Technical Notes

Purpose

The technical notes provide additional information about the data reported in the 2024 edition of Reported Tuberculosis in the United States.
Bar chart with five bars showing a slight decrease then increasing

Introduction

Information in the 2024 edition of Reported Tuberculosis in the United States summarizes incident cases of tuberculosis (TB) reported to Centers for Disease Control and Prevention's (CDC) National Tuberculosis Surveillance System (NTSS) by each of the 50 U.S. states and the District of Columbia (D.C.) unless otherwise specified. In addition to the 50 U.S. states and D.C., 5 U.S. territories (American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and the U.S. Virgin Islands) and 3 independent countries that are in compacts of free association with the United States (Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau) report incident cases of TB to CDC. NTSS has collected information on all newly reported cases of TB since 1953, and cases reported since 1993 are maintained in an electronic database. Small variations in historical data included in this edition, compared with previous editions, are attributable to updated information submitted in the interim by reporting areas. Some jurisdictions require reporting of latent TB infection (LTBI), a related condition in which TB bacteria live in the body without making a person sick. However, LTBI is not required to be reported to CDC, so this report focuses exclusively on cases of TB disease reported to NTSS.

About the data

National Tuberculosis Surveillance System

Reporting areas (i.e., the 50 U.S. states, D.C., New York City, Puerto Rico, and other U.S. jurisdictions in the Pacific Ocean and Caribbean Sea) provide information about TB cases to the NTSS by using a standard case report format, the Report of Verified Case of TB (RVCT).

All reporting jurisdictions implemented a revised RVCT for the first time in 2023. CDC expects minor fluctuations in data quality and completeness while reporting jurisdictions are adjusting to the revised RVCT.

TB cases are verified according to the TB case definition for public health surveillance and are reported and counted according to the recommendations for reporting and counting TB cases as described in 2020 RVCT Instruction Manual.1

TB Case Definition

The current TB surveillance case definition was adopted by the Council of State and Territorial Epidemiologists in 2009. TB cases are verified according to the following specified laboratory and clinical criteria.

Laboratory Criteria for Diagnosis

A TB case may be verified by the laboratory case definition with ≥1 of the following criteria: (1) isolation of Mycobacterium tuberculosis complex from a clinical specimen; or (2) demonstration of M. tuberculosis complex from a clinical specimen by nucleic acid amplification (NAA) test, or (3) demonstration of acid-fast bacilli (AFB) in a clinical specimen when a culture has not been or cannot be obtained or is falsely negative or contaminated.

Clinical Case Criteria

A TB case may be verified by the clinical case definition in the presence of all of the following clinical criteria: (1) a positive tuberculin skin test (TST) result or positive interferon-gamma release assay (IGRA) result for M. tuberculosis complex; and (2) other signs and symptoms compatible with TB (e.g., abnormal chest radiograph, abnormal chest computerized tomography [CT] scan, or other chest imaging study or clinical evidence of current disease); and (3) treatment with ≥2 anti-TB drugs; and (4) a completed diagnostic evaluation.

Provider Diagnosis

Provider diagnosis is not a component of the case definition for TB. However, when cases of TB are diagnosed but do not meet either the clinical or laboratory case definition, reporting areas have the option of verifying TB cases on the basis of provider diagnosis as described in 2020 RVCT instruction manual.1

TB Case Verification Criteria Calculation

The software for TB surveillance developed by CDC includes a calculated variable for TB case verification called "VERCRIT."

VERCRIT is calculated by using the following criteria in hierarchical order (beginning with the most preferred method of verification):

  1. Positive culture,
  2. Positive NAA test,
  3. Positive AFB,
  4. Clinical case confirmation, or
  5. Provider diagnosis.

Reporting and Counting of TB Cases

TB cases that are verified but not countable for morbidity statistics should still be reported to CDC as a measure of programmatic and case management burden. However, data for noncountable TB cases are not included in this report.

Immigrant and refugee populations, and non-U.S.–born visitors examined after arriving in the United States and receiving a diagnosis of TB disease requiring TB treatment, should be reported and counted by the locality of their residence at the time the diagnostic evaluation for TB began. Persons residing in the United States ≥90 consecutive days (inclusive of report date) who are medically evaluated or treated for TB while in the United States should be reported and counted by the locality where the diagnostic evaluation for TB began.

