disease have one or more symptoms of TB disease.
All persons with either symptoms or a positive TB test result should be evaluated for TB
disease. If a person has symptoms, but a negative TB test result, they should still be
evaluated for TB disease.

Diagnosis of Latent TB Infection

A diagnosis of latent TB infection is made if a person has a positive TB test result and a
medical evaluation does not indicate TB disease. The decision about treatment for latent TB
infection will be based on a persons chances of developing TB disease by considering their
risk factors.

Diagnosis of TB Disease

TB disease is diagnosed by medical history, physical examination, chest x-ray, and other
laboratory tests. TB disease is treated by taking several drugs as recommended by a health
care provider.

TB disease should be suspected in persons who have any of the following symptoms:

Unexplained weight loss

Loss of appetite

Night sweats

Fever

Fatigue

If TB disease is in the lungs (pulmonary), symptoms may include:

Coughing for longer than 3 weeks

Hemoptysis (coughing up blood)

Chest pain
If TB disease is in other parts of the body (extrapulmonary), symptoms will depend on the
area affected.

People suspected of having TB disease should be referred for a complete medical evaluation,
which will include the following:

1. Medical History

Clinicians should ask about the patients history of TB exposure, infection, or disease. It is
also important to consider demographic factors (e.g., country of origin, age, ethnic or racial
group, occupation) that may increase the patients risk for exposure to TB or to drug-resistant
TB. Also, clinicians should determine whether the patient has medical conditions, such as
HIV infection or diabetes, that increase the risk of latent TB infection progressing to TB
disease.

2. Physical Examination

A physical exam can provide valuable information about the patients overall condition and
other factors that may affect how TB is treated, such as HIV infection or other illnesses.

3. Test for TB Infection

The Mantoux tuberculin skin test (TST) or the TB blood test can be used to test for M.
tuberculosis infection. Additional tests are required to confirm TB disease.

4. Chest Radiograph

A posterior-anterior chest radiograph is used to detect chest abnormalities. Lesions may

appear anywhere in the lungs and may differ in size, shape, density, and cavitation. These
abnormalities may suggest TB, but cannot be used to definitively diagnose TB. However, a
chest radiograph may be used to rule out the possibility of pulmonary TB in a person who has
had a positive reaction to a TST or TB blood test and no symptoms of disease.

5. Diagnostic Microbiology

The presence of acid-fast-bacilli (AFB) on a sputum smear or other specimen often indicates
TB disease. Acid-fast microscopy is easy and quick, but it does not confirm a diagnosis of TB
because some acid-fast-bacilli are not M. tuberculosis. Therefore, a culture is done on all
initial samples to confirm the diagnosis. (However, a positive culture is not always necessary
to begin or continue treatment for TB.) A positive culture for M. tuberculosis confirms the
diagnosis of TB disease. Culture examinations should be completed on all specimens,
regardless of AFB smear results. Laboratories should report positive results on smears and
cultures within 24 hours by telephone or fax to the primary health care provider and to the
state or local TB control program, as required by law.

6. Drug Resistance

For all patients, the initial M. tuberculosis isolate should be tested for drug resistance. It is
crucial to identify drug resistance as early as possible to ensure effective treatment. Drug
susceptibility patterns should be repeated for patients who do not respond adequately to
treatment or who have positive culture results despite 3 months of therapy. Susceptibility
results from laboratories should be promptly reported to the primary health care provider and
to the state or local TB control program.

Treatment
Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions
exist: latent TB infection and TB disease. Both latent TB infection and TB disease can be
treated.

Without treatment latent TB infection can progress to TB disease. If not treated properly, TB
disease can be fatal.

Deciding When to Treat Latent TB

Infection
People with latent TB infection do not have symptoms, and they cannot spread TB bacteria to
others. However, if TB bacteria become active in the body and multiply, the person will go
from having latent TB infection to being sick with TB disease. For this reason, people with
latent TB infection are often prescribed treatment to prevent them from developing TB
disease. Treatment of latent TB infection is essential for controlling and eliminating TB in the
United States.

Treatment of latent TB infection should be initiated after the possibility of TB disease has
been excluded.

Groups Who Should be Given High Priority for Latent TB Infection Treatment

People with a positive IGRA result or a TST reaction of 5 or more millimeters

HIV-infected persons

Recent contacts of a TB case

Persons with fibrotic changes on chest radiograph consistent with old TB

 Organ transplant recipients

Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of
>15 mg/day of prednisone for 1 month or longer, taking TNF- antagonists)

People with a positive IGRA result or a TST reaction of 10 or more millimeters

Recent immigrants (< 5 years) from high-prevalence countries

Injection drug users

Residents and employees of high-risk congregate settings (e.g., correctional facilities,

nursing homes, homeless shelters, hospitals, and other health care facilities)

Mycobacteriology laboratory personnel

Children under 4 years of age, or children and adolescents exposed to adults in high-
risk categories

Persons with no known risk factors for TB may be considered for treatment of LTBI if they
have either a positive IGRA result or if their reaction to the TST is 15 mm or larger. However,
targeted TB testing programs should only be conducted among high-risk groups. All testing
activities should be accompanied by a plan for follow-up care for persons with TB infection
or disease.

Treatment Regimens for Latent TB

Infection (LTBI)
The four treatment regimens for latent TB infection (LTBI) use isoniazid (INH), rifapentine
(RPT), or rifampin (RIF). Treatment must be modified if the patient is a contact of an
individual with drug-resistant TB disease. Consultation with a TB expert is advised if the
known source of TB infection has drug-resistant TB.

Latent TB Infection Treatment Regimens

Drugs Duration Interval Comments

Isoniazid 9 months Daily Preferred treatment for:

Persons living with HIV

 Drugs Duration Interval Comments

Children aged 2-11

Pregnant Women (with pyridoxine/vitamin

B6 supplements)

Preferred treatment for:

Twice
Pregnant Women (with pyridoxine/vitamin
weekly*
B6 supplements)

Isoniazid 6 months Daily

Twice
weekly*
Isoniazid and 3 months Once
Rifapentine weekly* Treatment for:

Persons 12 years or older

Not recommended for persons who are:

Younger than 2 years old,

Living with HIV/AIDS taking antiretroviral

treatment,

Presumed infected with INH or RIF-resistant

M. tuberculosis, and

Women who are pregnant or expect to

become pregnant within the 12week
regimen.

Rifampin 4 months Daily

*Use Directly Observed Therapy (DOT)

Note: Due to the reports of severe liver injury and deaths, CDC recommends that the
combination of rifampin (RIF) and pyrazinamide (PZA) should generally not be offered for
the treatment of latent TB infection.
Treatment for TB Disease

When TB bacteria become active (multiplying in the body) and the immune system cant stop
the bacteria from growing, this is called TB disease. TB disease will make a person sick.
People with TB disease may spread the bacteria to people with whom they spend many hours.

It is very important that people who have TB disease are treated, finish the medicine, and take
the drugs exactly as prescribed. If they stop taking the drugs too soon, they can become sick
again; if they do not take the drugs correctly, the TB bacteria that are still alive may become
resistant to those drugs. TB that is resistant to drugs is harder and more expensive to treat.

TB disease can be treated by taking several drugs for 6 to 9 months. There are 10 drugs
currently approved by the U.S. Food and Drug Administration (FDA) for treating TB. Of the
approved drugs, the first-line anti-TB agents that form the core of treatment regimens are:

isoniazid (INH)

rifampin (RIF)

ethambutol (EMB)

pyrazinamide (PZA)

Expand All Collapse All

Related Links

State TB Control Programs

For Patients

TB - General Information (Fact sheet)

TB Can Be Treated (Fact sheet)

You Can Prevent TB (Fact sheet)

Staying on track with TB medicine (Pamphlet) (PDF - 511k)

Questions and Answers About TB

For Health Care Providers

Treatment Fact Sheets

 Treatment of Drug-Susceptible Tuberculosis Disease in Persons Not
Infected with HIV

Treatment of Drug-Resistant Tuberculosis

Treatment of Multidrug-Resistant Tuberculosis: Bedaquiline

Treatment Guidelines

Adverse Events
Patients on treatment for latent TB infection (LTBI) or TB disease should report any signs
and symptoms of adverse drug reactions to their health care provider, including

Unexplained anorexia, nausea or vomiting, dark urine*, or icterus (yellowing of skin

or eyes)

Persistent paresthesia (tingling, numbness, or burning) of hands or feet

Persistent weakness, fatigue, fever, or abdominal tenderness

Easy bruising or bleeding

Blurred vision or changed vision

*Patients taking rifampin (RIF) or rifapentine (RPT) should be informed that they will notice
a normal orange discoloration of body fluids, including urine and tears. Contact lenses may
be permanently stained.

Patients should provide a list of current medications to avoid drug interactions. Some
interactions to note:

Isoniazid (INH) increases blood levels of phenytoin (Dilantin) and disulfiram

(Antabuse)

RIF and RPT decrease blood levels of many drugs including oral contraceptives,
warfarin, sulfonureas, and methadone

RIF and RPT are contraindicated in HIV-infected individuals being treated with
protease inhibitors (PIs) and most nonnucleoside reverse transcriptase inhibitors
(NNRTIs)

Treatment of Persons Living with HIV

People living with HIV who also have either latent TB infection or TB disease can be
effectively treated. The first step is to ensure that people living with HIV are tested for TB
infection. If found to have TB infection, further tests are needed to rule out TB disease. The
next step is to start treatment for latent TB infection or TB disease based on test results.

Fortunately, there are a number of treatment options for people living with HIV who also
have latent TB infection or TB disease. Consult with your state or local health department for
treatment options.

Latent TB Infection and HIV

Someone with untreated latent TB infection and HIV infection is much more likely to
develop TB disease during his or her lifetime than someone without HIV infection.

The recommended treatment of latent TB infection in adults infected with HIV is a daily dose
of isoniazid (INH) for 9 months.

TB Disease and HIV

The recommended treatment of TB disease in adults infected with HIV (when the disease is
caused by organisms that are known or presumed to be susceptible to first-line drugs) is a 6-
month daily regimen consisting of:

An intensive phase of isoniazid (INH), a rifamycin (see Drug Interactions below),

pyrazinamide (PZA), and ethambutol (EMB) for the first 2 months.

A continuation phase of INH and a rifamycin for the last 4 months.

Once-weekly INH and rifapentine in the continuation phase should not be used in any
patient infected with HIV.

Six months should be considered the minimum duration of treatment for adults with HIV,
even for patients with culture-negative TB. In the uncommon situation in which HIV-infected
patients do NOT receive antiretroviral therapy during tuberculosis treatment, prolonging
treatment to 9 months (extend continuation phase to 7 months) is recommended. Prolonging
treatment to 9 months (extend continuation phase to 7 months) for HIV-infected patients with
delayed response to therapy (e.g., culture positive after 2 months of treatment) should be
strongly considered.

