Pediatric and Adolescent Tuberculosis in the United States, 2008 2010 · 2008–2010, and results of analyses of newly available national data for pedi-atric and adolescent TB surveillance

Pediatric and Adolescent Tuberculosis in the UnitedStates, 2008–2010

WHAT’S KNOWN ON THIS SUBJECT: Foreign-born children andadolescents in the United States experience higher tuberculosis(TB) morbidity rates than US-born children and adolescents.Pediatric risk assessment should account for country of birth,contact with a known TB case, or travel to TB-endemic countries.

WHAT THIS STUDY ADDS: Our study reports national data onparental/guardian countries of origin and international residenceof pediatric patients with TB. Two-thirds of US-born children withTB have international family connections, and many have lived incountries with increased risk for TB acquisition.

abstractOBJECTIVE: We examined heterogeneity among children and adoles-cents diagnosed with tuberculosis (TB) in the United States, and weinvestigated potential international TB exposure risk.

METHODS: We analyzed demographic and clinical characteristics byorigin of birth for persons ,18 years with verified case of incidentTB disease reported to National TB Surveillance System from 2008 to2010. We describe newly available data on parent or guardian coun-tries of origin and history of having lived internationally for pediatricpatients with TB (,15 years of age).

RESULTS: Of 2660 children and adolescents diagnosed with TB during2008–2010, 822 (31%) were foreign-born; Mexico was the mostfrequently reported country of foreign birth. Over half (52%) offoreign-born patients diagnosed with TB were adolescents aged 13to 17 years who had lived in the United States on average .3 yearsbefore TB diagnosis. Foreign-born pediatric patients with foreign-bornparents were older (mean, 7.8 years) than foreign-born patients withUS-born parents (4.2 years) or US-born patients (3.6 years). AmongUS-born pediatric patients, 66% had at least 1 foreign-born parent,which is .3 times the proportion in the general population. Only 25%of pediatric patients with TB diagnosed in the United States had noknown international connection through family or residence history.

CONCLUSIONS: Three-quarters of pediatric patients with TB in theUnited States have potential TB exposures through foreign-born parentsor residence outside the United States. Missed opportunities to preventTB disease may occur if clinicians fail to assess all potential TBexposures during routine clinic visits. Pediatrics 2012;130:e1425–e1432

AUTHORS: Carla A. Winston, PhD, MA and Heather J.Menzies, MD, MPH

Division of Tuberculosis Elimination, Centers for Disease Controland Prevention, Atlanta, Georgia

KEY WORDSemigration and immigration, public health practice,epidemiologic factors, tuberculosis, vulnerable populations

ABBREVIATIONSCDC—Centers for Disease Control and PreventionMDR—multidrug-resistant, resistant to isoniazid and rifampinTB—tuberculosis

Both authors made substantial intellectual contributions to thestudy. Dr Winston acquired and had full access to all the data inthe study and takes responsibility for the integrity of the dataand accuracy of the data analysis. Both Drs Winston andMenzies participated in study concept and design and ininterpretation of data. Dr Winston drafted the article, which DrMenzies critically revised for important intellectual content.Both authors approved the final version.

The findings and conclusions are those of the authors and donot necessarily represent the views of the Centers for DiseaseControl and Prevention.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-1057

doi:10.1542/peds.2012-1057

Accepted for publication Jul 12, 2012

Address correspondence to Carla A. Winston, PhD, MA, Centersfor Disease Control and Prevention, 1600 Clifton Rd NE, MailstopE-91, Atlanta, GA 30333. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275);published in the public domain by the American Academy ofPediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: Authors were salaried by the Centers for DiseaseControl and Prevention. No funding was received for the study.

COMPANION PAPERS: Companions to this paper can be foundon pages e1433 and e1672, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2011-3742 and www.pediatrics.org/cgi/doi/10.1542/peds.2012-2832.