RVCT Versions

In 2020, CDC published updates to the RVCT. This updated version, known as the "2020 RVCT," includes items that are either new or revised from the previous RVCT that was published in 2009, known as the "2009 RVCT." Since 2020, reporting areas have been gradually implementing the 2020 RVCT; in 2023, all reporting jurisdictions fully implemented the 2020 RVCT for the first time.

The instructions for completing the 2020 RVCT are available in the 2020 RVCT Instruction Manual.1

Tabulation and Presentation of TB Data

This report presents summary data for TB cases counted by reporting areas through the end of 2024. TB cases are tabulated by year in which a reporting area verified a TB case and included it in its official annual TB case count. Since 2004, the published report has reflected updated information about the numbers of confirmed TB cases for each year from 1993 onward. U.S. totals include data from the 50 U.S. states and DC.

Trend data are presented in Tables 1, 2–21, 23 and Figure 2. Age-group tabulations are based on a person's age during the month and year reported to the health department as having a presumptive TB case. State tabulations are based on a person's reported residence. Percentages and rates are calculated using unrounded numbers.

Origin of Birth

CDC uses U.S. Census Bureau definitions for national origin. Persons are U.S.-born if they were entitled to U.S. citizenship at birth, i.e., they were born in the United States, certain U.S. territories (Puerto Rico, U.S. Virgin Islands, Guam, and Commonwealth of the Northern Mariana Islands) or elsewhere to at least one U.S. citizen parent (with certain minor exceptions). All other persons are categorized as non-U.S.–born.2

Rates

Rates are expressed as the number of cases reported each calendar year per 100,000 persons. Percentage change in all TB rates is calculated with unrounded figures. Percentage change results are reported to one decimal. Population denominators used in calculating TB rates are based on official census and midyear postcensal estimates from the U.S. Census Bureau. In Table 1, the U.S. total populations for 1990–1999 are taken from the Bridged-Race Intercensal Population Estimates for July 1, 1990–July 1, 1999: Single-year of age State estimates; 3populations for 2000–2009 are taken from the U.S. Census Intercensal Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico for April 1, 2000–July 1, 2010; 4populations for 2010–2019 are taken from the U.S. Census Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2020;5 and populations for 2020 through 2024 are taken from the U.S. Census Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico for April 1, 2020 to July 1, 2024.6

During 2003, two modifications were made to the RVCT form: (1) multiple race entries (≥2 races reported for a person) were allowed, and (2) the previous category of "Asian or Pacific Islander" was divided into "Asian" and "Native Hawaiian or Other Pacific Islander." In 2023, "Other" race entries were allowed as a selection in the 2020 RVCT.

To calculate rates for Table 4 and Table 7, denominators for 1993–1999 were obtained from the U.S. Census Monthly Postcensal Resident Population, by single year of age, sex, race, and Hispanic origin. 7For 2000–2009, denominators for Table 4 were obtained from U.S. Census Intercensal Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States: April 1, 2000–July 1, 2010,8 and denominators for Table 7 were obtained from Intercensal Estimates of the Resident Population by Single Year of Age and Sex for States and the United States: April 1, 2000–July 1, 2010.8 For 2010–2019, denominators for Table 4 were obtained from the U.S. Census Monthly National Population Estimates by Age, Sex, Race, Hispanic Origin, and Population Universe for the United States: April 1, 2010 to December 1, 2020,9 and denominators for Table 7 were obtained from U.S. Census Annual Estimates of the Resident Population by Single Year of Age and Sex for the United States: April 1, 2010 to July 1, 2020. 9For 2020–2024, denominators for Table 4 were obtained from the U.S. Census Annual Estimate of the Resident Population by Sex, Race, and Hispanic Origin for the United States: April 1, 2020 to July 1, 2024,10 and denominators for Table 7 were obtained from the U.S. Census Annual Estimates of the Resident Population by Single Year of Age and Sex for the United States: April 1, 2020 to July 1, 2024.10