Drug-Resistant TB and HIV

Treatment of drug-resistant TB in persons with HIV infection is the same as for patients
without HIV; however, management of HIV-related TB requires expertise in the management
of both HIV and TB.
Anti-retroviral Therapy During Tuberculosis Treatment

Anti -retroviral therapy should be initiated during tuberculosis treatment, rather than at the
end, to improve outcomes among tuberculosis patients co-infected with HIV. Anti-retroviral
therapy should ideally be initiated within the first 2 weeks of tuberculosis treatment for
patients with CD4 cell counts <50/mm3 and by 8-12 weeks of tuberculosis treatment
initiation for patients with CD4 cell counts 50/mm3. An important exception is HIV-
infected patients with tuberculosis meningitis, in whom antiretroviral therapy should not be
initiated in the first 8 weeks of antituberculosis therapy.

Drug Interactions

One concern is the interaction of rifampin (RIF) with certain antiretroviral agents (some
protease inhibitors [PIs] and nonnucleoside reverse transcriptase inhibitors [NRTIs]).
Rifabutin, which has fewer problematic drug interactions, may be used as an alternative to
RIF for HIV-infected patients.

As new antiretroviral agents and more pharmacokinetic data become available, these
recommendations on managing interactions are likely to be modified. Visit Managing Drug
Interactions in the Treatment of HIV-Related Tuberculosis for the most recent
recommendations.

Case Management

Directly observed therapy (DOT) and other adherence promoting strategies should be used in
all patients with HIV-related TB. The care for HIV-related TB should be provided by, or in
consultation with, experts in management of both TB and HIV. The care for persons with
HIV-related TB should include close attention to adherence to both regimens of TB and
antiretroviral treatment, drug-drug interactions, paradoxical reaction or Immune
Reconstitution Inflammatory Syndrome (IRIS), side effects for all drugs used, and the
possibility of TB treatment failure or relapse.

TB Treatment and Pregnancy

Untreated tuberculosis (TB) disease represents a greater hazard to a pregnant woman and her
fetus than does its treatment. Treatment should be initiated whenever the probability of TB is
moderate to high.

Infants born to women with untreated TB may be of lower birth weight than those
born to women without TB and, in rare circumstances, the infant may be born with
TB.

Although the drugs used in the initial treatment regimen for TB cross the placenta,
they do not appear to have harmful effects on the fetus.

TB Treatment Regimens for Pregnant Women

Diagnosis Treatment

Isoniazid (INH) daily or twice weekly for 9 months, with pyridoxine

(vitamin B6) supplementation
Latent TB
Infection
3HP INH and Rifapentine is not recommended for pregnant women or
women expecting to be pregnant in the next 3 months

The preferred initial treatment regimen is INH, rifampin (RIF), and

ethambutol (EMB) daily for 2 months, followed by INH and RIF daily,
or twice weekly for 7 months (for a total of 9 months of treatment).

TB Disease Streptomycin should not be used because it has been shown to have
harmful effects on the fetus.

Pyrazinamide (PZA) is not recommended to be used because its effect

on the fetus is unknown.

Treatment of TB disease for pregnant women co-infected with HIV

HIV-Related should be the same as for nonpregnant women, but with attention given
TB Disease to additional considerations. For more information please review the
Guidelines for Prevention and Treatment of Opportunistic Infections in
HIV-Infected Adults and Adolescents.

Contraindications

The following antituberculosis drugs are contraindicated in pregnant women:

Streptomycin

Kanamycin

Amikacin

Capreomycin

Fluoroquinolones

Drug-Resistant TB
Pregnant women who are being treated for drug-resistant TB should receive counseling
concerning the risk to the fetus because of the known and unknown risks of second-line
antituberculosis drugs.

Breastfeeding

Breastfeeding should not be discouraged for women being treated with the first-line
antituberculosis drugs because the concentrations of these drugs in breast milk are too small
to produce toxicity in the nursing newborn. For the same reason, drugs in breast milk are not
an effective treatment for TB disease or latent TB infection in a nursing infant. Breastfeeding
women taking INH should also take pyridoxine (vitamin B6) supplementation.

TB Treatment for Children

Once infected with TB bacteria, children are more likely

to get sick with TB disease and to get sick more quickly than adults. In comparison to
children, TB disease in adults is usually due to past TB infection that becomes active years
later, when a persons immune system becomes weak for some reason (e.g., HIV infection,
diabetes).

A pediatric TB expert should be involved in the treatment of TB in children and in the

management of infants, young children, and immunocompromised children who have been
exposed to someone with infectious TB disease. It is very important that children or anyone
being treated for latent TB infection or TB disease finish the medicine and take the drugs
exactly as instructed.

Latent TB Infection Treatment for Children

Treatment is recommended for children with latent TB infection to prevent them from
developing TB disease. Infants, young children, and immunocompromised children with
latent TB infection or children in close contact with someone with infectious TB disease,
require special consideration because they are at increased risk for getting TB disease.
Consultation with a pediatric TB expert is recommended before treatment begins. Isoniazid is
the anti-TB medicine that is most commonly used for treatment of latent TB infection. In
children, the recommended length of treatment with isoniazid is 9 months.

TB Disease Treatment for Children

TB disease is treated by taking several anti-TB medicines for 6 to 9 months. It is important to

note that if a child stops taking the drugs before completion, the child can become sick again.
If drugs are not taken correctly, the bacteria that are still alive may become resistant to those
drugs. TB that is resistant to drugs is harder and more expensive to treat, and treatment lasts
much longer (up to 18 to 24 months).

Drug-Resistant TB

Tuberculosis (TB) is a disease caused by bacteria that are spread from person to person
through the air. TB usually affects the lungs, but it can also affect other parts of the body,
such as the brain, the kidneys, or the spine. In most cases, TB is treatable and curable;
however, people with TB can die if they do not get proper treatment. Sometimes drug-
resistant TB occurs when bacteria become resistant to the drugs used to treat TB. This means
that the drug can no longer kill the TB bacteria.

Drug-resistant TB (DR TB) is spread the same way that drug-susceptible TB is spread. TB is
spread through the air from one person to another. The TB bacteria are put into the air when a
person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People
nearby may breathe in these bacteria and become infected.

Drug-resistant TB can occur when the drugs used to treat TB are misused or mismanaged.
Examples of misuse or mismanagement include

People do not complete a full course of TB treatment

Health care providers prescribe the wrong treatment (the wrong dose or length of
time)

Drugs for proper treatment are not available

Drugs are of poor quality

Drug-resistant TB is more common in people who

Do not take their TB drugs regularly

 Do not take all of their TB drugs

Develop TB disease again, after being treated for TB disease in the past

Come from areas of the world where drug-resistant TB is common

Have spent time with someone known to have drug-resistant TB disease

Multidrug-Resistant TB (MDR TB)

Multidrug-resistant TB (MDR TB) is caused by TB bacteria that is resistant to at least

isoniazid and rifampin, the two most potent TB drugs. These drugs are used to treat all
persons with TB disease.

TB experts should be consulted in the treatment of MDR TB.

Extensively Drug-resistant TB (XDR TB)

Extensively drug-resistant TB (XDR TB) is a rare type of MDR TB that is resistant to

isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-
line drugs (i.e., amikacin, kanamycin, or capreomycin).

Because XDR TB is resistant to the most potent TB drugs, patients are left with treatment
options that are much less effective.

XDR TB is of special concern for people with HIV infection or other conditions that can
weaken the immune system. These people are more likely to develop TB disease once they
are infected, and also have a higher risk of death once they develop TB.

TB experts should be consulted in the treatment of XDR TB.

Extensively Drug-Resistant TB (Fact sheet)

Laboratory Guidance

The emergence of Mycobacterium tuberculosis strains that cause XDR TB has prompted the
issuance of interim guidelines for clinical and research laboratories handling XDR TB
specimens.

Interim Laboratory Biosafety Guidance for Extensively Drug-Resistant (XDR)

Mycobacterium tuberculosis strains

The most important way to prevent the spread of drug-resistant TB is to take all TB drugs
exactly as prescribed by the health care provider. No doses should be missed and treatment
should not be stopped early. People receiving treatment for TB disease should tell their health
care provider if they are having trouble taking the drugs.
Health care providers can help prevent drug-resistant TB by quickly diagnosing cases,
following recommended treatment guidelines, monitoring patients response to treatment, and
making sure therapy is completed.

Another way to prevent getting drug-resistant TB is to avoid exposure to known drug-

resistant TB patients in closed or crowded places such as hospitals, prisons, or homeless
shelters. People who work in hospitals or health-care settings where TB patients are likely to
be seen should consult infection control or occupational health experts.

Drug-resistant TB is caused by TB bacteria that are resistant to at least one first-line anti-TB
drug. Multidrug-resistant TB (MDR TB) is resistant to more than one anti-TB drug and at
least isoniazid (INH) and rifampin (RIF).

Extensively drug-resistant TB (XDR TB) is a rare type of MDR TB that is resistant to

isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-
line drugs (i.e., amikacin, kanamycin, or capreomycin).

Treating and curing drug-resistant TB is complicated. Inappropriate management can have

life-threatening results. Drug-resistant TB should be managed by or in close consultation with
an expert in the disease.

Safety Announcement Regarding Fluoroquinolone Antibacterial Drugs

The US Food and Drug Administration (FDA) has advised restricting fluoroquinolone
antibiotic use for certain uncomplicated infections because of adverse effects from these
medications (available at http://www.fda.gov/Drugs/DrugSafety/ucm500143.htm).
Specifically, FDA indicated that the risks of adverse effects of fluoroquinolone antibacterial
drugs generally outweigh the benefits for patients with sinusitis, bronchitis, and
uncomplicated urinary tract infections who have other treatment options.

While patients receiving fluoroquinolone antibacterial drugs for tuberculosis (TB) also have a
chance of experiencing the adverse effects noted by FDA, fluoroquinolone antibacterial drugs
are absolutely necessary for some patients who have drug-resistant TB disease or drug-
resistant latent TB infection or who cannot tolerate first-line TB drugs. For these TB patients,
there are no better alternatives, and the benefits of fluoroquinolone antibacterial drugs
outweigh the risks because TB is not a minor infection, but potentially fatal or debilitating.

If you are a TB patient receiving fluoroquinolone antibacterial drugs and have questions,
please contact your medical provider or local or state TB control program. If you are a
medical provider and have questions about the use of fluoroquinolone antibacterial drugs in
TB treatment, please contact your local or state TB control program.

While MDR TB and XDR TB are relatively rare in the U.S., their treatment comes at a
terrible price it is very expensive, takes a long time to complete, disrupts lives, and has
potentially life-threatening side effects. A substantial proportion of patients treated for these
forms of drug-resistant TB experience serious side effects, including: depression or
psychosis, hearing loss, hepatitis, and kidney impairment.
The average cost of treating a person with TB disease increases with greater resistance. Direct
costs (in 2014 U.S. dollars) average from $17,000 to treat drug-susceptible TB to $482,000 to
treat the most drug-resistant form of the disease (XDR TB). When including productivity
losses (e.g., lost income) experienced by patients while undergoing treatment, costs are even
higher.