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Tuberculosis (TB) among young chil-dren represents recent transmissionand isamarker for TBcontrol.1 Childrenand adolescents with latent TB in-fection also represent a pool of futuredisease. In the United States, routinetuberculin skin testing for TB infectionis not recommended because of thelow incidence of TB disease.1,2 Instead,TB risk assessment during well-childvisits and other clinical encounters isencouraged. Such assessments helpdetermine which children and adoles-cents may benefit from targeted test-ing for and treatment of latent infectionto prevent development of TB disease.Validated TB risk questionnaires as-sess whether family members or closecontacts have TB infection or disease,and whether the child was born in aTB-endemic country or has traveledoutside the United States and hadcontact with populations where TB isendemic.1,3,4 Although health care pro-viders may be able to assess risk fac-tors for individual patients, these datafor pediatric TB cases have been un-available at the national level untilnow.

TB is a nationally notifiable diseasein the United States. Cases verifiedaccording toastandardcasedefinition5

are reported electronically by healthdepartments to the Centers for DiseaseControl and Prevention (CDC). The CDCmaintains the US National TB Surveil-lance System, which has collected de-tailed demographic and clinical dataon TB cases since 1993.2 Beginning in2009, data are now reported regardingwhether patients have an epidemio-logic link to another verified TB case,andwhether cases are identified throughcontact investigation, targeted testingfor TB infection, incidental findings inan asymptomatic patient, or evalua-tion of clinical signs and symptoms.Since 2009, data for pediatric patients(,15 years old) also include parent orguardian countries of birth and his-

tory of having lived outside the UnitedStates. We examined characteristicsof children and adolescents diagnosedwith TB in the United States during2008–2010, and results of analyses ofnewly available national data for pedi-atric and adolescent TB surveillanceduring 2009–2010.

METHODS

Analyses included all persons ,18years old with a verified case of in-cident TB disease reported to the CDCfrom January 1, 2008, through Decem-ber 31, 2010, by the 50 United Statesand the District of Columbia. We ex-amined TB case frequency by US Cen-sus Bureau categorization of US- orforeign-born origin (anyone not a UScitizen at birth is considered foreign-born)6 according to patient age, gen-der, race and ethnicity per self-reportor parental report (Hispanic, or non-Hispanic white, black, Asian/Pacific Is-lander, American Indian/Native Alaskan),disease site (pulmonary, extrapulmo-nary, or both), hierarchical TB verifi-cation criteria (ie, [1] positive cultureor [2] nucleic acid amplification testfor Mycobacterium tuberculosis, [3]positive smear or examination for acid-fast bacilli, [4] clinical confirmation bytuberculin skin test or interferon g

release assay results and chest radio-graph or scan, or [5] provider diag-nosis in the absence of clinical results),HIV infection status (positive, negative,or not reported to TB surveillance), andTB drug resistance pattern (no knownresistance, isoniazid resistance, orisoniazid and rifampin resistance[multidrug-resistant (MDR) TB]). Wereported P values comparing patientcharacteristics by using x2 tests, orwhen cell sizes were,5, Fisher’s exacttests. We compared mean age by usingt tests. For foreign-born children andadolescents, we examined age at USarrival and age at TB diagnosis by coun-try of origin. Analyses were approved by

the CDC as routine public health sur-veillance, which does not require in-stitutional board review.

We analyzed data newly available in2009–2010 regarding the primary rea-son persons ,18 years were initiallyevaluated for TB disease and whetherthey had epidemiologic links to anotherpatient with TB (Fig 1). We identifiedwhat proportion of cases among chil-dren and adolescents had identical TBstrains as an epidemiologically linkedcase, defined as matching M tubercu-losis genotypes based on spoligotypeand 12-locusmycobacterial interspersedrepetitive units; both methods areused routinely in national TB surveil-lance and have .95% discriminatorypower.7–10 Matching TB genotypesmay indicate that 2 cases are in thesame chain of disease transmission;however, no information was availableregarding whether the reported epi-demiologic link was considered asource case, simultaneously exposedperson, or unrelated in the chain oftransmission.