The population source for nativity is the Current Population Survey,11 which is used to calculate case rates for U.S.-born and non-U.S.–born persons with diagnosed TB. U.S.-born populations include persons born in the 50 states and DC, those born abroad to U.S. parents, and those born in U.S. certain territories. To compute rates for Table 3, the population denominators for U.S.-born and non-U.S.–born persons for 1993 were obtained from Quarterly Estimates of the United States Foreign-Born and Native Resident Populations: April 1, 1990–July 1, 1999,12 and for 1994–2024 were obtained from U.S. Census Bureau's MDAT tool.13 Denominators for computing 2024 rates in Table 22 were obtained from the U.S. Census Bureau's MDAT tool.13

Four trend tables with case rates were originally created for the 2020 Annual TB Report using data from 1994 and onward. Tables 5 and 6 report the trends of race-ethnicity among U.S.-born persons (Table 5) and non-U.S.–born persons (Table 6). Tables 8 and 9 report trends for different age groups among U.S.-born persons (Table 8) and non-U.S.–born persons (Table 9). Denominators for these tables were obtained from the U.S. Census Bureau's MDAT tool.13

Mortality Data

The annual mortality rate is calculated as the number of deaths caused by TB in that year, divided by the estimated population for the year, multiplied by 100,000 (Table 1). The number of deaths was obtained from CDC's National Center for Health Statistics, Multiple Cause of Death Files, 1999–2023,14 available from CDC's WONDER online database. Finalized 2024 TB-related death data were unavailable at the time of publication.

Initial Reason Evaluated for TB

Tables 30, 37, and 38 reflect the 2020 RVCT variable, Initial Reason Evaluated for TB, which modified the Primary Reason Evaluated for TB Disease in the 2009 RVCT. During 2020–2022, TB cases were submitted in either the 2009 or 2020 RVCT versions. Since 2023, all cases were submitted in the 2020 RVCT version. The 2009 RVCT responses Targeted Testing, Health Care Worker, Employment/Administrative Testing, and Immigration Medical Exam were combined into the 2020 RVCT Screening response. Initial reasons for evaluation related to an Incidental Lab Result or Abnormal Chest Radiograph were combined into the Other category.

Isoniazid (INH) Drug-resistant and Multidrug-resistant (MDR) TB

Organisms resistant to one of the most common anti-TB drugs, isoniazid (INH), cause INH-resistant TB. Multidrug-resistant (MDR) TB is caused by an organism that is resistant to at least isoniazid and rifampin. In Tables 12–14, INH-resistant and MDR cases are displayed by year; Tables 13–14 also provide stratifications by a patient's history of previous TB disease.

Starting in 2023, information on drug resistance included results of molecular drug susceptibility testing in addition to growth-based susceptibility testing for isoniazid and rifampin. An isolate was considered resistant to isoniazid or rifampin if either the growth-based test or molecular test detected resistance.

Persons who are current or former smokers

The numbers and percentages of reported cases of persons who are current or former smokers are displayed in Table 31. The variable "current or former smokers" includes persons with TB who currently use tobacco every day, use tobacco some days (but not every day), were smokers (or tobacco users) but current status is unknown, or have smoked tobacco (or nicotine) at least 100 times in their lifetime and have quit. The data exclude persons with TB who have not smoked at least 100 times in their lifetime or whose tobacco history is not known. Smoking includes consumption of tobacco (or nicotine) through combustible tobacco products or electronic nicotine delivery systems. It does not include chewing tobacco or smoking of substances other than tobacco.

TB Therapy

The percentages of reported cases for persons with initial drug regimen information and who are alive at diagnosis are displayed in Table 15. The methods of administration for drug therapies are displayed in Table 16 for persons on an initial drug therapy with at least one drug.

Extensively Drug-resistant (XDR) and Pre-XDR TB

In 2021, CDC adopted new definitions of extensively drug-resistant (XDR) and pre-XDR TB. Pre-XDR TB is caused by an organism that is resistant to isoniazid, rifampin, and a fluoroquinolone OR by an organism that is resistant to isoniazid, rifampin, and a second-line injectable drug (amikacin, capreomycin, and kanamycin). XDR TB is caused by an organism that is resistant to isoniazid, rifampin, a fluoroquinolone, and a second-line injectable drug (amikacin, capreomycin, and kanamycin) OR by an organism that is resistant to isoniazid, rifampin, a fluoroquinolone, and bedaquiline or linezolid.15 Table 12 displays case counts for pre-XDR and XDR TB.