Data and Statistics

Tuberculosis (TB) is one of the worlds deadliest diseases:

One third of the worlds population is infected with TB.

In 2014, 9.6 million people around the world became sick with TB disease. There
were 1.5 million TB-related deaths worldwide.

TB is a leading killer of people who are HIV infected.

A total of 9,421 TB cases (a rate of 2.96 cases per 100,000 persons) were reported in the
United States in 2014. Both the number of TB cases reported and the case rate decreased; this
represents a 1.5% and 2.2% decline, respectively, compared to 2013. This is the smallest
decline in more than a decade.

Leveling of Tuberculosis Incidence United States, 20132015

For local or county specific information, please contact your State TB Control Program.

Fact Sheet

Trends in Tuberculosis, 2014

How many cases of tuberculosis (TB) were reported in the United States
in 2014?

A total of 9,421 TB cases (a rate of 2.96 cases per 100,000 persons) were reported in the
United States in 2014. Both the number of TB cases reported and the case rate decreased; this
represents a 1.5% and 2.2% decline, respectively, compared to 2013*. This is the smallest
decline in more than a decade.

*Ratio calculation is based on unrounded data values.

Is the rate of TB declining in the United States?

Yes. Since the 1992 peak of TB resurgence in the United States, the number of TB cases
reported each year has decreased.

How do the TB rates compare between U.S.-born persons and foreign-

born persons living in the United States?

In 2014, a total of 66% of reported TB cases in the United States occurred among foreign-
born persons. The case rate among foreign-born persons (15.4 cases per 100,000 persons) in
2014 was approximately 13 times higher than among U.S.-born persons (1.2 cases per
100,000 persons).

How many people died from TB in the United States?

There were 555 deaths from TB in 2013, the most recent year for which these data are
available. This is an 8% increase from the 510 TB deaths in 2012. Overall, the number of TB
deaths reported annually has decreased by 67% since 1992.

What are the rates of TB for different racial and ethnic populations?

American Indians or Alaska Natives: 5.0 TB cases per 100,000 persons

Asians: 17.8 TB cases per 100,000 persons

Blacks or African Americans: 5.1 TB cases per 100,000 persons

Native Hawaiians and other Pacific Islanders: 16.9 TB cases per 100,000
persons

Hispanics or Latinos: 5.0 TB cases per 100,000 persons

 Whites: 0.6 TB cases per 100,000 persons

For this report, persons identified as white, black, Asian, American Indian/Alaska Native,
native Hawaiian or other Pacific Islander, or of multiple races are all non-Hispanic. Persons
identified as Hispanic may be of any race.

Is multidrug-resistant tuberculosis (MDR TB) on the rise?

Overall, the percentage of MDR TB cases decreased slightly from 1.4% (96 cases) in 2013 to
1.3% (91 cases) in 2014.**
Of the total number of reported MDR TB cases, the proportion occurring among foreign-born
persons increased from 31% (149 of 484) in 1993 to 88% (80 of 91) in 2014.

* MDR TB is defined as TB disease that is resistant to at least isoniazid and rifampin.

** Among culture-positive TB cases in the United States with initial drug-susceptibility
testing results.

Where can I find TB data for my state?

The most recent surveillance report, Reported Tuberculosis in the United States, 2014,
includes data from 60 reporting areas (the 50 states, the District of Columbia, New York City,
Puerto Rico, and seven other U.S. jurisdictions in the Pacific and Caribbean). The report can
be found online at http://www.cdc.gov/tb/statistics/default.htm. If you need additional state-
specific data not available in this report, you can contact your state TB control office:
https://www.cdc.gov/tb/links/tboffices.htm.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

(NCHHSTP) Atlas (2008-2013) NCHHSTP Atlas is an interactive tool that
allows users to observe trends and patterns by creating detailed reports,
maps, and other graphics showing geographic patterns and time trends.
Available at http://www.cdc.gov/nchhstp/atlas/.

Online Tuberculosis Information System (OTIS) (2009-2013) OTIS is an

interactive data system containing information on TB cases reported to
CDC. Users can select criteria to produce specific reports. Data are
available by year, state, and demographic factors. Available at
http://wonder.cdc.gov/tb.html.

References
CDC. Reported Tuberculosis in the United States, 2014. Atlanta, GA: U.S. Department of
Health and Human Services, CDC, October 2015. Available at
http://www.cdc.gov/tb/statistics/reports/2014

TB Incidence in the United States, 1953-

2014
 TB Incidence in the United States, 1953-2014
TB Cases and Case Rates per 100,000 Population
Rat
Year Number of Cases
e
2014 9,421 3.0
2013 9,582 3.0
2012 9,945 3.2
2011 10,517 3.4
2010 11,163 3.6
2009 11,520 3.8
2008 12,895 4.2
2007 13,282 4.4
2006 13,727 4.6
2005 14,061 4.8
2004 14,498 4.9
2003 14,835 5.1
2002 15,055 5.2
2001 15,945 5.6
2000 16,309 5.8
1999 17,499 6.3
1998 18,287 6.6
1997 19,751 7.2
1996 21,210 7.9
1995 22,727 8.5
1994 24,205 9.2
1993 25,103 9.7
1992 26,673 10.4
1991 26,283 10.4
1990 25,701 10.3
1989 23,495 9.5
1988 22,436 9.2
1987 22,517 9.3
1986 22,768 9.5
1985 22,201 9.3
1984 22,255 9.4
1983 23,846 10.2
1982 25,520 11.0
1981 27,373 11.9
1980 27,749 12.2
19793 27,669 12.3
1978 28,521 12.8
1977 30,145 13.7
1976 32,105 14.7
1975 33,989 15.7
19742 30,122 14.1
1973 30,998 14.6
1972 32,882 15.7
1971 35,217 17.0
 TB Incidence in the United States, 1953-2014
TB Cases and Case Rates per 100,000 Population
1970 37,137 18.1
1969 39,120 19.3
1968 42,623 21.2
1967 45,647 23.0
1966 47,767 24.3
1965 49,016 25.2
1964 50,874 26.5
1963 54,042 28.6
1962 53,315 28.6
1961 53,726 29.2
1960 55,494 30.7
1959 57,535 32.4
1958 63,534 36.3
1957 67,149 39.0
1956 69,895 41.4
1955 77,368 46.6
1954 79,775 48.9
1953 84,304 52.6

1
Case data after 1974 are not comparable to prior years due to changes in the surveillance
case definition that became effective in 1975.

Note: 1993 to 2011 tuberculosis case counts and rates updated as of June 25, 2012, using
Bridged-Race 19901999 Intercensal Population Estimates for 19901999
(ftp://ftp.cdc.gov/pub/health_statistics/nchs/datasets/nvss/bridgepop/documentationbridgedint
ercena1.doc) (accessed July 20, 2012) and Annual Estimates of the Population for the United
States and States, and for Puerto Rico (July 1, 2000 July 1, 2010)
(www.census.gov/popest/states/tables/NST-PEST2010-01.xls) (accessed July 20, 2012) and
Annual Estimates of the Population for the United States, Regions, States, and Puerto Rico:
April 1, 2010 to July 1, 2011 (http://www.census.gov/popest/data/national/totals/2011/index.
html) (accessed August 8, 2012). Percentage change results reported to one decimal. Ellipses
indicate data not available. See Surveillance Slides #2 and #3.

Research

TB Epidemiologic Studies Consortium

he TB Epidemiologic Studies Consortium (TBESC) was established to strengthen, focus, and

coordinate tuberculosis (TB) research. The TBESC is designed to build the scientific research
capacities of state and metropolitan TB control programs, participating laboratories, academic
institutions, hospitals, and both non- and for-profit organizations.

TB Trials Consortium

The TB Trials Consortium (TBTC) is a collaboration of North American and international

clinical investigators whose mission is to conduct programmatically relevant research
concerning the diagnosis, clinical management, and prevention of TB infection and disease.

Behavioral and Social Science Research

Behavioral and social science research has the potential to make a tremendous
impact on TB elimination efforts. This research is needed to 1) understand how
behaviors of both patients and providers affect TB-related care seeking,
diagnosis, treatment success, and prevention; and 2) understand how other
social, cultural, and environmental influences affect health seeking and
treatment outcomes related to TB.
Tuberculosis Epidemiologic Studies Consortium (TBESC)

TBESC II - Striving to Prevent, Control, and Eliminate

Tuberculosis
TBESC II focuses its research on latent TB infection. Latent TB infection
is the condition when a person is infected with Mycobacterium tuberculosis
(M. tuberculosis), but has not yet developed TB disease, has no symptoms,
and cannot pass the bacteria to others.

Why Focus on Latent TB Infection?

In recent years, the U.S. has recorded the lowest TB rates in history. One factor that has
contributed to this decline is a strong scientific approach to TB control. To accelerate the
decline and achieve the goal of TB elimination, research is needed for improved diagnostic
tools, treatments, and approaches.

Preventing TB disease by detecting and treating those with latent TB

infection is a cornerstone of the U.S. strategy for TB elimination.

It is estimated that more than 11 million people in the U. S. have latent TB

infection; however, most of these people are unaware of their infection.

If not treated, about 5 to 10 percent of people with latent TB infection will

develop TB disease. This equates to approximately 550,000 to 1.1 million
people in the U.S.
 Diagnosis and treatment of latent TB infection can be difficult with existing
diagnostic tools and treatment regimens.

Primary Study of TBESC II

The primary study of TBESC II:

Evaluates tests used to detect latent TB infection. These tests include the
tuberculin skin test (TST) and the interferon-gamma release assays
(IGRAs): QuantiFERON-TB Gold In-Tube (QFT-GIT), and T-SPOT.TB test
(T-Spot).

Compares the ability of the TST and IGRAs to predict progression from
latent TB infection to TB disease. This study is one of the largest of its
kind. Approximately 6,000 patients will be enrolled each year for a total
enrollment of about 42,000 patients over a 7 year period.

TBESC II will also evaluate:

Strategies to ensure latent TB infection treatment acceptance and

completion.

Shorter, safer, and cost-effective latent TB infection treatment regimens.

A State-of-the-Art Data Management System

TBESC II is supported by a Web-based data management system. The system operates on
one platform with modules to oversee patient enrollment, case management, clinical
documentation, appointment scheduling, reporting, invoicing, and security/access.