For pediatric patients, we analyzedvariables newly available in 2009–2010:countries of birth for parents orguardians, whether patients lived out-side the United States for .2 months,and countries outside the United Stateswhere pediatric patients resided.These data are limited to children,15years old because data on parents/guardians and international residenceare only collected on this subset ofpatients with TB (Fig 1). We refer toparent or primary guardian as parent.

RESULTS

Characteristics of Children andAdolescents Diagnosed With TB

Thenumberof TB cases amongchildrenand adolescents ,18 years old in theUnited States declined from 977 in 2008to 865 in 2009 and 818 in 2010. Childrenand adolescents comprised 7% of all TBcases reported annually.

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Of children and adolescents diagnosedwith TB in the United States during2008–2010 (Fig 1), 822 (31%) wereforeign-born and 1826 (69%) were US-born. Foreign-born patients were older(11.0 years versus 5.5 years, P, .0001)and more likely to have pulmonarydisease than US-born patients (72% vs67%), who were more likely to haveextrapulmonary or combined pulmo-nary and extrapulmonary presentation(Table 1). More than half of US-bornpatients (52%) were Hispanic com-pared with 30% of foreign-born pa-tients. Just over one-third (36%) offoreign-born patients were Asian orPacific Islander compared with 13% ofUS-born patients, whereas non-Hispanicblack patients made up 25% of US-bornand 30% of foreign-born patients. Alarger proportion of foreign-born pa-tients had results reported for HIVstatus (59%) than did US-born patients(39%). Among those with known status,1% of both US- and foreign-born chil-dren were HIV-positive (P = .58). Cor-responding with their older age andclinical presentation (ie, more likelyto have pulmonary TB), foreign-born

patients were more likely to have apositive culture than US-born patients(43% vs 32%). Over 96% of culture-positive patients had initial drug sus-ceptibility testing results, with higherproportions of isoniazid-resistant (11%vs 6%) and MDR (4% vs 1%) TB amongforeign-born compared with US-bornpatients.

Country of Origin and Age at TBDiagnosis Among Foreign-bornChildren and Adolescents

Over half (52%) of all foreign-bornpatients were diagnosed between age13 and 17 years (Table 1); on average,these adolescents had lived in theUnited States for 3.5 years before di-agnosis. Top countries of origin amongforeign-born children and adolescentswere Mexico (19%), the Philippines(9%), Ethiopia (6%), Haiti (6%), Burma(5%), Somalia (5%), Vietnam (4%),China (4%), and India (4%). Childrenborn in Mexico were generally older atTB diagnosis though younger at firstarrival to the United States comparedwith other foreign-born patients (Fig 2).The longest average time from US

arrival to TB diagnosis was 4.5 yearsamong patients born in Mexico, fol-lowed by Somalia (3.0 years), Vietnam(2.9 years), and India (2.7 years). Theshortest average times from USarrival to diagnosis were amongpatients from China (1.2 years), andBurma and Ethiopia, averaging ,1year (0.6 years) for the latter 2 coun-tries. Children born in Ethiopia madeup a disproportionate share of foreign-born patients with TB ,1 year of age(6 of 17 infants).

Epidemiologic Links to Known TBCases and Primary ReasonEvaluated for TB

Of 1680 patients with TB,18 years oldin 2009–2010 (Fig 1), 201 (12%) wereepidemiologically linked to at least 1other patient with TB in the US NationalTB Surveillance database. Among 188US-born children and adolescents, 103(55%) were linked to a foreign-borncase. Among 13 foreign-born childrenand adolescents, 2 (15%) were linkedto a US-born case. Patients with TB towhom children and adolescents wereepidemiologically linked ranged from,1 to 87 years old and were pre-dominantly Hispanic among both US-born (40%) and foreign-born (69%)patients. Among US-born children andadolescents, 39% of epidemiologicallylinked patients with TB were non-Hispanic black.

