Tuberculosis Surveillance Report
Arizona, 2005

Arizona Department of Health Services
Bureau of Epidemiology and Disease Control
Office of Infectious Disease Services
June 2006

Tuberculosis Control Program
150 N. 18th Avenue, Suite 140
Phoenix, Arizona 85007
(602) 364-4750

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Purpose of the Report
The Tuberculosis Annual Report is designed to be a source of data regarding tuberculosis (TB)
in Arizona for purposes of prevention and control of the disease through interventions, new or
changes in policies, rules and statutes, allocation of funds and planning services. The target
audience includes government agencies, health care organizations and providers and other
interested parties or individuals. The program can provide more detailed information upon
request.

TB Surveillance, Prevention, and Control in Arizona
The Arizona Department of Health Services (ADHS) Tuberculosis Control (TBC) Program is
assigned the responsibility of monitoring, controlling and preventing infection, disease, and
death associated with tuberculosis (TB) statewide through surveillance, data analyses, health
education, dissemination of guidelines, consultation, and rule making. Tracking TB disease,
completion of therapy, and drug susceptibility results of new TB cases are at the heart of the
work of the TB Control program. Other critical functions include monitoring the contacts of
cases with active TB. To that end, the program maintains registries to monitor: (1) the
occurrence, distribution, characteristics (risk factors), and trends of TB morbidity; (2) completion
of therapy; (3) TB drug-resistance patterns; and (4) the follow-up of persons exposed to active
TB cases to ensure absence of latent TB infection (LTBI) or medical evaluation and completion
of preventive therapy if positive for LTBI.
While the TBC assesses burden of disease/infection, its characteristics and distribution and the
risk factors associated with disease, the local health departments (county and tribal) and the
Indian Health Service units provide the direct patient care (tests, medical evaluation, therapy,
and contact investigations). Local health departments also coordinate with private and other
public providers (eg, correctional health) who provide these services t patients with TB disease
or LTBI.
The Arizona State Public Health Laboratory provides testing services including AFB smear,
culture, identification, and susceptibility testing for clinical mycobacterial samples statewide and
serves as a reference laboratory for all isolates suspected to be positive for TB in the state.
Starting in 2004, all first time positive isolates at the state laboratory have been forwarded to an
outside laboratory for genotyping to allow for epidemiological linking of cases. The State
Laboratory also performs drug susceptibility testing on all first time positive isolates. The State
Laboratory currently has the capacity to test susceptibility to the following drugs: isonaizid,
rifampin, ethambutol, pyrazinamide, capreomycin, ethionamide, ofloxacin, and streptomycin.
We acknowledge with gratitude the efforts of all public and private (clinicians and laboratorians)
providers who make this report possible via their consistent and timely reporting of disease and
drug susceptibility results.

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Incidence of TB
Arizona reported 281 cases of active tuberculosis (TB) in 2005, ranking 13th among reporting
states in the U.S. This reflects a 3% increase from the previous year. While the U.S. has seen a
34% decline in the number of TB cases for the past 10 years (1996-2005), Arizona has
documented a relatively stable number of cases with a mean of 276 cases and range between
254 and 296 cases in the ten year period. (Table 1 and Figure 1). However, due to a significant
increase in population growth in the past 10 years, TB rates in Arizona have decreased from 6.1
cases per 100,000 population in 1996 to 4.6 in 2005.

Table 1. Tuberculosis Cases and Case Rates per 100,000 Population, Arizona and
United States, 1996 - 2005
United Statesa

Arizona
b

Year

Cases

Population

Rate

Cases

Rate

1996
1997
1998
1999
2000
2001
2002
2003
2004
2005

282
296
254
262
261
289
263
295
272
281

4,586,940
4,736,990
4,883,342
5,023,823
5,130,632
5,306,966
5,456,453
5,580,811
5,743,834
6,044,985