For further information, contact TBESC at TBESC@cdc.gov

TBESC I

Research Projects

Publications

Tuberculosis Epidemiologic Studies Consortium I (TBESC I)

Research Projects
Tuberculosis Epidemiologic Studies Consortium Research Projects
Task Principal Numbe
Orde Task Order Title Investigat r of Status
r or Sites
Jenny Pang
The Current Cost of TB within urban
32 Thad Miller 5
United States
Dolly Katz
31 Evaluation of Interferon Gamma Denise Dom: 1 Complet
Release Assays in Overseas Garrett Intl: 3 ed
 John Painter
Drew Posey
Immigration Examination of Children in
Domestic:
Moderate- and High-burden Countries
Randall
Reves
Suzanne
Quantifying the risk of premature death Beavers Complet
30 3
in TB survivors Thad Miller ed
Jenny Pang
Improving testing for TB and LTBI for
Suzanne Complet
29 Persons with HIV Infection at HRSA- 2
Marks ed
funded HIV/AIDS Clinics
Treatment Practices, Outcomes and
Suzanne
Cost of Multidrug-resistant (MDR TB)
Marks
28 and Extensively Drug Resistant 3
Lori
Tuberculosis (XDR TB) in the United
Armstrong
States
Use of Nucleic Acid Amplification Test to
Suzanne Complet
27 Determine the Relative Infectiousness 4
Marks ed
of Pulmonary TB Patients
Improving the Utilization and
Roque
Integration of TB Genotyping into
Miramontes
26 Routine TB Program Practice: Analyzing 3
Wendy
the Impact Through Public Health
Cronin
Interventions
Tuberculosis Mortality in the United Suzanne
25 States: Epidemiology and Prevention Beavers 12
Opportunities Jenny Flood
Robin
Perceptions of TB among the Karen- Complet
24 Shrestha- 1
Burmese: An Ethnographic Study ed
Kuwahara
National Study of Determinants of Early Rachel
23 Diagnosis, Prevention, and Treatment of Royce 7
TB in the African-American Community Dolly Katz
Acquired Rifamycin-resistant TB among Sundari
21
HIV infected patients Mase
Randall
Assessing QFT as an initial screening
Reves
tool for U.S. bound applicants for Complet
20 John Painter 2
immigration and feasibility of follow-up ed
Lilia
in U.S. immigrants
Manangan
Lauren
Effectiveness of Quantiferon- TB Gold Lambert
19 2
(QFT-G) in contact tracing Sharon
Welbel
18 Evaluation of New Interferon-y Release Denise 4
 Garrett
Charles
Assays in the Diagnosis of Latent TB
Daley
Infection in Health Care Workers
Susan
Dorman
Sue Etkind
African Refugee Womens Health
16Alt Jennifer 1
Improvement Project
Cochran
Enhancing TB Programs Capacity for
Maureen Complet
15 Self-Evaluation: Testing New Tools and 1
Wilce ed
Developing an Evaluation Toolkit
Culturally Appropriate TB Educational
Wanda Complet
14 Materials for Leaders and Staff of 1
Walton ed
Hispanic Service Organizations
Robin
Shrestha-
Factors Associated with Acceptance of,
Kuwahara
Adherence to and Toxicity From
Stefan Complet
13 Treatment for Latent TB Infection and 20
Goldberg ed
Pilot Study of Treatment for Latent TB
Paul Colson,
Infection Effectiveness
Yael Hirsch-
Moverman
Assessing the TB Knowledge, Attitudes,
Wanda
Beliefs, and Practices Among Private
12 Walton 1
Providers Serving Foreign-born
Jenny Pang
Populations at Risk for TB
Addressing TB Among African
Americans in the Southeast: Identifying Wanda
and Overcoming Barriers to Treatment Walton Complet
11 1
Adherence for Latent TB Infection and Rachel ed
TB Disease Royce

New Model for Assessing TB

Scott Complet
10 Surveillance and Action Performance 2
McNabb ed
and Cost
Dolly Katz
Missed Opportunities for TB Prevention Randall
9 in Foreign-Born Population in the United Reves 20
States and Canada Amy
Davidow
Edward
An Analysis of Molecular Epidemiology Graviss
Complet
8 of Multi-Drug Resistant M. tuberculosis Patrick 17
ed
in the United States Moonan
Jenny Flood
7 Use of Network Analysis Methods to Peter 3 Complet
 Characterize M. tuberculosis McElroy
Transmission Patterns Among Women Maureen ed
and Other High-Risk Populations Wilce
Regional Capacity-Building in Low- Paul Tribble Complet
6 1
Incidence Areas ed
Prevalence of Latent TB Infection Rachel
Complet
5 Among High Risk Populations in the Albalak 3
ed
United States
Models for Incorporating HIV
Suzanne Complet
4 Counseling, Testing, and Referral into 4
Marks ed
Tuberculosis Contact Investigations
Mark Complet
3 Zero Tolerance for Pediatric TB 3
Lobato ed
Prospective Evaluation of
Immunogenetic and Immunologic
Mary
Markers for Susceptibility to
2 Reichler 9
Tuberculosis Infection and Progression
Tim Sterling
from M. Tuberculosis infection to active
TB
Complet
1 TBES Consortium: Core Requirements 21
ed
*Alternate Track Task Order: Local initiative not reviewed and
monitored by Research Committee
**Outside Funding Task Order: Project funded from outside of CDC
Division of TB Elimination. Reviewed and monitored by Research
Committee

Tuberculosis Epidemiologic Studies Consortium I (TBESC I)

Research Projects
Tuberculosis Epidemiologic Studies Consortium Research Projects
Task Principal Numbe
Orde Task Order Title Investigat r of Status
r or Sites
Jenny Pang
The Current Cost of TB within urban
32 Thad Miller 5
United States
Dolly Katz
Denise
Garrett
Evaluation of Interferon Gamma
John Painter
Release Assays in Overseas Dom: 1 Complet
31 Drew Posey
Immigration Examination of Children in Intl: 3 ed
Domestic:
Moderate- and High-burden Countries
Randall
Reves
30 Quantifying the risk of premature death Suzanne 3 Complet
in TB survivors Beavers ed
 Thad Miller
Jenny Pang
Improving testing for TB and LTBI for
Suzanne Complet
29 Persons with HIV Infection at HRSA- 2
Marks ed
funded HIV/AIDS Clinics
Treatment Practices, Outcomes and
Suzanne
Cost of Multidrug-resistant (MDR TB)
Marks
28 and Extensively Drug Resistant 3
Lori
Tuberculosis (XDR TB) in the United
Armstrong
States
Use of Nucleic Acid Amplification Test to
Suzanne Complet
27 Determine the Relative Infectiousness 4
Marks ed
of Pulmonary TB Patients
Improving the Utilization and
Roque
Integration of TB Genotyping into
Miramontes
26 Routine TB Program Practice: Analyzing 3
Wendy
the Impact Through Public Health
Cronin
Interventions
Tuberculosis Mortality in the United Suzanne
25 States: Epidemiology and Prevention Beavers 12
Opportunities Jenny Flood
Robin
Perceptions of TB among the Karen- Complet
24 Shrestha- 1
Burmese: An Ethnographic Study ed
Kuwahara
National Study of Determinants of Early Rachel
23 Diagnosis, Prevention, and Treatment of Royce 7
TB in the African-American Community Dolly Katz
Acquired Rifamycin-resistant TB among Sundari
21
HIV infected patients Mase
Randall
Assessing QFT as an initial screening
Reves
tool for U.S. bound applicants for Complet
20 John Painter 2
immigration and feasibility of follow-up ed
Lilia
in U.S. immigrants
Manangan
Lauren
Effectiveness of Quantiferon- TB Gold Lambert
19 2
(QFT-G) in contact tracing Sharon
Welbel
Denise
Garrett
Evaluation of New Interferon-y Release
Charles
18 Assays in the Diagnosis of Latent TB 4
Daley
Infection in Health Care Workers
Susan
Dorman
16Alt African Refugee Womens Health Sue Etkind 1
Improvement Project Jennifer
 Cochran
Enhancing TB Programs Capacity for
Maureen Complet
15 Self-Evaluation: Testing New Tools and 1
Wilce ed
Developing an Evaluation Toolkit
Culturally Appropriate TB Educational
Wanda Complet
14 Materials for Leaders and Staff of 1
Walton ed
Hispanic Service Organizations
Robin
Shrestha-
Factors Associated with Acceptance of,
Kuwahara
Adherence to and Toxicity From
Stefan Complet
13 Treatment for Latent TB Infection and 20
Goldberg ed
Pilot Study of Treatment for Latent TB
Paul Colson,
Infection Effectiveness
Yael Hirsch-
Moverman
Assessing the TB Knowledge, Attitudes,
Wanda
Beliefs, and Practices Among Private
12 Walton 1
Providers Serving Foreign-born
Jenny Pang
Populations at Risk for TB
Addressing TB Among African
Americans in the Southeast: Identifying Wanda
and Overcoming Barriers to Treatment Walton Complet
11 1
Adherence for Latent TB Infection and Rachel ed
TB Disease Royce

New Model for Assessing TB

Scott Complet
10 Surveillance and Action Performance 2
McNabb ed
and Cost
Dolly Katz
Missed Opportunities for TB Prevention Randall
9 in Foreign-Born Population in the United Reves 20
States and Canada Amy
Davidow
Edward
An Analysis of Molecular Epidemiology Graviss
Complet
8 of Multi-Drug Resistant M. tuberculosis Patrick 17
ed
in the United States Moonan
Jenny Flood
Use of Network Analysis Methods to Peter
Characterize M. tuberculosis McElroy Complet
7 3
Transmission Patterns Among Women Maureen ed
and Other High-Risk Populations Wilce
Regional Capacity-Building in Low- Paul Tribble Complet
6 1
Incidence Areas ed
5 Prevalence of Latent TB Infection Rachel 3 Complet
Among High Risk Populations in the ed
 Albalak
United States

Models for Incorporating HIV

Suzanne Complet
4 Counseling, Testing, and Referral into 4
Marks ed
Tuberculosis Contact Investigations
Mark Complet
3 Zero Tolerance for Pediatric TB 3
Lobato ed
Prospective Evaluation of
Immunogenetic and Immunologic
Mary
Markers for Susceptibility to
2 Reichler 9
Tuberculosis Infection and Progression
Tim Sterling
from M. Tuberculosis infection to active
TB
Complet
1 TBES Consortium: Core Requirements 21
ed
*Alternate Track Task Order: Local initiative not reviewed and
monitored by Research Committee
**Outside Funding Task Order: Project funded from outside of CDC
Division of TB Elimination. Reviewed and monitored by Research
Committee

uberculosis Epidemiologic Studies Consortium I (TBESC I)

Publications
Peer-reviewed Journal Articles

Katz D, Albalak R, Wing JS, Combs V; Tuberculosis Epidemiologic Studies

Consortium. . Setting the agenda: a new model for collaborative
tuberculosis epidemiologic research. Tuberculosis 2007;87:1-6.

Fiske CT, Yan FX, Hirsch-Moverman Y, Sterling TR, Reichler MR;

Tuberculosis Epidemiologic Studies Consortium Task Order 2 Team. Risk
factors for treatment default in close contacts with latent tuberculous
infection. Int J Tuberc Lung Dis. 2014;18:421-7.

Hirsch-Moverman Y, Cronin WA, Chen B, Moran JA, Munk E, Reichler

MR; Tuberculosis Epidemiological Studies Consortium Task Order 2 Team.
HIV counseling and testing in tuberculosis contact investigations in the
United States and Canada. Int J Tuberc Lung Dis 2015;19:94353.