Completion of TB Therapy (COT)

Date and reason therapy was stopped (e.g., the person with TB completed therapy, or the person died) are collected in the RVCT with a 2-year lag and were used to calculate COT percentages. Cases were stratified by the indicated length of therapy, based on American Thoracic Society, CDC, and Infectious Diseases Society of America treatment guidelines in effect during the period covered and the person's initial drug-susceptibility test results, age, and disease site.16

In Table 17, the first column lists the total number of cases eligible to complete treatment within 1 year reported by year and the remaining columns are grouped under two headings: persons reported as having completed therapy and persons who did not complete therapy. Persons eligible to complete therapy in ≤1 year were alive at time of diagnosis and were initiated on therapy with ≥1 drug. Eligible persons did not have rifampin resistance; did not die in ≤1 year after initiating therapy; did not move out of the country in ≤1 year after initiating therapy; and did not have meningeal TB, bone or joint TB, or TB of the central nervous system, regardless of age. Additionally, persons aged 0–14 years old with TB were ineligible to complete therapy in ≤1 year if they had disseminated disease (defined for this report as miliary TB, a positive TB blood culture, or a positive NAA test on a blood specimen). Persons with culture-negative disease, those with an unknown culture status, and those with culture-positive disease but unknown initial drug-susceptibility test results were included under the category of therapy of ≤1 year indicated. COT percentages, regardless of duration, were calculated by dividing the number of persons reported as having completed therapy by the number of total eligible persons.

For the group that completed therapy, the percentage of cases are displayed for COT regardless of duration (i.e., duration of therapy ≤1 year or >1 year or duration unknown). For COT ≤1 year, the numerator included only those persons completing therapy in ≤366 days based on the dates therapy was started and stopped. Persons with missing dates were classified as "duration unknown" for this calculation.

For the group that did not complete therapy, the percentage of cases are displayed for all persons with an outcome other than completed therapy (i.e., moved, lost to follow-up, refused treatment, or other). Persons with an unknown outcome were also classified as "did not complete therapy."

Miliary Disease

Miliary disease should be reported as a pulmonary form of TB (Table 20). Beginning in 2009, miliary disease was classified as a TB disease site because of the understanding that it is a clinical or a radiologic finding.

National Tuberculosis Molecular Surveillance Center

In 2018, the National Tuberculosis Molecular Surveillance Center (NTMSC) began whole-genome sequencing (WGS) for ≥1 isolate from every culture-positive TB case in the United States. Effective June 30, 2022, whole-genome multilocus sequence typing (wgMLSType) superseded earlier, conventional genotyping methods based on spoligotyping and 24-locus MIRU-VNTR (GENType). Appendix A contains additional details on genotyping methods.

Genotype Clustering

For this report, a genotype cluster comprises ≥2 cases that have M. tuberculosis complex isolates with matching wgMLSType in a single county or county-like jurisdiction within a 3-year period. Cases that are part of the same genotype cluster are likely to be related by TB transmission in some way; however, the cases might not be directly related (i.e., one person did not necessarily transmit M. tuberculosis to another person in the cluster) or recently related (i.e., both persons might have contracted TB from the same person, but the exposure might have happened years ago).

Mycobacterium bovis

For this report, Mycobacterium bovis has been defined on the basis of spoligotyping or WGS (Table 21). Since 2018, M. bovis has been defined using WGS-based lineage. During 2004–2017, the spoligotype-based definition for M. bovis required either (1) the absence of spoligotyping spacers 3, 9, 16, and 39–43; the presence of ≥1 of the spacers 29–32; and the presence of ≥1 of the spacers 33–36; (2) the absence of spacers 3, 9, 16, and 39–43 and ≥2 copies of the repeated sequence at MIRU-VNTR locus 24 (i.e., loci 2687); 17or (3) determination based on microbiologic expertise. Data reported since 2004 exclude cases of bacillus Calmette-Guérin M. bovis, defined as spoligotype 676773777777600 with x, y, or z in the second MIRU-VNTR position or WGS-based lineage.

Recent Transmission

CDC estimates the number and percentage of cases attributed to recent transmission using a plausible source-case method, which was first validated in 2015. 18For each genotyped case, the plausible source-case method searches surveillance and genotype data to identify any plausible source cases with a case date within the prior 2 years that meet a set of criteria. If one or more plausible sources are identified, then the case is attributed to recent transmission.