6.1
6.2
5.2
5.2
5.1
5.4
4.8
5.3
4.7
4.6

21,337
19,851
18,361
17,531
16,377
15,989
15,078
14,871
14,511
14,093

8.0
7.4
6.8
6.4
5.8
5.6
5.2
5.1
4.9
4.8

a

Data from U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, available
at: http://www.cdc.gov/nchstp/tb/surv/surv2003/default.htm

b

Population denominators for 1995-2003 are estimates from the National Center for Health Statistics
(http://www.cdc.gov/nchs/about/major/dvs/popbridge/popbridge.htm), with the exception of year 2000, which is taken
from the 2000 U.S. Census

Cases per 100,000

Figure 1. Tuberculosis Case Rates per 100,000,
Arizona and United States, 1996 - 2005
10.0
8.0
6.0
4.0
2.0
0.0

1996

1997

1998

Arizona

1999

2000

United States

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2001

2002

2003

2004

2010 Target (1/100,000)

2005

Age/Gender/Race/Ethnicity
The majority of TB cases (63%) in Arizona in 2005 were in the 25 to 64 year old age group with
a mean and median age of 41.4 and 41.0 years, respectively (Figure 2). Of great concern is the
percentage of cases among persons under the age of 25 (22%). There were also a significant
number of cases in individuals over the age of 65. This group comprised 16% of the total
cases. Males accounted for 65% of cases (n=182). The breakdown by race/ethnicity was 62%
Hispanic; 19% White, non-Hispanic; 8% Black, non-Hispanic; 7% Asian; and 5% Native
American (Figure 3). The highest TB case rate occurred in Asians with 17.2 cases per 100,000
n=20). However, the Asian population in Arizona is small, which translates to a high rate but
small number of cases. The TB case rate for Hispanics was 11.4 cases per 100,000 (n=174)
(Table 2).

Number of Cases

Figure 2. Tuberculosis Cases by Age Group and Gender, Arizona,
2005
70
60
50
40
30
20
10
0

Male
Female

0-4

5-14

15-24

25-44

45-64

65+

70
60
50
40
30
20
10
0

20.0

17.2
11.4

15.0

10.7

10.0
4.5
1.4

5.0
0.0

Asian

Hispanic

Black
Percentage

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American
Indian
Rate

White

Cases per 100,000

Percentage

Figure 3. Case Rates and Percentage of Tuberculosis Cases
by Race/Ethnicity, Arizona, 2005

Table 2. Tuberculosis Cases by Ethnicity, Gender and Age Group, Arizona, 2005

Total by Ethnicity
American Indianc
Male
Female
Total
Asian
Male
Female
Total
Black, Not Hispanic
Male
Female
Total
Hispanic or Latinod
Male
Female
Total
Native Hawaiiane
Male
Female
Total
White, Not Hispanic
Male
Female
Total
More than one race
Male
Female
Total
Total by Gender
Male
Female
Total by Age Group
No.
(%)
Ratea,b

Age Group (years)
15254524
44
64

<5

514

0
0
0

0
0
0

2
1
3

1
0
1

1
0
1

0
0
0

0
0
0

1
3
4

1
2
3

12
5
17

Total by Ethnicity
65+

No.

(%)

Ratea,b

0
2
2

6
1
7

9
4
13

(4.6)

4.5

2
6
8

4
4
8

2
1
3

9
11
20

(7.1)

17.2

5
0
5

1
1
2

4
1
5

2
0
2

14
7
21

(7.5)

11.2

8
3
11

9
7
16

51
24
75

31
6
37

9
9
18

120
54
174

(61.9)

11.4

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

(0.0)

N/A

0
0
0

0
1
1

1
0
1

10
0
10

14
11
25

5
11
16

30
23
53

(18.9)

1.4

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

(0.0)

N/A

14
8

9
6

17
8

65
31

53
24

24
22

182
99

(64.8)
(35.2)

