Cases of Tuberculosis in the U.S. increases 9% in 2021, compared to cases between 2019 and 2020 | 與 2019 年至 2020 年之間的病例相比,2021 年美國的結核病病例增加了 9%

中文版谷歌中文翻譯(90% 準確率) | English translation
Buy/Sell Your Domains Here。在這裡購買/出售您的域名
Contact Dr. Lu for information about cancer treatments。聯繫盧博士,獲取有關癌症治療資訊。

Comment: This is an official report by the Centers for Disease Control and Prevention.  The report says that cases of tuberculosis in the U.S. during 2021 are 9% higher than that in the previous year.  CNN reported the CDC findings and tried to explain that the pandemic lockdown causes the delaying of diagnosis as the reason for the increase.  This explanation does not make sense.  Lockdowns are supposed to prevent the spreading of the disease.  Without lockdown, people would be more likely to visit hospitals and would be much more likely to get diagnosed.  So essentially, the CNN explanation actually reminds people that the actual cases of tuberculosis can be much higher.

Now how do people get tuberculosis?  Covid pandemic lockdown logically helps reduce the spreading the bacterial infection.   So external origins of the contagious disease play less of a role in the increased cases of tuberculosis in 2021.  It is only logical to speculate that the clinically significant or active tuberculosis results from likely re-activation of dormant tuberculosis causing bacteria due to compromised immunity in individual patients.  Studies have found evidence suggesting that spike protein from natural Sar Cov 2 infection or covid 19 or from covid 19 vaccination can actually hamper natural immunity and the repeated vaccination can enhance the reduction in the immunity.  Some studies indicate that covid vaccines could cause AIDS-like disease.

In the United States, Sandra Lindsey of Queens, New York was the first human who received a covid 19 vaccine, on December 14, 2020.  So 2021 is the year of covid 19 vaccination.   So vaccination is linked to the manifestation of the increase in cases of tuberculosis in terms of timing.  Studies of the impact on immunity reduction spike protein poses also point to the possibility that covid 19 can be the cause for the increased cases of tuberculosis in the U.S. in 2021.  Actually, reports abound that cases of many cancers since the start of the covid 19 vaccination have skyrocketed.  Cancer occurrence is more likely in immunity-compromised people.

All these are speculations, but the cause-effect association between covid vaccination and increased cases of tuberculosis is not impossible.

評論:這是疾病控制和預防中心的官方報告。報告稱,2021 年美國的肺結核病例比上一年增加了 9%。美國有線電視新聞網報導了疾病預防控制中心的調查結果,並試圖解釋大流行的封鎖導致診斷延遲是增加的原因。這種解釋沒有意義。封鎖應該防止疾病的傳播。如果沒有封鎖,人們更有可能去醫院就診,也更有可能被診斷出來。所以本質上,CNN 的解釋實際上提醒人們,結核病的實際病例可能要高得多。

現在人是怎麼得肺結核的? Covid大流行鎖定邏輯上有助於減少細菌感染的傳播。因此,傳染病的外部起源在 2021 年結核病病例增加中所起的作用較小。推測具有臨床意義或活動性的結核病可能是由於免疫受損導致休眠結核病細菌可能重新激活而引起的,這是合乎邏輯的。個別患者。研究發現有證據表明,來自天然 Sar Cov 2 感染或 covid 19 或來自 covid 19 疫苗接種的刺突蛋白實際上會阻礙自然免疫力,而重複接種疫苗可以增強免疫力的降低。一些研究表明,新冠疫苗可能會導致類似艾滋病的疾病。

在美國,紐約皇后區的 Sandra Lindsey 於 2020 年 12 月 14 日成為第一個接種 covid 19 疫苗的人。因此,2021 年是 covid 19 疫苗接種的一年。就時間而言,疫苗接種與肺結核病例增加的表現有關。對免疫降低刺突蛋白影響的研究還指出,covid 19 可能是 2021 年美國結核病病例增加的原因。實際上,自 covid 19 疫苗接種開始以來,許多癌症病例的報導比比皆是。疫苗接種率飆升。免疫力低下的人更容易患癌症。

所有這些都是猜測,但新冠疫苗接種與肺結核病例增加之間的因果關係並非不可能。

Tuberculosis — United States, 2021

Thomas D. Filardo, MD1,2; Pei-Jean Feng, MPH2; Robert H. Pratt2; Sandy F. Price2; Julie L. Self, PhD2 (View author affiliations)

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Summary

What is already known about this topic?