Similar to the proportion among allpatients,18 years old, one-third (34%)of child and adolescent patients with TBwith an epidemiologic link had a posi-tive culture for M tuberculosis; amongepidemiologically linked patients withTB (mostly adults), 90% were culturepositive. A total of 60 pairs of child andadolescent patients and linked casepatients had genotyping results, ofwhom 55 (92%) had identical or nearlyidentical TB genotypes (53 matched ex-actly; 2 differedby 1position in spoligotypeor 12-locus mycobacterial interspersedrepetitive units).

FIGURE 1Pediatric and adolescent TB data diagram.

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Of US-born child and adolescent caseswith epidemiologic links, 70% wereinitially evaluated for TB because theywerecontactsofaknowncase,whereas16% sought attention for symptoms(Table 2). By comparison, among US-born child and adolescent patientswith TB overall, one-third (32%) wereevaluated during a contact investiga-tion, one-third (29%) were symptom-atic, and 15%were diagnosed based onradiographic findings when TB was notinitially suspected. Among foreign-bornchildren and adolescents, similar pro-portions to the US-born overall weresymptomatic (33%) or identified due toincidental radiographic findings (22%).All 13 foreign-born patients with epi-demiologic links were assessed duringa TB case contact investigation, com-pared with 8% of overall foreign-borncases; immigration medical examina-tions also yielded 8%. Targeted testingprograms resulted in 4% of all childand adolescent TB cases, and 19%weremissing data on reason evaluatedfor TB.

Country of Origin of Parents ofPediatric Patients With TB Aged,15 Years

Therewere 1282 pediatric patientswithTB in 2009–2010 (Fig 1), including 291foreign-born and 991 US-born patients.Data for parent countries of birth wereavailable for 805 patients. Amongforeign-born pediatric patients, lead-ing parent countries of birth were theUnited States (15%), Mexico (12%), thePhilippines (10%), Burma (8%), Haiti(7%), and Somalia (6%). Among US-born pediatric patients, leading par-ent countries of birth were the UnitedStates (35%), Mexico (29%), Guatemala(5%), India (4%), Vietnam (3%), El Sal-vador (3%), and Honduras (3%).

Among patients with data, 85% (169 of198) of foreign-born and 66% (400 of607) of US-born children with TB had atleast 1 foreign-born parent (Table 3).

TABLE 1 Characteristics of Children and Adolescents With TB, United States, 2008–2010

US-born, 1826 (100), N (%) Foreign-born, 822 (100), N (%) P

Boy 945 (52) 447 (54) .21Age, y ,.0001,1 268 (15) 17 (2)1–4 839 (46) 135 (16)5–12 369 (20) 240 (29)13–17 350 (19) 430 (52)

Race/ethnicitya ,.0001Hispanic 947 (52) 242 (30)White 139 (8) 38 (5)Black 454 (25) 244 (30)Asian or Pacific Islander 240 (13) 291 (36)American Indian or Native Alaskan 32 (2) 1 (0.1)

Site of disease .002Pulmonary 1225 (67) 593 (72)Extrapulmonary 439 (24) 184 (22)Both 161 (9) 42 (5)

TB case verification ,.0001Positive culture 592 (32) 353 (43)Nucleic acid amplification test 18 (1) 9 (1)Positive smear absent culture 14 (0.8) 2 (0.2)Clinical case 804 (44) 332 (40)Provider diagnosis 398 (22) 126 (15)

HIV status ,.0001HIV positive 7 (0.4) 6 (0.7)HIV negative 707 (39) 476 (58)Not reported 1112 (61) 340 (41)

Drug resistanceb

None 466 (82) 279 (80) .65Isoniazid 35 (6) 37 (11) .01Isoniazid and rifampin (MDR TB)c 6 (1) 14 (4) .003

N (%) may vary slightly from total (100%) due to missing data or rounding.a Hispanic may be of any race. Excludes 20 patients of other, multiple, or unknown race responses.b Among patients with positive culture for M tuberculosis and drug susceptibility results (571 US-born; 347 foreign-born).c MDR TB is defined as M tuberculosis isolate with resistance to at least isoniazid and rifampin.