6.0
3.3

22
(7.8)
4.9

15
(5.3)
1.7

25
(8.9)
2.9

96
(34.2)
5.4

77
(27.4)
6.1

46
(16.4)
5.9

281
(100.0)
4.6

a

Rate per 100,000 population

b

In order to obtain the 2005 population denominators, the 2000 percentages of population breakdowns (or census shares)
were applied to total state and county population estimates for 2005 released by the Department of Economic Security on
2/23/2006.
c
Includes American Indians and Native Alaskans
d
Persons of Hispanic or Latino origin may be either Black or White
e
Includes Native Hawaiians and Pacific Islanders

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TB in Children <5 Years of Age
Active TB in young children is indicative of ongoing transmission in the community and more
importantly missed opportunities for preventive therapy. This group accounted for 8% (n=22) of
all cases. Children <5 years of age had a case rate of 4.9 cases per 100,000 compared to the
overall rate of 4.6 cases per 100,000 in Arizona. Nationwide, children <5 had a rate of 2.8
cases per 100,000 and comprised 3.8% of overall cases in 2004, the most recent year for which
data is available. Additionally, 77% of pediatric (<5 years) TB cases in 2005 occurred among
Hispanics in Arizona (Table 2). Of the 22 pediatric cases, 16 were born in the United States
and 6 were foreign born. Mexico was the country of origin for three of the six foreign born
pediatric cases.

Site of Infection and Deaths
Pulmonary TB with no additional site of disease accounted for 82.2% of all cases in 2005 (Table
3). Extrapulmonary disease accounted for 12.8% of all cases. Cervical lymphadenopathy with
no pulmonary involvement comprised 36.1% of all extrapulmonary cases and 4.6% (n=13) of
total cases. There were eleven deaths documented in 2005 due to tuberculosis.

Table 3. Tuberculosis Cases by Form of Disease and Vital Status at Diagnosis,
Arizona, 2005
Form of Disease

Alive at Diagnosis

Diagnosis After Death
No.

Total Cases

No.

(%)

(%)

No.

(%)

229

(99.1)

2

(0.9)

231

(100.0)

Extrapulmonaryb

35

(97.2)

1

(2.8)

36

(100.0)

Persons with Both Pulmonary and Extrapulmonary
Disease

12

(85.7)

2

(14.3)

14

(100.0)

276

(98.2)

5

(1.8)

281

(100.0)

Pulmonarya

Total Cases (%)
a

Includes cases with pulmonary listed as major site of disease and no additional site of disease

b

Includes cases with pleural, lymphatic, bone and/or joint, meningeal, peritoneal, or other site, excluding
pulmonary, listed as the major site of disease

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(%)
(82.2)
(12.8)
(5.0)
(100.0)

Risk Factors

Table 4. Tuberculosis Cases by Selected Risk Factors, Arizona, 2000 - 2005
2000
Occupation
Correctional Facility Worker
Health Care Worker
Migrant Farm Worker
Reported Behaviors
Injecting Drug Usea
Non-injecting Drug Usea
Excess Alcohol Usea
Type of Residence
Long Term Care Facilityb
Correctional Facilityb
Homelessa
Country of Birth
Foreign Bornc
Underlying Disease
HIV infection, All Agesd
HIV infection, 25-44 Years Oldd
Total Cases

2001

2002

2003

2004

2005

No.

(%)

No.

(%)

No.

(%)

No.

(%)

No.

(%)

No.

(%)

0
6
9

(0.0)
(2.3)
(3.4)

0
5
6

(0.0)
(1.7)
(2.1)

0
3
8

(0.0)
(1.1)
(3.0)

0
3
4

(0.0)
(1.0)
(1.4)

0
7
10

(0.0)
(2.6)
(3.7)

0
1
5

(0.0)
(0.4)
(1.8)

11
20
46

(4.2)
(7.7)
(17.6)

11
22
61

(3.8)
(7.6)
(21.1)

10
27
41

(3.8)
(10.3)
(15.6)

5
24
57

(1.7)
(8.1)
(19.3)

7
31
48

(2.6)
(11.4)
(17.6)