The number of reported U.S. tuberculosis (TB) cases decreased sharply in 2020, possibly related to multiple factors associated with the COVID-19 pandemic.

What is added by this report?

Reported TB incidence (cases per 100,000 persons) increased 9.4%, from 2.2 during 2020 to 2.4 during 2021 but was lower than incidence during 2019 (2.7). Increases occurred among both U.S.-born and non–U.S.-born persons.

What are the implications for public health practice?

Factors contributing to changes in reported TB during 2020–2021 likely include an actual reduction in TB incidence as well as delayed or missed TB diagnoses. Timely evaluation and treatment of TB and latent tuberculosis infection remain critical to achieving U.S. TB elimination.

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During 1993–2019, the incidence of tuberculosis (TB) in the United States decreased steadily; however, during the later years of that period the annual rate of decline slowed (1) until 2020 when a substantial decline (19.9%) was observed. This sharp decrease in TB incidence might have been related to multiple factors coinciding with the COVID-19 pandemic, including delayed or missed TB diagnoses or a true reduction in TB incidence related to pandemic mitigation efforts and changes in immigration and travel (2). During 2021, a total of 7,860 TB cases were provisionally reported to CDC’s National Tuberculosis Surveillance System (NTSS) by the 50 U.S. states and the District of Columbia (DC). National incidence of reported TB (cases per 100,000 persons) rose 9.4% during 2021 (2.37) compared with that in 2020 (2.16) but remained 12.6% lower than the rate during 2019 (2.71).* During 2021, TB incidence increased among both U.S.-born and non–U.S.-born persons. The increased TB incidence observed during 2021 compared with 2020 might be partially explained by delayed diagnosis of cases in persons with symptom onset during 2020; however, the continued, substantial reduction from prepandemic levels raises concern for ongoing underdiagnosis. TB control and prevention services, including early diagnosis and complete treatment of TB and latent TB infection, should be maintained and TB awareness promoted to achieve elimination in the United States.

Health departments in the 50 U.S. states and DC report TB cases to CDC based on the Council of State and Territorial Epidemiologists’ surveillance case definition, which includes both laboratory and clinically verified cases. For each case, health departments electronically submit a report of a verified TB case to CDC. Midyear U.S. Census Bureau population estimates§ were used to calculate national- and state-level TB incidence per 100,000 persons along with incidence stratified by age groups. Persons with TB were grouped by self-reported race and ethnicity according to federal guidelines. Persons who self-identified as Hispanic were categorized as Hispanic irrespective of self-reported race, persons not identifying as Hispanic were categorized by self-reported race, and non-Hispanic persons who reported more than one race were categorized as “multiple races.” Midyear population estimates from the Current Population Survey** were used to calculate incidence by birth origin†† and race/ethnicity. Percent changes in incidence were calculated using unrounded figures.

A total of 7,860 TB cases were reported during 2021, 687 more than during 2020 (7,173) and 1,040 fewer than during 2019 (8,900) (Table 1). From 2020 to 2021, TB incidence (cases per 100,000 population) rose 9.4%, from 2.16 to 2.37, but remained 12.6% lower than during 2019 (2.71). California reported the highest number of cases (1,750), and Alaska reported the highest incidence (7.92). Eighteen states and DC reported the same number or fewer TB cases during 2021 than during 2020; the remaining 32 states reported more cases during 2021 than 2020.