Lobato MN, Sun SJ, Moonan PK, Weis SE, Saiman L, Reichard AA, Feja K;
Zero Tolerance for Pediatric TB Study Group. Underuse of effective
measures to prevent and manage pediatric tuberculosis in the United
States. Arch Pediatr Adolesc Med. 2008;162:426-31.

Li J, Marks SM, Driver CR, Diaz FA, Castro AF 3rd, de Regner AF, Gibson AE,
Dokubo-Okereke K, Munsiff SS; Tuberculosis Epidemiologic Studies
Consortium. Human immunodeficiency virus counseling, testing, and
 referral of close contacts to patients with pulmonary tuberculosis:
feasibility and costs. J Public Health Manag Pract. 2007;13:252-62.

Weinfurter P, Blumberg HM, Goldbaum G, Royce R, Pang J, Tapia J, Bethel J,

Mazurek GH, Toney S, Albalak R; Tuberculosis Epidemiological Studies
Consortium. Predictors of discordant tuberculin skin test and
QuantiFERON-TB Gold In-Tube results in various high-risk groups. Int J
Tuberc Lung Dis 2011;15:1056-61.

Talati NJ, Seybold U, Humphrey B, Aina A, Tapia J, Weinfurter P, Albalak R,

Blumberg HM. Poor concordance between interferon-gamma release
assays and tuberculin skin tests in diagnosis of latent tuberculosis
infection among HIV-infected individuals. BMC Infect Dis. 2009;9:9-15.

Freimanis Hance L, Steingart KR, Hahn CG, Pascopella L, Nolan CM. Field
assessment of a model tuberculosis outbreak response plan for low-
incidence areas. BMC Public Health 2007;7:307.

Cook VJ, Sun SJ, Tapia J, Muth SQ, Arguello DF, Lewis BL, Rothenberg RB,
McElroy PD. Transmission network analysis in tuberculosis contact
investigations. J Infect Dis 2007;196:1517-27.

Moonan PK, Teeter LD, Salcedo K, Ghosh S, Ahuja SD, Flood J, Graviss EA.
Transmission of multidrug-resistant tuberculosis in the USA: a cross-
sectional study. Lancet Infect Dis 2013;13:777-84.

Davidow AL, Katz D, Reves R, Bethel J, Ngong L; Tuberculosis

Epidemiologic Studies Consortium. The challenge of multisite
epidemiologic studies in diverse populations: design and implementation
of a 22-site study of tuberculosis in foreign-born people. Public Health Rep
2009;124:391-9.

Colson PW, Couzens GL, Royce RA, Kline T, Chavez-Lindell T, Welbel S,

Pang J, Davidow A, Hirsch-Moverman Y; Tuberculosis Epidemiologic Studies
Consortium (TBESC). Examining the impact of patient characteristics and
symptomatology on knowledge, attitudes, and beliefs among foreign-born
tuberculosis cases in the US and Canada. J Immigr Minor Health
2014;16:125-35.

Pang J, Teeter LD, Katz DJ, Davidow AL, Miranda W, Wall K, Ghosh S, Stein-
Hart T, Restrepo BI, Reves R, Graviss EA; Tuberculosis Epidemiologic
Studies Consortium. Epidemiology of tuberculosis in young children in the
United States. Pediatrics 2014;133:e494-504.

Davidow AL, Katz D, Ghosh S, Blumberg H, Tamhane A, Sevilla A, Reves R;

Tuberculosis Epidemiologic Studies Consortium. Preventing infectious
pulmonary tuberculosis among foreign-born residents of the United
States. Am J Public Health 2015;105:e81-8.

Collins JM, Reves RR, Belknap RW. High rates of tuberculosis and
opportunities for prevention among international students in the U.S. Ann
Am Thorac Soc. Epub 2016 Jan 5.
 Phillips VL, Teweldemedhin B, Ahmedov S, Cobb J, McNabb SJ. Evaluation
of program performance and expenditures in a report of performance
measures (RPM) via a case study of two Florida county tuberculosis
programs. Eval Program Plann 2010;33:373-8.

Miller TL, Hilsenrath P, Lykens K, McNabb SJ, Moonan PK, Weis SE. Using
cost and health impacts to prioritize the targeted testing of tuberculosis in
the United States. Ann Epidemiol 2006;16:305-12.

McNabb SJ, Surdo AM, Redmond A, Cobb J, Wiley J, Chakrabarti S, Duncan

H, Qualls N, Moore M. Applying a new conceptual framework to evaluate
tuberculosis surveillance and action performance and measure the costs,
Hillsborough County, Florida, 2002. Ann Epidemiol 2004;14:640-5.

Royce RA, Colson PW, Woodsong C, Swinson-Evans T, Walton W, Maiuri A,

DeLuca N; Tuberculosis Epidemiologic Studies Consortium (TBESC).
Tuberculosis Knowledge, Awareness, and Stigma Among African-Americans
in Three Southeastern Counties in the USA: a Qualitative Study of
Community Perspectives. J Racial Ethn Health Disparities epub 2015 Dec
29.

Sterling TR, Bethel J, Goldberg S, Weinfurter P, Yun L, Horsburgh CR;

Tuberculosis Epidemiologic Studies Cosortium. The scope and impact of
treatment of latent tuberculosis infection in the United States and
Canada. Am J Respir Crit Care Med 2006;173:927-31.

Horsburgh CR Jr, Goldberg S, Bethel J, Chen S, Colson PW, Hirsch-

Moverman Y, Hughes S, Shrestha-Kuwahara R, Sterling TR, Wall K,
Weinfurter P; Tuberculosis Epidemiologic Studies Consortium. Latent TB
infection treatment acceptance and completion in the United States and
Canada. Chest 2010;137:401-9.

Colson PW, Hirsch-Moverman Y, Bethel J, Vempaty P, Salcedo K, Wall K,

Miranda W, Collins S, Horsburgh CR; Tuberculosis Epidemiologic Studies
Consortium. Acceptance of treatment for latent tuberculosis infection:
prospective cohort study in the United States and Canada. Int J Tuberc
Lung Dis 2013;17:473-9.

Pettit AC, Bethel J, Hirsch-Moverman Y, Colson PW, Sterling TR;

Tuberculosis Epidemiologic Studies Consortium. Female sex and
discontinuation of isoniazid due to adverse effects during the treatment of
latent tuberculosis. J Infect 2013;67:424-32.

Hirsch-Moverman Y, Shrestha-Kuwahara R, Bethel J, Blumberg HM,

Venkatappa TK, Horsburgh CR, Colson PW; Tuberculosis Epidemiologic
Studies Consortium (TBESC). Latent tuberculous infection in the United
States and Canada: who completes treatment and why? Int J Tuberc Lung
Dis 2015;19:31-8.

Lurie S, Weis S, Munguia G. Roles of Hispanic service organizations in

tuberculosis education and health promotion. Chapter 12 in: Building
Community Capacity: Minority and Immigrant Populations. R. Caron and J.
Merrick, editors. N.Y.: Nova Science Publishers, 2012.
 Dorman SE, Belknap R, Graviss EA, Reves R, Schluger N, Weinfurter P,
Wang Y, Cronin W, Hirsch-Moverman Y, Teeter LD, Parker M, Garrett DO,
Daley CL; Tuberculosis Epidemiologic Studies Consortium. Interferon-
release assays and tuberculin skin testing for diagnosis of latent
tuberculosis infection in healthcare workers in the United States. Am J
Respir Crit Care Med 2014;189:77-87.

Hirsch-Moverman Y, Wall K, Weinfurter P, Munk E, Moran JA, Maiuris A,

Khan A, DeLuca N; TB Epidemiologic Studies Consortium. Acceptability of
interferon-gamma release assays among healthcare workers who receive
routine employee tuberculosis testing. Int J Occup Environ Health
2013;19:319-24.

Painter JA, Graviss EA, Hai HH, Nhung DT, Nga TT, Ha NP, Wall K, Loan le
TH, Parker M, Manangan L, O'Brien R, Maloney SA, Hoekstra RM, Reves R.
Tuberculosis screening by tuberculosis skin test or QuantiFERON-TB Gold
In-Tube Assay among an immigrant population with a high prevalence of
tuberculosis and BCG vaccination. PLoS One 2013;8:e82727.

Walter ND, Painter J, Parker M, Lowenthal P, Flood J, Fu Y, Asis R, Reves R;

Tuberculosis Epidemiologic Studies Consortium. Persistent latent
tuberculosis reactivation risk in United States immigrants. Am J Respir Crit
Care Med 2014;189:88-95.

Aiona K, Lowenthal P, Painter JA, Reves R, Flood J, Parker M, Fu Y, Wall K,

Walter ND. Transnational record linkage for tuberculosis surveillance and
program evaluation. Public Health Rep 2015;130:475-84.

Howley MM, Rouse CD, Katz DJ, Colson PW, Hirsch-Moverman Y, Royce RA;
Tuberculosis Epidemiologic Studies Consortium. Knowledge and attitudes
about tuberculosis among U.S.-born blacks and whites with tuberculosis. J
Immigr Minor Health 2015;17:1487-95.

Pagaoa MA, Royce RA, Chen MP, Golub JE, Davidow AL, Hirsch-Moverman
Y, Marks SM, Teeter LD, Thickstun PM, Katz DJ; Tuberculosis Epidemiologic
Studies Consortium. Risk factors for transmission of tuberculosis among
United States-born African Americans and whites. Int J Tuberc Lung Dis
2015;19:1485-92.

Marks SM, Cronin W, Venkatappa T, Maltas G, Chon S, Sharnprapai S,

Gaeddert M, Tapia J, Dorman SE, Etkind S, Crosby C, Blumberg HM,
Bernardo J. The health-system benefits and cost-effectiveness of using
Mycobacterium tuberculosis direct nucleic acid amplification testing to
diagnose tuberculosis disease in the United States. Clin Infect Dis
2013;57:532-42.

Marks SM, Hirsch-Moverman Y, Salcedo K, Graviss EA, Oh P, Seaworth B,

Flood J, Armstrong L; TB Epidemiologic Studies Consortium.
Characteristics and costs associated with hospitalization for multidrug-
resistant tuberculosis care in the United States, 2005-2007. IJTLD.

Pascopella L, Franks J, Marks SM, Salcedo K, Schmitz K, Colson PW, Hirsch-

Moverman Y, Flood J, Sayles J. Opportunities for tuberculosis diagnosis
 and prevention among persons living with HIV: a cross-sectional study of
policies and practices at four large Ryan White Program-Funded HIV
clinics. PLoS One 2014;9:e101313.

Hoger S, Lykens K, Beavers SF, Katz D, Miller TL. Longevity loss among
cured tuberculosis patients and the potential value of prevention. Int J
Tuberc Lung Dis 2014;18:1347-52

Miller TL, Wilson FA, Pang JW, Beavers S, Hoger S, Sharnprapai S, Pagaoa
M, Katz DJ, Weis SE. Mortality hazard and survival after tuberculosis
treatment. Am J Public Health 2015;105:930-7.