10
19
28

(3.6)
(7.0)
(10.3)

7
21
39

(2.7)
(8.0)
(14.9)

12
16
45

(4.2)
(5.5)
(15.6)

7
19
32

(2.7)
(7.2)
(12.2)

5
39
36

(1.7)
(13.2)
(12.2)

9
36
20

(3.3)
(13.2)
(7.4)

7
40
22

(2.5)
(14.2)
(7.8)

147

(56.3)

134

(46.4)

137

(52.1)

172

(58.3)

156

(57.4)

172

(61.2)

18
13

(6.9)
(14.3)

12
8

(4.2)
(8.9)

18
12

(6.8)
(14.0)

17
13

(5.8)
(14.6)

23
19

(8.5)
(18.3)

19
12

(6.8)
(12.5)

261

289

263

295

272

a

281

Within one year prior to diagnosis of tuberculosis.
Residence at time of diagnosis.
c
Includes persons born outside the United States and its territories.
d
Tuberculosis cases with a reported positive HIV test result. The percent positive represents HIV co-infection among all verified TB cases, including those not tested
for HIV infection.
b

i) Foreign-Born Cases
Per Table 4, in 2005, the single most important risk factor (among those widely used
nationwide) associated with TB was birth outside the U.S. (61.2% of all cases). When
considering foreign born cases only, the majority (68%) were from Mexico (Figure 4). Over the
last ten years there is an increasing trend in percentage of foreign born individuals in relation to
overall number of cases in Arizona (Figure 5).

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Figure 4. Country of Origin for
Foreign-born TB Cases, Arizona,
2005
Guatemala

Philippines
India
Vietnam
El
Salvador

Mexico
68%

Other

Figure 5. Percentage of TB Cases in
Foreign-Born Persons, Arizona, 1995 2005
100%
80%

U.S.

60%

Foreign

40%
20%
0%
1995

1997

1999

2001

2003

2005

ii) Correctional Facilities and Related Risk Factors
Other individuals at higher risk of exposure to M. tuberculosis are those in correctional facilities,
those with a history of drug/alcohol abuse, or those with a history of homelessness (Table 4).
Arizona had the highest percentage (14.2%) of its total cases in correctional facilities nationally
in 2005 (Figure 6). Routine evaluation for TB of all inmates during intake allows for diagnosis of
both latent and active infection in this population. Cases were identified in local jails (n=10),
state (n=5) and federal prisons/US Immigrations and Customs Enforcement (ICE) (n=12) and
private facilities (n=13). The mean age of those diagnosed with TB in a correctional facility in
2005 was 36.4 years and 98% (n=39) were male. Eighty-three percent (n=33) of the
correctional TB cases were foreign born with Mexico being reported as the country of origin by

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58% (n=23) of the foreign-born patients. New inmate TB screening requirements in
correctional facilities were implemented in 2004 to address the problem of tuberculosis in this
setting. Additionally, the program has been working closely with correctional health staff on TB
education and regulation implementation.

Figure 6. Number and Percent of TB Cases Diagnosed in
*

50
Number

40
30
20
16

18

23

14

18

19
97

19
98

19
99

20
00
20
01
20
02
20
03
20
04
20
05

19
95

0

19
96

10
21

16

19

39

36

40

16
14
12
10
8
6
4
2
0

Percent

Correctional Facilities, Arizona and the U.S., 1995-2005

Year
Number

Percent

US Percent

iii) TB/HIV
Co-infection with HIV in individuals with TB is a major concern due to the fact that immune
system suppression by HIV can impact the body’s ability to fight TB. Individuals with coinfection have higher mortality and are susceptible to increased drug resistance leading to
longer and more complex treatment regimens. HIV testing results were available for 84% of
cases in 2005 (Figure 7). Of these, 19 (6.8% of total) cases of active TB had documented HIV
co-infection (Table 4). Twelve of the 19 cases were in individuals between the ages 25 and 44
reflecting 12.5% of cases in this age group. Additionally 2 cases of co-infection occurred in
individuals in correctional facilities.