FIGURE 2Mean age at US arrival and at TB diagnosis among foreign-born children and adolescents, United States,2008–2010.

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Forty percent (40%) of foreign-bornpediatric patients with foreign-bornparents were Asian, whereas 68% ofUS-born patients with foreign-bornparents were Hispanic, and 43% ofUS-born patients with only US-bornparents were non-Hispanic black.Among foreign-born pediatric patientswith US-born parents, 62% were be-tween age 1 and 4, 72% were black,and 15 of 29 were from Ethiopia.Foreign-born pediatric patients withforeign-born parents were older(mean, 7.8 years) than foreign-bornpatients with US-born parents (4.2years) or US-born patients with aforeign-born parent (3.6 years) or onlyUS-born parents (3.7 years; P, .0001for all comparisons to foreign-bornpatient and foreign-born parent, noother significant differences). None ofthese children were reported to bepositive for HIV infection; however,51% did not have HIV status reported.Among children with positive cultureand drug susceptibility results, 17%with any foreign-born parent versus2% of patients with only US-bornparents were infected with drug-resistant TB (P = .004).

International Residence HistoryAmong Pediatric Patients With TB

Data for international residencehistorywere available for 859 patients. Among212 foreign-bornpediatricpatientswithdata, 187 (88%) reported ever havinglived outside the United States for .2months. For most (95%), the onlycountry in which children had livedoutside the United States was theircountry of birth. The few discordantresponses were suggestive of refugeeor displaced person migration (eg,Somalia–Kenya). Among 647 US-bornpatients with responses, 81 (13%)were reported to have ever lived out-side the United States for .2 months.Most frequently named countries wereMexico (n = 31), India (n = 8), and Haiti(n = 5). Among 765 pediatric patientswith complete data, 188 (25%) werenot foreign-born, did not have aforeign-born parent or guardian, andhad never resided outside the UnitedStates for .2 months.

DISCUSSION

Consistent with overall declines in theUnited States, the numberof TB cases in

children and adolescents declined in2009 and 2010. The decline in 2009 wasunusually steep and likely related toeconomic and immigration trends, asdescribed elsewhere.11 Continued at-tention to TB prevention among chil-dren and adolescents is critical tosustaining these declines and acceler-ating progress toward achieving a TB-free generation. Our findings highlight4 diverse groups that bear an in-creased burden of TB disease and inwhom preventive efforts could beenhanced: (1) US-born children withforeign-born parents, (2) foreign-bornchildren with US-born parents, (3)foreign-born adolescents, and (4) US-born children traditionally at risk forTB.

Two-thirds (66%) of US-born pediatricpatients with TB in our data havea foreign-born parent compared with18% of the general US-born populationyounger than 18 years.12 Our estimateis higher than reported in a previousstudy,13 perhaps reflecting the in-creasing impact of the global burden ofTB on the United States over time. Themajority of foreign-born parents of US-born children with TB are from Mexicoor Central America, where TB infectionprevalence is higher than the UnitedStates.14 Just over half (52%) of US-born child and adolescent patientswith TB are Hispanic, compared with19% of all US-born patients with TB;both proportions have increased inrecent years.2,15 Non-Hispanic Asianand black persons are also dispro-portionately represented among foreign-born patients with TB and parents ofpatients with TB, highlighting the di-versity of TB risk based on TB prevalencein countries of origin and emigrationtrends.16

Inourdata, 4%ofpediatricpatientswithTB are foreign-born (not US citizens atbirth) with only US-born parents, whichmay reflect international adoption. Be-cause surveillance data do not ask

TABLE 2 Primary Reason Evaluated Among Children and Adolescents With TB, United States,2009–2010

US-born WithLinked TB Case,188 (100), N (%)

All US-born,1162 (100),

N (%)

Foreign-born WithLinked TB Case,13 (100), N (%)