Howley MM, Painter JA, Katz DJ, Graviss EA, Reves R, Beavers SF, Garrett
DO; Tuberculosis Epidemiologic Studies Consortium. Evaluation of
QuantiFERON-TB gold in-tube and tuberculin skin tests among immigrant
children being screened for latent tuberculosis infection. Pediatr Infect Dis
J 2015;34:35-9.

Infection Control

Infection Control in Health Care Settings

Tuberculosis (TB) transmission has been documented in health care settings where health
care workers and patients come in contact with people who have TB disease.

People who work or receive care in health care settings are at higher risk for becoming
infected with TB; therefore, it is necessary to have a TB infection control plan as part of a
general infection control program designed to ensure the following:

prompt detection of infectious patients,

airborne precautions, and

treatment of people who have suspected or confirmed TB disease.

In all health care settings, particularly those in which people are at high risk for exposure to
TB, policies and procedures for TB control should be developed, reviewed periodically, and
evaluated for effectiveness to determine the actions necessary to minimize the risk for
transmission of TB.

The TB infection control program should be based on a three-level hierarchy of control

measures and include:

1. Administrative measures

2. Environmental controls

3. Use of respiratory protective equipment

 Administrative measures

Environmental controls

Respiratory Protective Equipment

Administrative controls are the first and most important level of the hierarchy. These are
management measures that are intended to reduce the risk or exposure to persons with
infectious TB. These control measures consist of the following activities:

Assigning someone the responsibility for TB infection control in the health

care setting;

Conducting a TB risk assessment of the setting;

Developing and implementing a written TB infection-control plan;

Ensuring the availability of recommended laboratory processing, testing,

and reporting of results;

Implementing effective work practices for managing patients who may

have TB disease;

Ensuring proper cleaning, sterilization, or disinfection of equipment that

might be contaminated (e.g., endoscopes);

Educating, training, and counseling health care workers, patients, and

visitors about TB infection and TB disease;

Testing and evaluating workers who are at risk for exposure to TB disease;

Applying epidemiology-based prevention principles, including the use of

setting-related TB infection-control data;

Using posters and signs to remind patients and staff of proper cough
etiquette (covering mouth when coughing) and respiratory hygiene; and

Coordinating efforts between local or state health departments and high-

risk health-care and congregate settings.

TB in Specific Populations
Tuberculosis (TB) is a challenging disease to diagnose, treat, and control. It is
critical to target prevention and control efforts to certain populations so as to
reduce disparities related to TB, and further reduce TB rates both in the United
States and worldwide.
African-American Community

Blacks in the United States continue to have a disproportionate share of TB. The percentage
of TB cases that occur in blacks or African Americans is higher than expected based on the
percentage of blacks in the U.S. population. If looking at only people born in the United
States, the proportion of TB in African Americans is even greater. We must better target our
efforts to prevent and control TB in this group.

AfricanAmerican Community

Disparities in tuberculosis (TB) persist among members of

racial and ethnic minority populations. In 2014, the majority (85%) of all reported TB cases
in the United States (US) occurred in racial and ethnic minorities. Black, non-Hispanic
persons, have a disproportionate share of TB in the United States.

In 2014, TB was reported in 2,010 black, non-Hispanic persons, 21% of all persons reported
with TB nationally. Also in 2014, the rate of TB in black, non-Hispanic persons was 5.1 cases
per 100,000 population, which is 8 times higher than the rate of TB in white, non-Hispanic
persons (0.6 cases per 100,000 population).

The proportion of TB in black, non-Hispanic persons, is even greater if only US-born

(AfricanAmerican) blacks reported with TB are examined. In 2014, among US-born persons
reported with TB, 37% were African Americans (black, non-Hispanic).

Although rates of TB in both blacks and whites have declined substantially over the past
decade, the disparity remains. We must better target our efforts to prevent and control TB in
this population. Addressing the TB disparity among African Americans and other US-born
racial/ethnic groups is an important priority.
Source: Reported Tuberculosis in the United States, 2014

Stop TB in the AfricanAmerican

Community Summit
Return to AfricanAmerican Community

In May, 2006, the Stop TB in the AfricanAmerican Community Summit, convened by the
Division of Tuberculosis Elimination (DTBE) and RTI International (RTI), was attended by
more than 100 individuals, from a myriad of organizations, with an interest in this topic.
Summit attendees met to discuss and identify ways to address the problem of TB in the
AfricanAmerican community. This page contains links to materials and resources related to
the 2006 Stop TB in the AfricanAmerican Summit.

Background of the Stop TB in the AfricanAmerican Community Summit

Executive Summary: Stop TB in the AfricanAmerican Community Summit Draws

More Than 100 (May, 2006)
( PDF - 74k)

Letter of Invitation to the Stop TB in the AfricanAmerican Community Summit

(March, 2006)
( PDF - 147k)

Agenda for the Stop TB in the AfricanAmerican Community Summit (May, 2006)
( PDF - 315K)

Slide Presentation: Epidemiology of Tuberculosis in AfricanAmerican Population,

United States 1993-2005, by Kenneth Castro, Director, Division of Tuberculosis
Elimination, CDC
(May, 2006)

RTI International (RTI) Webpage: Stop Tuberculosis in the AfricanAmerican

Community Conference (2006)

Advisory Council for the Elimination of Tuberculosis

ACET Consultation - TB in America: Disparities in the Southeast Executive Summary
(May, 2003)
( PDF - 44K)

Historical Background of the Stop TB in

the AfricanAmerican Community Summit
Return to Stop TB in the AfricanAmerican Community Summit
In 2003, the Advisory Council for the Elimination of Tuberculosis (ACET) and the Centers
for Disease Control and Prevention (CDC) co-sponsored a consultation with African
American organizations and agencies whose programs could have an impact on TB control
efforts in the AfricanAmerican population. This was an initial step in addressing the
disparity between the tuberculosis (TB) case rates of African Americans and other United
States (US)-born racial/ethnic groups in the Southeastern United States. The consultation was
intended to raise awareness about the disparity, solicit support for eliminating TB in USborn
African Americans, and develop recommendations for accelerating the decline in TB rates
among US-born African Americans in the Southeastern states.

Participants at the 2003 consultation called for increased research and resources to improve
TB prevention and control efforts in these populations. As one strategy, ACET prepared and
sent a letter in June 2003 to the Secretary of the Department of Health and Human Services
summarizing the consultation and bringing this health disparity to his attention. Meeting
participants also called for increased research in this population. One response from CDC
was a formative research and intervention study entitled Addressing Tuberculosis Among
African Americans in the Southeast. The CDCs Division of Tuberculosis Elimination
(DTBE) and RTI are conducting this study, as a part of the Tuberculosis Epidemiologic
Studies Consortium, to address the excess burden of TB among African Americans in the
southeast. This multi-phase research project was developed to understand the individual,
institutional, and community-level barriers and facilitators to TB control in African
Americans in the southeastern region of the US.

As a follow-up to the success of the 2003 consultation, DTBE and RTI co-sponsored the Stop
TB in the AfricanAmerican Community Summit in May, 2006. This Summit was used to
highlight the accomplishments since the previous consultation in 2003, as well as to further
engage partners in collaborative efforts to address the impact of the TB disparity in the
AfricanAmerican community. The goals of this meeting were to raise awareness about the
problem of TB in the AfricanAmerican community, and create links and build networks that
will lead to ongoing activities and strategies to decrease TB in the AfricanAmerican
community. The Summit brought together community and religious leaders, health care
providers, public health leaders, policy and decision makers, state and local health
department staff, communications professionals, academicians, and others, who committed to
undertaking specific goals and action items.

TB in African Americans

Epidemiology of Tuberculosis in African-American

Population, United States 1993-2005
Children

TB disease in children under 15 years of age (also called pediatric tuberculosis) is a public
health problem of special significance because it is a marker for recent transmission of TB.
Also of special significance, infants and young children are more likely than older children
and adults to develop life-threatening forms of TB disease.

TB in Children in the United States

TB disease in children under 15 years of age (also called pediatric tuberculosis) is a public
health problem of special significance because it is a marker for recent transmission of TB.
Also of special significance, infants and young children are more likely than older children
and adults to develop life-threatening forms of TB disease (e.g., disseminated TB, TB
meningitis). Among children, the greatest numbers of TB cases are seen in children less than
5 years of age, and in adolescents older than 10 years of age.

Basic TB Facts
TB is caused by a bacterium called Mycobacterium tuberculosis. TB bacteria are spread from
person to person through the air. The TB bacteria are put into the air when a person with TB
disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in
these bacteria and become infected.

People with TB disease of the lungs or throat can spread bacteria to others with whom they
spend time every day. However, children are less likely to spread TB bacteria to others. This
is because the forms of TB disease most commonly seen in children are usually less
infectious than the forms seen in adults.

Not everyone infected with TB bacteria becomes sick. As

a result, two TB-related conditions exist: latent TB infection and TB disease.

More: Basic TB Facts

Latent TB Infection
Persons with latent TB infection:
 Usually have a skin test or blood test indicating TB infection;

Have TB bacteria in their bodies, but the bacteria are not active;

Are not sick and do not have symptoms;

Cannot spread bacteria to others; and

Are often given medicine to prevent them from developing TB disease.

TB Disease
If TB bacteria become active in the body and multiply, the person will get sick with TB
disease.

Persons with TB disease:

Usually have a skin test or blood test indicating TB infection;

Are sick from TB bacteria that are active (meaning that they are
multiplying and destroying tissue in their body);

Usually have symptoms of TB disease; and

Must be given medicine to treat TB disease.

Once infected with TB bacteria, children are more likely to get sick with TB disease and to
get sick more quickly than adults. In comparison to children, TB disease in adults is usually
due to past TB infection that becomes active years later, when a persons immune system
becomes weak for some reason (e.g., HIV infection, diabetes).

Confirming the diagnosis of TB disease in children with a laboratory test can be challenging.
This is because:

It is difficult to collect sputum specimens from infants and young children;

and

The laboratory tests used to find TB in sputum are less likely to have a
positive result in children; this is due to the fact that children are more
likely to have TB disease caused by a smaller number of bacteria
(paucibacillary disease).

For these reasons, the diagnosis of TB disease in children is often made without laboratory
confirmation and instead based on combination of the following factors:

Clinical signs and symptoms typically associated with TB disease,

Positive tuberculin skin test (TST) or positive TB blood test (IGRA),

Chest x-ray that has patterns typically associated with TB disease, and
 History of contact with a person with infectious TB disease.

Testing for TB in Children

In the absence of symptoms, usually the only sign of TB

infection is a positive reaction to the TB skin test or TB blood test. TB skin testing is
considered safe in children, and is preferred over TB blood tests for children less than 5 years
of age.

