TB Cases Rebound to Near Pre-Pandemic Levels, CDC Data Show

Tuberculosis (TB) case counts in the U.S. increased to near pre-pandemic numbers in 2022, according to preliminary surveillance data from the CDC.

With a 5% increase over the year prior, a total of 8,300 cases were recorded in 2022, for an incidence rate of 2.5 per 100,000 individuals. That compared with 8,895 cases in 2019 (2.7 per 100,000), reported Kimberly R. Schildknecht, MPH, of the CDC in Atlanta, and colleagues in the Morbidity and Mortality Weekly Report (MMWR).

The small uptick in 2022 comes after a substantial 20% decline for TB cases in 2020, which was followed by a partial rebound in 2021 with a roughly 10% increase.

“The message is loud and clear — TB is still here,” said Philip LoBue, MD, director of CDC’s Division of Tuberculosis Elimination, in a statement. “For the second year in a row, TB disease cases in the U.S. have continued to rise, with concerning increases among young children and other groups at increased risk for TB disease.”

By age, there was a notable increase in 2022 among children age 4 and under compared with 2021 (28.8% increase in incidence) and individuals ages 15 to 24 years (23.7% increase), and a small decrease among those 65 and older (1.8% decrease), though this age group still had the highest incidence (3.9 per 100,000).

“Communities, providers, and public health partners must work together to make sure we are reaching the right people with testing and treatment, so we can prevent and stop the spread of TB,” LoBue added.

The return to pre-pandemic TB incidence is “likely due to factors associated with the COVID-19 pandemic including missed or delayed diagnoses,” wrote CDC Director Rochelle Walensky, MD, MPH, in a letter addressed to colleagues marking World TB Day. “Timely diagnosis and treatment of both active TB disease and latent TB infection [LTBI] are critical steps to eliminating TB in the United States.”

Most cases over the past 2 years were LTBIs, which disproportionately affect non-U.S.-born individuals. A total of 73% and 72% of all TB cases occurred among people born outside the U.S. in 2022 and 2021, respectively.

“Although preventing TB transmission in the United States remains a priority, >80% of U.S. TB cases are attributed to reactivation of LTBI,” Schildknecht’s group explained. “To achieve TB elimination in the United States, the U.S. Preventive Services Task Force recommends testing and treatment among populations at higher risk for LTBI, including non-U.S.-born persons and persons in congregate living settings.”

To treat LTBI, the “CDC recommends short-course (3- or 4-month), rifamycin-based regimens,” they noted. “Shorter regimens are also available to treat TB: in 2022, CDC recommended a 4-month treatment regimen for drug-susceptible pulmonary TB as an alternative to the standard 6-month regimen. Shorter treatment durations improve treatment adherence and completion.”

Recent trial results also suggested an 8-week regimen could be effective for some patients.

Video Monitoring of TB Medication Adherence

The CDC simultaneously updated its recommendations for medication adherence monitoring of TB in order to save time and costs, suggesting the use of video directly observed therapy (DOT) as an alternative to in-person DOT.

Since missed doses of medication or treatment interruptions for TB can lead to many complications like suboptimal drug concentrations, drug resistance, longer treatment times, treatment failure, or recurrence, medication monitoring for adherence and safety is a top priority, said Joan Mangan, PhD, also of the CDC, and colleagues in a second MMWR publication.

They cited a prior randomized trial that found video DOT was just as effective as in-person DOT at ensuring people took their medication (89.8% vs 87.2%). Other studies in their literature review found treatment completion was similar for patients managed with video DOT or in-person DOT (79% vs 68%, respectively, in a meta-analysis; 96% vs 90% in an observational study).

Furthermore, radiography and negative sputum smear test looking for microbiologic resolution of TB was similar between patients receiving either form of DOT.

“Based on this evidence, CDC has updated the recommendation for DOT during TB treatment to include as an equivalent alternative to in-person DOT,” said Mangan’s group. “[Video DOT] can assist health department TB programs meet the U.S. standard of care for patients undergoing TB treatment, while using resources efficiently.”