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14

90
80
70
60
50

12
10
8

40
30
20
10
0

6
4
2
0

% of all TB cases HIV tested

% of all TB cases HIV positive

Figure 7. HIV Co-infection of TB Cases,
Arizona and US, 1995-2005

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
HIV positive, US
% tested, US

HIV positive, AZ
% tested, AZ

Contacts
Controlling spread of TB through contact investigations is an important piece in TB control and
prevention. Contacts are identified through investigations after a sputum AFB-smear positive
case is identified. Individuals who are shedding TB in their sputum provide a higher risk of
exposure to close contacts. These contacts are identified and evaluated for TB exposure and
treated if warranted. In 2003, the last year for which data is finalized, 83% (101/121) of sputum
AFB-smear positive cases had contacts identified. The average number of contacts identified
per sputum AFB-smear positive case was 35.3 (4272/121) which reflects a four fold increase
compared to the previous year. This could be attributed to expanded contact investigations
performed in correctional facilities and in schools. Preliminary data for 2004 and 2005 show an
average of 3.4 (349/104) and 3.3 (337/101) contacts identified per case, respectively (Tables 5
and 6).

Table 5. Number of Contacts to AFB Sputum Smear Positive TB Cases, Arizona, 2000-2005.

No.
Cases with Contacts
Cases without Contacts

95
14

Total AFB-Smear Positive
Cases

109

2001
(%)

No.

2002
(%)

No.

2003
(%)

(87)
(13)

104
17

(86)
(14)

101
20

(83)
(20)

121

* Preliminary data

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121

No.
62
42
104

2004*
(%)
(60)
(40)

No.
43
58
101

2005*
(%)
(43)
(57)

Table 6. Evaluation of Contacts to Sputum AFB-Smear Positive TB Cases, Arizona, 20002005.

No.

2001
(%)

No.

2002
(%)

Contacts Evaluated
Contacts not Evaluated

826
197

(81)
(19)

872
197

(82)
(18)

Total Contacts to AFB-Smear
Positive Cases

1023

1069

No.

2003
(%)

2637
1635
4272

(62)
(38)

No.

2004*
(%)

No.

2005*
(%)

310
39

(89)
(11)

326
11

(97)
(3)

349

337

* Preliminary data

Location
Four of Arizona’s 15 counties accounted for 92.0% of the state’s TB cases. Maricopa County,
which includes Phoenix, the fifth largest U.S city, led the state with 169 cases (60.1%). Pima
County, a U.S.-Mexico border county that includes Tucson, Arizona’s second largest urban
area, had 33 cases (11.7%). Yuma County, the border county on the western side of Arizona
had 32 cases (11.3%). Pinal County, which contains Arizona’s two largest state prison facilities,
four private prisons, Immigration and Customs Enforcement Service Processing Center (ICESPC), and a county jail, had 25 cases (8.8%). Correctional facilities In Pinal County diagnosed
22 of the 25 reported cases (88%). There were no TB cases reported in 3 counties in 2005, and
Greenlee County has not reported a TB case in six years (Figure 8). Even though Gila and La
Paz counties had high rates in 2005, it is important to note that they should not be considered
reliable given their small populations.

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Figure 8. Tuberculosis Cases (in parentheses) and Case Rates per 100,000 by County, Arizona, 2005.

- 12 -

Completion of Therapy
Directly observed therapy (DOT) is the preferred method of administration for TB medication. In
DOT, public health field workers observe the patient take his/her medications to ensure
compliance. Due to the length of time to complete treatment for TB the most recent finalized
data is for 2003. In 2003, 86% of cases had either DOT or a combination of DOT and selfadministered treatment (Table 7).
Table 7. Use of Directly Observed Therapy (DOT), Arizona, 1999-2003
1999

2000

2001

2002

2003

No.

%

No.

%

No.

%

No.

%

No.