During 2021, 71% of TB cases occurred among non–U.S.-born persons, the same proportion as in 2020 and 2019. Incidence (cases per 100,000 population) among U.S.-born persons increased from 0.71 in 2020 to 0.79 in 2021 and among non-U.S.-born persons from 11.71 in 2020 to 12.16 in 2021 (Figure). Among U.S.-born persons reported as having TB disease, 4% identified as American Indian or Alaska Native (AI/AN), 6% as Asian, 33% as Black, 25% as Hispanic, 2% as Native Hawaiian or other Pacific Islander (NH/OPI), 29% as White, and 1% as multiple races.§§ From 2020 to 2021, TB incidence decreased 0.4% among U.S.-born Black persons and 5.7% among U.S.-born NH/OPI persons and increased among all other U.S.-born groups (including AI/AN [5.0%], Asian [32.6%], Hispanic [16.3%], and White [13.8%] persons) (Table 2). Among non–U.S.-born persons reported as having TB disease, <1% identified as AI/AN, 48% as Asian, 12% as Black, 34% as Hispanic, 1% as NH/OPI, 4% as White, and 1% as multiple races. From 2020 to 2021, TB incidence decreased 8.7% among non–U.S.-born Black persons and 40.3% among non–U.S.-born NH/OPI persons and increased among all other non–U.S.-born groups (including Asian [3.7%], Hispanic [7.9%], and White [4.5%] persons).¶¶ Compared with TB incidence in 2020, incidence during 2021 declined 2.2% among children aged ≤4 years, 0.3% among children and adolescents aged 5–14 years, and 2.9% among persons aged 15–24 years. Incidence increased among adults aged 25–44 years (5.3%), 45–64 years (10.6%), and ≥65 years (13.2%).

During 2021, among non–U.S.-born persons reported as having TB, 9.3% (507 of 5,456) received a diagnosis <1 year after arrival in the United States, compared with 9.7% (499 of 5,149) during 2020 and an average of 15.6% (996 of 6,377) during 2015–2019. Among non–U.S.-born persons with reported TB during 2021, approximately one third (1,811; 33.2%) had lived in the United States for at least 20 years before receiving a diagnosis, similar to the percentage during 2020 (1,662; 32%), and slightly more than the average of 28% (1,766) during 2015–2019. The proportion of persons who received a diagnosis of TB who had visible acid-fast bacilli on sputum smear microscopy, a marker of infectiousness and more advanced disease, during 2020 (46.4%) and 2021 (48.1%) were higher than the average proportion during 2015–2019 (44.3%).*** When stratified by birth origin, the prevalence of smear positivity among non–U.S.-born persons during 2020 (45.5%) and 2021 (47.8%) were higher than the average during 2015–2019 (42.6%). This increase in smear-positivity was not observed among U.S.-born persons who had received a diagnosis of TB (2021 = 48.2%; 2020 = 48.9%; average 2015–2019 = 48.7%).

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Discussion

U.S. TB incidence during 2021 increased by 9.4% following a large decrease during 2020 (2). Although TB cases and incidences have gradually declined in the United States since 1993, with a slowing pace of decline in recent years (1), larger changes in reported TB have occurred during the COVID-19 pandemic. Similar changes in TB incidence have been reported globally (3,4). In the United States, the causes for the changes in TB incidence are likely multifactorial. Probable explanations include a true reduction in TB disease resulting from reduced TB transmission because of pandemic mitigation efforts and fewer new arrivals from countries with higher TB incidence than the United States. In addition, delayed or missed TB diagnoses because of disruptions in health care access or assumptions that patients with respiratory symptoms had COVID-19 might contribute to the observed changes (5).

The reduction in the number of persons with TB disease reported <1 year after arrival in the United States coincides with changes in immigration and travel associated with the pandemic. Immigration to the United States declined by 31% during 2020,††† and similar patterns are suggested during 2021.§§§ However, immigration and travel reductions during 2020–2021 cannot fully account for the reduction in TB, because most TB cases among non–U.S.-born persons occur among those who have lived in the United States for many years and are likely the result of reactivation of latent TB infection (LTBI) (1). Despite overall case count declines, the number of TB cases among non–U.S.-born persons living in the United States for 20 years or longer before diagnosis increased during 2021 compared with average case counts during 2015–2019, highlighting the importance of evaluation and treatment of LTBI to prevent progression to TB disease. CDC is working to raise awareness of TB and LTBI among communities at risk and their health care providers through the new “Think. Test. Treat TB” campaign.¶¶¶