All Foreign-born,518 (100),N (%)

Contact investigation 131 (70) 367 (32) 13 (100) 39 (8)TB symptoms 31 (16) 334 (29) — 169 (33)Abnormal radiograph 17 (9) 170 (15) — 112 (22)Targeted testing 5 (3) 40 (3) — 32 (6)Immigration examination Not applicable Not applicable — 43 (8)Other 2 (1) 36 (3) — 18 (3)Unknown 2 (1) 215 (19) — 105 (20)

Data collection instructions were, “Select the single primary or initial reason the patient was evaluated for TB disease…thesituation or reason that led to the initial suspicion that the patient might have TB disease.” Definitions: contact investigation:result of a contact investigation or source case finding; TB symptoms: signs and symptoms consistent with TB (eg, prolongedpersistent cough, fever, lymphadenopathy, night sweats, weight loss) if patient seeks medical attention because of symptomsnot to be selected if symptoms discovered during a screening program; abnormal chest radiograph: incidental chestradiograph consistent with TB disease, independent of other choices and not the result of suspicion of TB disease; targetedtesting: positive result of tuberculin skin test or interferon g release assay administered because the patient was specificallyhigh risk for TB (eg, persons from area of the world with high rate of TB) or as part of a testing program focused on specificgroups at risk for TB, not to be selected if another reason (eg, contact investigation, immigration medical examination,employment/administrative testing, or health care worker status) is more appropriate; immigration examination: findings ofa medical examination as part of the immigration application process; other: incidental laboratory result for clinicalevaluation for something other than TB (eg, bronchoscopy or autopsy) or employment or administrative TB testing suchas school-based testing or testing of health care workers; unknown: reason for evaluating the patient not known. Percenttotals may vary slightly from 100% due to rounding.

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about adoption, we are not able toconfirm this directly. Foreign-bornchildren should be medically evalu-ated before leaving their homecountry and upon arrival to the UnitedStates.17–20 Children who are negativefor TB infection should be reexaminedwithin 6 months of US arrival and afterany subsequent exposure to TB risk.19–21

In national data, themajority of foreign-born patients younger than age 18 withTB are adolescents diagnosed aftermany years of residence in the UnitedStates. Foreign-born adolescents ex-perience the greatest TB disease dis-parity relative toUS-bornpersonsof thesame age.15 Providers should not as-sume that latent TB infection has beenassessed or adequately treated earlierin life, and should continue to assess

TB exposure during patient encoun-ters.1,13,22

US-born children diagnosedwith TB areyounger than foreign-born patients,reflecting high TB rates among youngchildren.15 Similar to national surveil-lance for all US-born patients with TB,2

pediatric patients with TB with only US-born parents are predominantly black(43%). Black persons in the UnitedStates are at increased risk for TBsince they are more likely to be latentlyinfected with TB23 and have 8 times therate of TB disease as white persons.2

Children and adolescents at risk for TBinclude both those with foreign asso-ciations and those who have no in-ternational connections, but otherdemographic, socioeconomic, or clini-cal risks for TB,13,24 which should

be assessed during routine clinicalencounters.

The fact that one-third (or more13,25) ofchildren and adolescents overall aresymptomatic at initial evaluationsuggests missed opportunities foridentifying and treating TB infection toprevent TB disease. The fact that one-fifth are identified based on incidentalradiographic findings suggests thatproviders may not be “thinking TB,”possibly leading to delays in care.Compared with an earlier era, our datareveal that a higher proportion ofchildren with TB have known HIV in-fection status, with a lower percentagereported HIV-positive than previously.15

All persons diagnosed with TB diseaseor latent TB infection should receivecounseling and testing for HIV.26

However, reporting of HIV results tothe US National TB Surveillance Sys-tem is incomplete2 and does not re-flect fully data that may be available atthe local or state level, which impactsthe analysis of these data at the na-tional level.