More: Testing for TB

All children with a positive test for TB infection, symptoms of TB, or a history of contact
with a person with infectious TB disease should undergo a medical evaluation. Medical
evaluations for TB disease include a chest x-ray and physical examination to exclude TB
disease, and must be done before beginning treatment for latent TB infection.

For more information on where to get a TB test, contact your State TB Control Program.

Signs and Symptoms of TB Disease in Children

Signs and symptoms of TB disease in children include:

Cough;

Feelings of sickness or weakness, lethargy, and/or reduced playfulness;

Weight loss or failure to thrive;

Fever; and/or

Night sweats.

The most common form of TB disease occurs in the lungs, but TB disease can affect other
parts of the body as well. Symptoms of TB disease in other parts of the body depend on the
area affected. Infants, young children, and immunocompromised children (e.g., children with
HIV) are at the highest risk of developing the most severe forms of TB such as TB meningitis
or disseminated TB disease.

Treatment
A pediatric TB expert should be involved in the treatment of TB in children and in the
management of infants, young children, and immunocompromised children who have been
exposed to someone with infectious TB disease. It is very important that children or anyone
being treated for latent TB infection or TB disease finish the medicine and take the drugs
exactly as instructed.

Latent TB Infection
Treatment is recommended for children with latent TB infection to prevent them from
developing TB disease. Infants, young children, and immunocompromised children with
latent TB infection or children in close contact with someone with infectious TB disease,
require special consideration because they are at increased risk for getting TB disease.
Consultation with a pediatric TB expert is recommended before treatment begins. Isoniazid is
the anti-TB medicine that is most commonly used for treatment of latent TB infection. In
children, the recommended length of treatment with isoniazid is 9 months.

TB Disease
TB disease is treated by taking several anti-TB medicines for 6 to 9 months. It is important to
note that if a child stops taking the drugs before completion, the child can become sick again.
If drugs are not taken correctly, the bacteria that are still alive may become resistant to those
drugs. TB that is resistant to drugs is harder and more expensive to treat, and treatment lasts
much longer (up to 18 to 24 months).

More: Treatment

Vaccines
BCG, or bacille Calmette-Guerin, is a vaccine to prevent TB disease. BCG is used in many
countries to prevent childhood TB disease. However, the BCG vaccine is not generally used
in the United States, because of the low risk of infection with TB bacteria and the variable
effectiveness of the vaccine. The BCG vaccine should only be considered for very select
persons who meet specific criteria and in consultation with a TB doctor.

More: TB Vaccine (BCG)

Statistics
In the United States, a total of 9,582 cases of TB were reported in 2013, of which 485 (5%)
cases were among children less than 15 years of age. Worldwide, it is estimated that there are
at least 1 million cases of TB among children less than 15 years of age each year. In high TB
burden settings outside of the United States, children account for an estimated 1520% of TB
cases.

Correctional Facilities
TB in correctional settings is a public health concern. Approximately 4-6% of TB cases
reported in the United States occur among people incarcerated at the time of diagnosis. The
incarcerated population contains a high proportion of people at greater risk for TB than the
overall population.

TB in Correctional Facilities in the United States

Background
Approximately 4-6% of TB cases reported in the United States occur among people
incarcerated at the time of diagnosis. The incarcerated population contains a high proportion
of people at greater risk for TB than the overall population.

TB Control in Correctional Facilities

Effective TB prevention and control measures in

correctional facilities include:

Early identification of persons with TB disease through entry and periodic

follow-up screening;

Successful treatment of TB disease and latent TB infection;

Appropriate use of airborne precautions (e.g., airborne infection isolation,

environmental controls, and respiratory protection);

Comprehensive discharge planning; and

Thorough and efficient contact investigations when a TB case has been

identified.

These measures should be instituted in close collaboration with local or state health
department TB-control programs and other key partners. Continuing education of inmates,
detainees, and correctional facility staff is necessary to maximize cooperation and
participation. To ensure TB prevention and control measures are effective, periodic program
evaluation should be conducted.

Data on TB in Correctional Facilities

Surveillance data
 o Tuberculosis Cases and Percentages by
Residence in Correctional Facilities, Age > 15: Reporting Areas,
2014 (Reported Tuberculosis in the United States, 2014).
This chart provides an overview of the number of TB cases reported
as diagnosed in correctional settings in the U.S. and a breakdown by
state.

o Epidemiology of Tuberculosis in
Correctional Facilities, United States, 1993-2014 (slide set)
This slide set provides a summary of TB cases in a correctional
facility at the time of diagnosis for the years 1993 through 2014.

Resources on TB and Correctional Facilities

CDC Recommendations

o Prevention and Control of Tuberculosis in Correctional and Detention

Facilities; Recommendations from CDC MMWR 2006; 55 (No, RR-09,
1-44)

o Tuberculosis in Correctional Settings: What Corrections Staff Need to

Know (Slide Set)

o Prevention and Control of Tuberculosis in Correctional and Detention

Facilities (Slide Set)

CDC Correctional and Public Health Resources by State

Southeastern National Tuberculosis Center Corrections Toolkit

 National TB Controllers Association (NTCA) CorrectTB Resources

For additional CDC resources on TB, see Patient and General Public Materials and Health
Care Providers and TB Program Materials.

Homelessness

TB in the homeless population is a public health concern. While the reported number of TB
cases in the United States decreased slightly in 2011, a disproportionate number of TB cases
still occur among high-risk populations, including people experiencing homelessness.

TB in the Homeless Population

Background
A disproportionate number of TB cases occur among high-risk populations, including people
experiencing homelessness.

In the United States, 1% of the population experiences homelessness in a given year, but
more than 5% of people with TB reported being homeless within the year prior to diagnosis.
These findings are not surprising, as people experiencing homelessness have a high
occurrence of conditions that increase the risk of TB, including substance abuse, HIV
infection, and congregation in crowded shelters. This combination of conditions is favorable
for spreading TB. In addition, people who are homeless often lack ready access to the
medical care required to make an early diagnosis of TB.
What CDC is Doing
To address TB among the homeless population, CDC is

Collaborating with other national and public health organizations to

improve screening, diagnosis, and treatment for people experiencing
homelessness.

Working to improve TB control activities in partnership with healthcare

agencies addressing the needs of people experiencing homelessness.

In the fall of 2015, CDC hosted a Workshop on Tuberculosis (TB) and Homelessness:
Infection-Control Measures in Homeless Shelters and Other Overnight Facilities that Provide
Shelter. The workshop brought together homeless service providers, TB controllers, and
public health department staff to engage in strategic planning around improving TB control
among persons experiencing homelessness and prevent new TB incidence among those
utilizing and providing services (i.e., clients, staff and volunteers).

The homeless population represents an important risk group among U.S.-born TB patients. To
achieve TB elimination, ongoing efforts are needed to address the disproportionate number of
TB cases among this high-risk population.

CDC Resources on the Homeless Population

Prevention and Control of Tuberculosis in Correctional and Detention

Facilities; Recommendations from CDC MMWR 2006; 55 (No, RR-09, 1-44)
 Reported Tuberculosis in the United States, 2014

Notes from the Field: Tuberculosis Cluster Associated with Homelessness

Duval County, Florida, 20042012 MMWR 2012; 61 (No. 28)

Tuberculosis Outbreak Associated with a Homeless Shelter Kane County,

Illinois, 20072011 MMWR 2012; 61 (No. 11, 186-189)

Tuberculosis Transmission in a Homeless Shelter Population - New York,

2000-2003
MMWR 2005; 54 (No. 06)

International Travelers

In many countries, TB is much more common than in the United States. TB is a serious
international public health problem. Although multidrug-resistant (MDR) and extensively
drug-resistant (XDR) TB are occurring globally, they are still rare. All travelers should avoid
high risk settings where there are no infection control measures in place.

International Travelers

Preventing Exposure to TB Disease While Traveling Abroad

In many countries, TB is much more common than in the United States. Travelers should
avoid close contact or prolonged time with known TB patients in crowded, enclosed
environments (for example, clinics, hospitals, prisons, or homeless shelters).

Although multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB are occurring

globally, they are still rare. HIV-infected travelers are at greatest risk if they come in contact
with a person with MDR or XDR TB.

Air travel itself carries a relatively low risk of infection with TB of any kind. Travelers who
will be working in clinics, hospitals, or other health care settings where TB patients are likely
to be encountered should consult infection control or occupational health experts. They
should ask about administrative and environmental procedures for preventing exposure to
TB. Once those procedures are implemented, additional measures could include using
personal respiratory protective devices.

Travelers who anticipate possible prolonged exposure to people with TB (for example, those
who expect to come in contact routinely with clinic, hospital, prison, or homeless shelter
populations) should have a TB skin test or a TB blood test before leaving the United States.
If the test reaction is negative, they should have a repeat test 8 to 10 weeks after returning to
the United States. Additionally, annual testing may be recommended for those who anticipate
repeated or prolonged exposure or an extended stay over a period of years. Because people
with HIV infection are more likely to have an impaired response to TB tests, travelers who
are HIV positive should tell their physicians about their HIV infection status.

Pregnancy

While dealing with a TB diagnosis in pregnancy is not easy, there is a greater risk to the
pregnant woman and her baby if TB disease is not treated. Babies born to women with
untreated TB disease may have lower birth weight than those babies born to women without
TB.

Pregnancy

TB and Pregnancy
While dealing with a TB diagnosis in pregnancy is not easy, there is a greater risk to the
pregnant woman and her baby if TB disease is not treated. Babies born to women with
untreated TB disease may have lower birth weight than those babies born to women without
TB. Rarely, a baby may be born with TB.

Testing for TB
The tuberculin skin test is considered both valid and safe to use throughout pregnancy. The
TB blood test is safe to use during pregnancy, but has not been evaluated for diagnosing TB
infection in pregnant women. Other tests are needed to diagnose TB disease.

Treatment
Pregnant women who are diagnosed with TB disease should start treatment as soon as TB is
detected. Although the TB drugs used in treatment cross the placenta, these drugs do not
appear to have harmful effects on the baby.

Diagnosis

Latent TB Infection

TB Disease
Diagnosis

HIV-Related TB Disease

Contraindications
The following antituberculosis drugs are contraindicated in pregnant women

Streptomycin

Kanamycin

Amikacin

Capreomycin

Fluoroquinolones

Women who are being treated for drug-resistant TB should receive counseling concerning the
risk to the fetus because of the known and unknown risks of second-line antituberculosis
drugs.

Breastfeeding

Breastfeeding should not be discouraged for women

being treated with the first-line antituberculosis drugs because the concentrations of these
drugs in breast milk are too small to produce toxicity in the nursing newborn. For the same
reason, drugs in breast milk are not an effective treatment for TB disease or LTBI in a nursing
infant. Breastfeeding women taking INH should also take pyridoxine (vitamin B6)
supplementation.
Health Disparities in TB

Despite prevention efforts, some groups of people are affected by TB more than others. The
occurrence of TB at greater levels among certain population groups is often referred to as a
health disparity. Differences may occur by gender, race or ethnicity, income, comorbid
medical conditions, or geographic location.