The increased TB incidence observed during 2021 compared with 2020 might be partially explained by delayed detection of cases with symptom onset during 2020 that were not diagnosed until 2021 because of delayed health care–seeking behavior, interruptions in health care access, or disrupted TB services related to the COVID-19 pandemic (6,7). The small increase in the prevalence of smear positivity at diagnosis, predominantly among non–U.S.-born persons, suggests more advanced pulmonary disease, which might result from delayed diagnosis. Avoiding missed or delayed diagnosis of TB is crucial to preventing transmission. TB should be considered in the differential diagnosis of patients with prolonged cough (>2 weeks) or TB symptoms such as unintentional weight loss or hemoptysis, particularly among persons with epidemiologic risk factors for TB (e.g., birth or former residence in a country with higher TB incidence than that in the United States, history of living in a congregate setting such as a homeless shelter or a correctional facility, or immune suppression).****

The findings in this report are subject to at least two limitations. First, this analysis is limited to provisional 2021 TB surveillance data and case counts might change. Second, calculated rates are based on population estimates that are subject to change.

Ongoing analyses of NTSS data and external data sources, including anti-TB drug dispensing and hospitalization data, will provide more information about the effects of the COVID-19 pandemic on U.S. TB epidemiology, including the extent to which delayed diagnosis has been a factor. Focusing on essential TB activities, including early diagnosis and complete treatment of TB and LTBI, remains critical to achieving TB elimination in the United States.

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Acknowledgments

State, local, and territorial health department personnel; Cynthia Adams, Stacey Parker, Jeanette Roberts, Katrina Williams, Peraton, Herndon, Virginia; Division of Tuberculosis Elimination surveillance team, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC; Molly Deutsch-Feldman, Adam Langer, Jonathan Wortham, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC.

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Corresponding author: Thomas D. Filardo, [email protected], 404-718-2792.

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1Epidemic Intelligence Service, CDC; 2Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC.

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All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

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* This report is limited to National Tuberculosis Surveillance System data verified as of February 9, 2022. Updated data will be available in CDC’s annual TB surveillance report later in 2022.

https://www.cdc.gov/tb/programs/rvct/instructionmanual.pdfpdf icon

§ 2021 vintage population estimates were used for 2021 and 2020. 2020 vintage population estimates were used for 2011–2019. https://www.census.gov/programs-surveys/popest/data/tables.htmlexternal icon

https://www.census.gov/topics/population/race/about.htmlexternal icon

** https://www.census.gov/programs-surveys/cps.htmlexternal icon

†† Persons born in the United States or a U.S. territory or elsewhere to at least one U.S. citizen parent are categorized as U.S.-born. All other persons are categorized as non–U.S.-born.

§§ Persons with missing race or ethnicity data are excluded from calculations of proportions.

¶¶ Percent change is not reported for non–U.S.-born AI/AN persons because there were no reported cases during 2020.

*** Percentage of positive sputum smears is calculated among persons with a positive or negative sputum smear result; those with unknown results or for whom testing was reported as not performed were excluded.

††† https://www.dhs.gov/immigration-statistics/yearbook/2020external icon

§§§ https://www.census.gov/library/stories/2021/12/net-international-migration-at-lowest-levels-in-decades.htmlexternal icon

¶¶¶ https://www.cdc.gov/thinktesttreattb/

**** Clinical consultation for potential TB cases is also available through state or local TB programs or the CDC-sponsored TB Centers of Excellence. https://www.cdc.gov/tb/education/professionaltools.htm

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References

  1. CDC. Reported tuberculosis in the United States, 2020. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. https://www.cdc.gov/tb/statistics/reports/2020/default.htm
  2. Deutsch-Feldman M, Pratt RH, Price SF, Tsang CA, Self JL. Tuberculosis—United States, 2020. MMWR Morb Mortal Wkly Rep 2021;70:409–14. https://doi.org/10.15585/mmwr.mm7012a1external icon PMID:33764959external icon
  3. World Health Organization. Global tuberculosis report 2021. Geneva, Switzerland: World Health Organization; 2021. https://www.who.int/publications/i/item/9789240037021external icon
  4. Pai M, Kasaeva T, Swaminathan S. COVID-19’s devastating effect on tuberculosis care—a path to recovery. N Engl J Med 2022. Epub January 5, 2022. https://doi.org/10.1056/NEJMp2118145external icon PMID:34986295external icon
  5. Narita M, Hatt G, Gardner Toren K, et al. Delayed tuberculosis diagnoses during the coronavirus disease 2019 (COVID-19) pandemic in 2020—King County, Washington. Clin Infect Dis 2021;73(Suppl 1):S74–6. https://doi.org/10.1093/cid/ciab387external icon PMID:33956137external icon
  6. Louie JK, Agraz-Lara R, Romo L, Crespin F, Chen L, Graves S. Tuberculosis-associated hospitalizations and deaths after COVID-19 shelter-in-place, San Francisco, California, USA. Emerg Infect Dis 2021;27:2227–9. https://doi.org/10.3201/eid2708.210670external icon PMID:34287142external icon
  7. Cronin AM, Railey S, Fortune D, Wegener DH, Davis JB. Notes from the field: effects of the COVID-19 response on tuberculosis prevention and control efforts—United States, March–April 2020. MMWR Morb Mortal Wkly Rep 2020;69:971–2. https://doi.org/10.15585/mmwr.mm6929a4external icon PMID:32701944external icon