Importantly, TB drug resistance re-mains a concern. Children with foreign-born parents are more likely to haveisoniazid resistance alone or in com-bination with rifampin resistance. Ourfindings are consistent with patternsamong US- and foreign-born Hispanicpopulations in the United States.27,28

These data point to the importance ofdrug susceptibility testing amongpatients with TB to whom children areexposed, to gauge which children mayrequire modified TB prophylaxis ortreatment regimens.26,29–31 Similar toother studies,32–34 we found that most(92%) child and adolescent patientswith TB have identical or near-identicalTB strains to a reported epidemiologi-cally linked case. Combining contacttracing and genotyping can help iden-tify presumed source cases, interruptongoing transmission, and aid treat-ment decisions.25,33–35

TABLE 3 Characteristics of Pediatric Patients With TB in the United States, 2009–2010, by Origin ofBirth and Parent Origin of Birth

Total FB Patient, AnyFB Parent,N = 169, %

FB Patient, OnlyUSB Parent,N = 29, %

USB Patient, AnyFB Parent,N = 400, %

USB Patient, OnlyUSB Parent,N = 207, %

Boy 55 76 51 52Age, y,1 2 3 17 181–4 25 62 55 525–12 54 34 24 2513–15 18 0 5 5

Race/ethnicityHispanic 18 3 68 28White 6 7 4 15Black 35 72 10 43Asian or Pacific Islander 40 17 17 9Other/unknown 1 0 1 5

Site of diseasePulmonary 69 72 67 70Extrapulmonary 25 21 23 23Both 5 7 10 7

TB case verificationLaboratory confirmeda 23 21 31 27Clinical case 68 69 54 55Provider diagnosis 9 10 16 18

HIV statusHIV positive 0 0 0 0HIV negative 61 86 44 46Not reported 39 14 56 54

Drug resistanceb

None 79 100 85 98Isoniazid 18 0 5 2Isoniazid and rifampinc 8 0 1 0

FB, foreign-born; USB, US-born; columns may not sum to 100% due to rounding.a Positive culture, nucleic acid amplification test, or positive smear in the absence of culture.b Among patients with positive culture for M tuberculosis and initial drug susceptibility results.c MDR TB is defined as M tuberculosis isolate with resistance to at least isoniazid and rifampin.

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This study is subject to a number oflimitations. The main limitation of ouranalyses using national surveillancereporting is missing data. Data com-pleteness for new pediatric variablesincreased in 2010 from 2009 whenreporting was first introduced; HIVreporting has also improved. We an-ticipate that future data will becomemore complete. However, we do nothave detailed immigration informationor full travel history to TB-endemicregions. Rather, surveillance defini-tions reflect Census designations forUS- and foreign-born, and the timeframe of .2 months living interna-tionally, which does not captureshorter trips that may be important interms of TB exposure.1,13,36,37 Moreover,

we can only identify country of birth ofparent or guardian, not current livingsituation, contact with internationalfamily or other visitors, or exposuresoutside of the home (eg, day care,schools, institutional settings).24,32–34,37

CONCLUSIONS

We estimate that three-quarters ofpediatric patients with TB in the UnitedStates have potential TB exposuresthrough foreign-born parents or resi-dence outside the United States thatmight remainundiscovered if providersassess only country of birth of the childor adolescent when assessing TB risk.As surveillance data for TB risk factorsamong pediatric patients becomemore

complete, combining national datawithlocal epidemiology and clinical as-sessmentswill be important forguidingTB control for the next generation.Continued attention to TB preventionand education are needed to achieve TBelimination among children in theUnited States.

ACKNOWLEDGMENTSWe acknowledge the state and localhealth department staff who servepatients with TB and collect datareported in these analyses. We thankRoque Miramontes, Tom Navin, andEleanor Click for their review ofpreliminary findings. We acknowl-edge Jan Brzuskiewicz for graphicalassistance.

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Carla A. Winston and Heather J. Menzies2010−Pediatric and Adolescent Tuberculosis in the United States, 2008

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