Health Disparities in TB

Racial and Ethnic Disparities

TB adversely affects groups that have historically experienced greater obstacles to health
based on their racial or ethnic group. The percentage of TB cases that occur in Hispanics,
blacks or African Americans, and Asians is higher than expected based on the percentage of
these minorities in the U.S. population. In 2014, about 85% of the TB cases reported in the
United States were in racial and ethnic minorities. The percentage of cases occurring in
foreign-born persons increased to 66% of the national case total in 2014.

Tuberculosis Cases, Percentages, and Case Rates per 100,000 Population

by Hispanic Ethnicity and non-Hispanic Race: United States, 19932014

Comorbid Conditions
Certain comorbid medical conditions contribute to disparities in the rate of TB. Medical
conditions such as diabetes, cancer, and HIV infection alter the immune systems ability to
fight TB germs. As a result, people with these medical conditions are more likely to develop
TB disease if they are infected with TB germs.

TB and HIV Coinfection

Geographic Disparities
TB rates vary by geographic location across the United States. CDC monitors these
geographic differences and provides funds to support TB control efforts in all states, as well
as certain metropolitan areas with high rates of TB.

Tuberculosis Cases and Case Rates per 100,000 Population: Reporting

Areas, 2014 and 2013

Tuberculosis in the United States. National Tuberculosis Surveillance

System Highlights from 2014
Other Disparities
CDC surveillance efforts and research demonstrate TB disparities in relation to other factors
such as age, housing insecurity, and incarceration.

TB in the Homeless Population

TB in Correctional Facilities in the United States

Achieving Equity by Addressing Disparities

What CDC is Doing to Address Disparities in TB
CDC is committed to improving the health of people disproportionately affected by TB. To
achieve TB elimination, ongoing efforts are needed to address the persistent disparities that
exist. CDC is continuing to work on a series of projects designed to identify the underlying
causes, as well as educate and raise awareness about health disparities in TB. This includes

Collaborating with other national and international public health

organizations to improve TB screening of immigrants and refugees, test
recent arrivals from countries with high rates of TB, and improve TB
control and prevention activities along the border between the United
States and Mexico;

Maintaining a Spanish TB website that provides Spanish-language TB

information on exposure, testing, and treatment;

Developing culturally appropriate patient education materials in English

and other languages;

Working on projects designed to educate and raise awareness about TB in

African-American communities;

Compiling national reports of TB cases and TB case rates by gender, race

and ethnicity, risk factors, and geographic location;

Implementing a study to identify the socio-cultural, racial, and health

system barriers specifically for African Americans with or at risk for TB;

Continuing the work of two CDC research consortiums to examine more

effective TB treatment options and to study the risks of TB among persons
with comorbid medical conditions.

Educational Resources

TB in Blacks (fact sheet)

TB in Hispanic/Latinos (fact sheet)

Tuberculosis Facts: TB and HIV/AIDS (fact sheet)

 Epidemiology of Tuberculosis in Correctional Facilities, United States, 1993-
2014 (slide set)

Find TB Resources

Laboratory Information
The Division of Tuberculosis Elimination (DTBE) Laboratory Branch (LB) provides services
for the following tests on mycobacterial cultures. Any local health department, licensed
physician's office, licensed laboratory or licensed health care facility may submit cultures for
testing but they must be routed through either their state health department or other
authorized facility.

Genotyping

State or local TB control programs

A genotyping laboratory, in Michigan is under contract with CDC to provide genotyping
services to TB programs in the United States. Three genotyping methods to identify TB
strains:

Spoligotyping

Mycobacterial interspersed repetitive unit (MIRU) analysis

IS6110-based restriction fragment length polymorphism (RFLP) analysis

For more information, view the Guide to the Application of Genotyping to Tuberculosis
Prevention and Control.

DTBE epidemiologic investigations and surveillance activities

The LB provides support for DTBE epidemiologic investigations and

surveillance activities. TB genotyping results, when combined with
epidemiologic data, help to distinguish TB patients who are involved in the
same chain of recent transmission.

Drug susceptibility testing

The LB performs drug susceptibility testing for selected Mycobacterium species referred
from state or other authorized health facilities. Cultures of mycobacteria are tested by the
indirect proportion method with antituberculosis drugs incorporated into 7H10 agar plates.

Molecular Detection of Drug Resistance (MDDR)

CDC offers a service for the molecular detection drug resistance to rapidly identify
multidrug-resistant TB. This service utilizes DNA sequencing for detection of
mutations most frequently associated with rifampin and isoniazid drug resistance.
Additional testing will be conducted to identify mutations associated with resistance
 to the most effective second-line drugs; fluroquinolones, amikacin, kanamycin, and
capreomycin.

o Molecular Detection of Drug Resistance Request Form (PDF - 24k)

o Laboratory User Guide for U.S. Public Health Laboratories: Molecular

Detection of Drug Resistance (MDDR) in Mycobacterium tuberculosis
Complex by DNA Sequencing (Version 2.0) (PDF - 119K)

o Specimen Submission Form

Additional Resources

Report of an Expert Consultation on the Uses of Nucleic Acid Amplification

Tests for the Diagnosis of Tuberculosis

Report of Expert Consultations on Rapid Molecular Testing to Detect Drug-

Resistant Tuberculosis in the United States

Model Performance Evaluation Program (MPEP)

Interim Laboratory Biosafety Guidance for Extensively Drug-Resistant

(XDR) Mycobacterium tuberculosis strains

Guidelines for Using the QuantiFERON-TB Gold Test for Detecting

Mycobacterium tuberculosis Infection, United States

Tuberculosis Laboratory Aggregate Reports

These reports contain annual workload and turnaround time data from
public health laboratories supported in part by the TB Elimination
Cooperative Agreement.

Model Performance Evaluation Program (MPEP)

On this Page

Background

CDCs Role in MPEP

Criteria to Participate in MPEP

MPEP Process

Background
As part of the continuing effort to assess and monitor the quality and effectiveness of
laboratory testing systems that support public health objectives of tuberculosis (TB) treatment
programs, the CDC Model Performance Evaluation Program (MPEP) was established to
analyze the performance and practices of all known clinical and public health laboratories in
the United States that perform drug susceptibility testing of isolates belonging to the
Mycobacterium tuberculosis complex (MTBC).

CDCs Role in MPEP

Accurate and timely reporting of test results is essential for the success of TB surveillance,
prevention, and treatment programs. CDC has maintained an active role in the assurance of
high quality laboratory testing through MPEP by

Providing a self-assessment tool for laboratories to monitor their ability to

test for drug-resistant isolates of MTBC,

Monitoring the level of performance and practices among public health

and private sector laboratories within the United States,

Collecting information on susceptibility testing practices and procedures to

determine variables related to good performance,

Assessing areas for training and development of practice standards, and

Compiling and analyzing susceptibility test results collected from

laboratories in an aggregate report to enable participants to evaluate their
relative performance.

Criteria to Participate in MPEP

To participate in MPEP, laboratories must

Follow recommended biosafety guidelines for working with M. tuberculosis,

as outlined in the Guidelines for Safe Work Practices in Human and Animal
Clinical Diagnostic Laboratories (MMWR: January 6, 2012),

Perform MTBC drug susceptibility testing at their facility, and

Return a signed Participant Biosafety Compliance Letter of Agreement

annually.

MPEP Process

Laboratories complete and sign a participant compliance letter annually

and send to CDC via email to TBMPEP@cdc.gov.

o Participant Biosafety Compliance Letter of Agreement

CDC will assign the participating laboratory an MPEP number, which is

needed for participants to enter data online.

CDC will send a pre-shipment email to participating laboratories to inform

them of the expected date to receive the culture shipment. The
participants should notify CDC of any changes in laboratory contact
information.
 CDC will send MTBC cultures to the laboratories with instructions for
handling, a manual worksheet, and a deadline for entering results.

CDC will send each participant a link to enter results online.Participants

who have not input their results two weeks prior to the deadline will be
notified by email or telephone.

Once the data has been collected and analyzed, CDC will send by email a
final aggregate report to all enrollees. The report is also posted online on
the CDC TB MPEP reports webpage.

Drug Susceptibility Testing

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Drug susceptibility testing is a difficult procedure to standardize, and proficiency in

performing these tests requires an understanding of many elements, including the

Origin of drug resistance and the criteria for resistance

Potency and stability of drugs during laboratory manipulation

Antimycobacterial activity of drugs when incorporated into different media

Reading, interpretation, and reporting of results

The LB uses an indirect proportion method for testing M. tuberculosis complex mycobacteria
to 12 drugs at 35C on Middlebrook 7H10 agar. The test requires 1 month to complete.
Growth on the control medium is compared to the growth on the drug-containing medium to
determine susceptibility or resistance. When performed properly, this method allows a
quantitation of the proportion of mutants resistant to a drug and can detect the 1% proportion
of drug- resistant mutants above which therapeutic failure is likely.

M. tuberculosis complex are tested by this method with the following drugs:

Isoniazid

Rifampin

Ethambutol

Ciprofloxacin

Ofloxacin

Streptomycin
 Kanamycin

Capreomycin

Amikacin

Rifabutin

Ethionamide

Para-aminosalicylic acid (PAS)

Pyrazinamide is tested by the MGIT 960 method.

Professional Resources & Tools

ools for Health Care Providers

Education and Training

Continuing Education Activities

TB 101 for Health Care Workers

Interactive Core Curriculum on Tuberculosis: What the Clinician Should

Know (web-based)

Self-Study Modules on Tuberculosis

o Modules 1-5 (continuing education information)

o Modules 6-9 (continuing education information)

Morbidity & Mortality Weekly Reports

Resources

Regional Training & Medical Consultation Centers

TB Education & Training Network

Find TB Resources

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Publications & Products

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Listed by date

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Latent Tuberculosis Infection: Guide for Diagnosis and Treatment - mobile

application for health care providers

Latent Tuberculosis Infection: A Guide for Primary Health Care Providers

Mantoux Tuberculin Skin Testing Products

Infection Control and Prevention

Guidelines for Preventing the Transmission of M. tuberculosis in Health-

Care Settings (slide set)

Treatment

Latent TB Infection

Latent Tuberculosis Infection: Guide for Diagnosis and Treatment - mobile

application for health care providers

Latent Tuberculosis Infection: A Guide for Primary Health Care Providers

New Treatment Regimen for Latent Tuberculosis Infection (Video)

o English version
 o Spanish version

12-Dose Regimen for Latent TB Infection-Patient Education Brochure

What You Need to Know About Your Medicine for Latent Tuberculosis (TB)
Infection-Fact Sheet Series

o Isoniazid-specific Regimen [PDF - 192 KB]

o Rifampin-specific Regimen [PDF - 196 KB]

o Isoniazid and Rifapentine [PDF - 196 KB]

Publications & Products

Language:
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