During 2015–2021, CDC used conventional genotyping (i.e., GENType) to estimate recent transmission. A case was attributed to recent transmission if a plausible source case could be identified in a person who had an M. tuberculosis isolate with the same GENType, resided within 10 miles based on ZIP code centroids, had an infectious form of TB (pulmonary or laryngeal), was 10 years of age or older, and had a case date ≤2 years before that of the case being evaluated.18

This year's report provides new estimates of recent transmission for 2020–2024 based on an updated method that incorporates whole-genome sequencing (WGS). For this period, a case was attributed to recent transmission if a plausible source case could be identified in a person who had an M. tuberculosis isolate with the same non-unique wgMLSType that differed by ≤5 single nucleotide polymorphisms (SNPs) and resided within 100 miles based on ZIP code centroids. The remaining criteria were not changed (pulmonary or laryngeal TB, age 10 years or older, case date ≤2 years before that of the case being evaluated). 18These updated criteria were validated using field epidemiologic data collected for 2,179 cases across 5 partner jurisdictions during 2021–2022. A manuscript describing this validation is under review and available by request (tbgenotyping@cdc.gov).

For both GENType-based estimates (2015–2021) and wgMLSType-based estimates (2020–2024), any TB cases in persons who had arrived in the United States <100 days before their case date were not attributed to recent transmission. For any case in a non-U.S.–born person, a plausible source's case date had to occur after the non-U.S.–born person's arrival in the United States. Finally, cases that were not culture-confirmed or genotyped were not assessed by the plausible source case method and, since cases of TB among children are less likely to be culture-confirmed than cases in adults, pediatric cases are likely underrepresented.

Large Outbreaks of Tuberculosis

CDC defines large outbreaks as ≥10 cases of TB related by recent transmission within a 3-year period. Large outbreaks are identified using detection algorithms that are run quarterly using national surveillance and genotyping data. 1920Briefly, each algorithm uses different geographic and statistical criteria to search for at least 10 genotype-matched cases during a 3-year period (Table). Because the algorithms are designed to detect outbreaks among genotyped cases, large outbreaks involving non-genotyped cases can also be identified manually through routine reviews of TB data by CDC staff and through reporting by state or local health departments. A case is considered outbreak-related if its M. tuberculosis isolate differs by ≤5 SNPs from another outbreak-related isolate or, if sequencing data are unavailable (e.g., for clinically diagnosed cases), through an epidemiologic link to the outbreak (i.e., known or probable contact with another patient during either patient's infectious period, as determined by the investigating health department).

Table. Methods for detecting large outbreaks

Detection method Genotype Geography Additional criteria
Detection algorithms County Exact genotype match County Log-likelihood ratio (LLR) statistic ≥10*
Negative Binomial Hurdle Model County Accrual of ≥10 cases in a 3-year period above the quarterly average case count during the previous 8 quarters once unexpected growth was first identified.†
State State No genotype-matched cases in the state 24 months before initial case in cluster
National United States No genotype-matched cases in the United States 24 months before initial case in cluster
SaTScan§ Up to 50-kilometer radius Significant geospatial concentration of cases based on LLR statistic and no genotype-matched cases 24 months before initial case in cluster
Manual identification TB program report Closely related by whole-genome sequencing or known epidemiologic link for non-genotyped cases Any None
Routine cluster review by CDC staff
*The log-likelihood ratio (LLR) statistic compares the ratio of cases with a particular genotype to all genotyped cases within a given county (i.e., observed) to this same ratio in the United States (i.e., expected).19 Values of ≥10 indicate an unexpected concentration of a genotype within a given county.
†Unexpected growth occurs when the number of TB cases in a quarter exceeds the 95th percentile of predicted values from a negative binomial hurdle model fit to the previous 8 quarters.20
§SaTScan is a spatial scan statistic that utilizes the LLR statistic to identify a significant geospatial concentration of genotype-matched cases.19 Clusters are identified within circular windows of up to a 50-km radius using ZIP code centroid.

Suggested citation

Centers for Disease Control and Prevention (CDC). Reported Tuberculosis in the United States, 2024. Atlanta, GA: US Department of Health and Human Services, CDC; 2025.

Resources

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National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention; About Division of Tuberculosis Elimination
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