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TABLE 1. Tuberculosis disease case counts and incidence, by U.S. state — 50 states and the District of Columbia, 2019–2021Return to your place in the text
U.S. jurisdiction No. of TB cases* TB incidence
2019 2020 2021 2019 2020 2021
Total 8,900 7,173 7,860 2.71 2.16 2.37
Alabama 87 72 92 1.77 1.43 1.83
Alaska 58 58 58 7.91 7.92 7.92
Arizona 183 136 129 2.51 1.89 1.77
Arkansas 64 59 69 2.12 1.96 2.28
California 2,111 1,706 1,750 5.35 4.32 4.46
Colorado 66 52 58 1.15 0.90 1.00
Connecticut 67 54 54 1.88 1.50 1.50
Delaware 18 17 43 1.84 1.71 4.29
District of Columbia 24 19 19 3.39 2.75 2.84
Florida 558 412 499 2.60 1.91 2.29
Georgia 302 221 228 2.84 2.06 2.11
Hawaii 99 92 106 6.99 6.34 7.35
Idaho 7 8 4 0.39 0.43 0.21
Illinois 326 216 255 2.57 1.69 2.01
Indiana 108 92 127 1.60 1.36 1.87
Iowa 52 39 49 1.65 1.22 1.53
Kansas 37 37 43 1.27 1.26 1.47
Kentucky 66 67 57 1.48 1.49 1.26
Louisiana 88 99 86 1.89 2.13 1.86
Maine 18 17 14 1.34 1.25 1.02
Maryland 209 148 192 3.45 2.40 3.11
Massachusetts 178 142 151 2.58 2.02 2.16
Michigan 131 101 136 1.31 1.00 1.35
Minnesota 148 117 134 2.62 2.05 2.35
Mississippi 58 41 45 1.95 1.39 1.53
Missouri 70 79 77 1.14 1.28 1.25
Montana 2 4 3 0.19 0.37 0.27
Nebraska 17 33 22 0.88 1.68 1.12
Nevada 53 57 61 1.71 1.83 1.94
New Hampshire 6 12 12 0.44 0.87 0.86
New Jersey 310 245 279 3.49 2.64 3.01
New Mexico 41 29 24 1.95 1.37 1.13
New York 746 605 681 3.83 3.00 3.43
North Carolina 185 159 178 1.76 1.52 1.69
North Dakota 18 10 15 2.36 1.28 1.94
Ohio 150 130 149 1.28 1.10 1.26
Oklahoma 73 67 69 1.84 1.69 1.73
Oregon 70 67 78 1.66 1.58 1.84
Pennsylvania 199 156 166 1.55 1.20 1.28
Rhode Island 14 7 17 1.32 0.64 1.55
South Carolina 80 67 88 1.55 1.31 1.70
South Dakota 16 16 12 1.80 1.80 1.34
Tennessee 129 113 85 1.89 1.63 1.22
Texas 1,154 883 991 3.98 3.02 3.36
Utah 27 29 17 0.84 0.88 0.51
Vermont 4 3 2 0.64 0.47 0.31
Virginia 191 169 161 2.23 1.96 1.86
Washington 221 163 199 2.90 2.11 2.57
West Virginia 9 13 7 0.50 0.73 0.39
Wisconsin 51 35 66 0.88 0.59 1.12
Wyoming 1 0 3 0.17 0.00 0.52

Abbreviation: TB = tuberculosis.
* Case counts are based on data reported to the National Tuberculosis Surveillance System as of February 9, 2022.
Cases per 100,000 persons using midyear population estimates from the U.S. Census Bureau. 2019 population estimates are based on the 2010 U.S. Census. 2020 and 2021 population estimates are based on the 2020 U.S. Census. https://www.census.gov/programs-surveys/popest/data/tables.htmlexternal icon

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Return to your place in the textFIGURE. Tuberculosis disease case counts* and incidence, by patient birth origin§ — United States, 2011–2021

Figure is a histogram that show tuberculosis disease case counts and incidence across two panels, by patient birth origin in the United States during 2011–2021.* Case counts are based on data from the National Tuberculosis Surveillance System as of February 9, 2022.

Cases per 100,000 persons. The Current Population Survey provides the population denominators used to calculate tuberculosis incidence according to national origin and racial/ethnic group. https://www.census.gov/programs-surveys/cps.htmlexternal icon (Accessed February 9, 2022).

§ Cases with unknown origin at birth excluded.

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TABLE 2. Tuberculosis disease case counts and incidence, by birth origin and race/ethnicity — United States, 2018–2021Return to your place in the text
Birth origin and race/ethnicity No. of TB cases* (incidence)
2018 2019 2020 2021
U.S.-born§
AI/AN 100 (3.91) 79 (3.35) 78 (3.54) 84 (3.72)
Asian 135 (1.88) 115 (1.50) 95 (1.15) 125 (1.53)
Black, non-Hispanic 950 (2.67) 909 (2.56) 731 (2.04) 739 (2.03)
Hispanic 584 (1.47) 609 (1.52) 475 (1.17) 553 (1.36)
NH/OPI 39 (5.17) 26 (3.92) 42 (6.20) 45 (5.85)
White, non-Hispanic 806 (0.43) 756 (0.41) 565 (0.30) 640 (0.35)
Unknown race/ethnicity or multiple races 28 (—) 31 (—) 21 (—) 38 (—)
Subtotal 2,642 (0.95) 2,525 (0.90) 2,007 (0.71) 2,224 (0.79)
Non–U.S.-born
AI/AN 2 (3.49) 2 (3.51) 0 (—) 1 (1.33)
Asian 3,074 (26.08) 3,049 (26.17) 2,478 (22.18) 2,613 (22.99)
Black, non-Hispanic 848 (20.36) 838 (19.83) 679 (15.67) 623 (14.30)
Hispanic 2,040 (10.28) 2,076 (10.24) 1,650 (8.17) 1,821 (8.81)
NH/OPI 73 (24.70) 80 (24.78) 75 (35.36) 68 (21.10)
White, non-Hispanic 260 (3.23) 254 (3.16) 212 (2.73) 225 (2.85)
Unknown race/ethnicity or multiple races 58 (—) 70 (—) 55 (—) 105 (—)
Subtotal 6,355 (14.33) 6,368 (14.23) 5,149 (11.71) 5,456 (12.16)
Unknown national origin 3 (—) 7 (—) 17 (—) 180 (—)
Total 9,000 (2.75) 8,900 (2.71) 7,173 (2.16) 7,860 (2.37)

Abbreviations: AI/AN = American Indian or Alaska Native; NH/OPI = Native Hawaiian or other Pacific Islander; TB = tuberculosis.
*Case counts are based on data from the National Tuberculosis Surveillance System as of February 9, 2022.
Incidence is calculated per 100,000 persons. The Current Population Survey (https://www.census.gov/programs-surveys/cps.htmlexternal icon) provides the population denominators used to calculate TB incidence according to national origin and racial/ethnic group. (Accessed February 9, 2022). Total rate was calculated by using midyear population estimates from the U.S. Census Bureau.
§ Persons born in the United States or a U.S. territory or elsewhere to at least one U.S. citizen parent are categorized as U.S.-born. All other persons are categorized as non–U.S.-born.
Incidence rates were not calculated for these categories because population estimates were not available.

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Suggested citation for this article: Filardo TD, Feng P, Pratt RH, Price SF, Self JL. Tuberculosis — United States, 2021. MMWR Morb Mortal Wkly Rep 2022;71:441–446. DOI: http://dx.doi.org/10.15585/mmwr.mm7112a1external icon.

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