%

163

(65)

157

(64)

186

(67)

169

(67)

210

(77)

Both DOT and
Self-Administered

33

(13)

40

(16)

40

(14)

34

(14)

24

(9)

Self-Administered Only

53

(21)

50

(20)

51

(18)

38

(15)

31

(11)

Unknown

0

(0)

0

(0)

1

(0)

0

(0)

1

(<1)

Not Available

0

(0)

0

(0)

1

(0)

10

(4)

7

(3)

249

(100)

247

(100)

279

(100)

251

(100)

273

(100)

DOT

a

Total
a

Includes persons alive at diagnosis with an initial drug regimen of one or more drugs.

The usual treatment for pulmonary TB in Arizona is six months of therapy starting with the
standard 4 drugs of isoniazid, rifampin, pyrazinamide, and ethambutol. A goal of 90%
completion of therapy within one year has been set by CDC. In 2003, 79% of cases completed
treatment within one year and 83% of cases completed therapy overall (Figure 9). Completion of
therapy within one year was 56.4% among inmates, 80% among homeless cases, and 79% in
non-correctional cases. These highlight the challenges to ensure completion of therapy among
inmates and also the successes with the homeless persons with TB in Maricopa County. In
2003, 8% (n=21) of cases in therapy died before completion of therapy. State and local
programs are working to improve completion of therapy performance.

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Figure 7. Completion of Tuberculosis Therapy, Arizona, 1996 - 2003

Percentage

100
80

73

81

88

76

95

84

95

82

89

89

78

78

81

90

79 83

60
40
20
0
1996

1997

1998

1999

2000

% Complete within 1 Year

2001

2002

2003

Overall Completion

Note: Completed in one year or less excludes persons resistant to RIF and
children <15 years with meningeal, bone or joint or miliary disease

Drug Susceptibility
Initial drug susceptibility testing was obtained on 94.7% (196/207) of culture-proven TB cases in
Arizona in 2005. INH resistance occurred among 20 cases, or 9.6% of culture confirmed cases.
Foreign-born individuals accounted for 65% of the drug resistant cases. One multi-drug
resistant case was identified in 2005. All multi-drug resistant cases since 2000 have occurred
among foreign-born persons (Table 8).

Table 8. Tuberculosis Cases Resistant to INH and Other Anti-TB Drugs, Arizona,
2000 - 2005
Year

2000
2001
2002
2003
2004
2005

Cases

261
289
263
295
272
281

Culture
Confirmed

228
228
212
228
206
207

Drug Sensitivity
Testing
No.
221
226
209
227
204
196

(%)
(96.9)
(99.1)
(98.6)
(99.6)
(99.0)
(94.7)

INH
Resistanta
No.
17
12
11
14
20
20

(%)
(7.7)
(5.3)
(5.3)
(6.2)
(9.8)
(9.6)

a

MDRb
No.
3
3
1
2
2
1

(%)
(1.4)
(1.3)
(0.5)
(0.9)
(1.0)
(<1)

Isolates may also be resistant to other drugs, including rifampim, includes initial and final susceptibility results

b

Resistant to at least isoniazid and rifampin, includes initial and final susceptibility results

c

Other patterns of drug resistance excluding INH resistance

d

Isolates with resistance to any first or second line TB drug

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Other
Resistancec

Total
Resistanced

No.
19
18
24
19
23
20

No.
36
30
35
33
43
41

(%)
(8.6)
(8.0)
(11.5)
(8.4)
(11.3)
(9.6)

(%)
(16.3)
(13.3)
(16.7)
(14.5)
(21.1)
(19.8)

International Referral and Case Management
The Arizona TB Control Programs coordinate with international referral agencies to ensure
continuity of care for individuals with TB or suspected of having TB who migrate to or from the
United States. CureTB facilitates the referral process with Mexican health officials. TBNet
facilitates the referral process for all other countries. An important tool that is used to track
some of these migrating patients (to/from Mexico) and their health care needs is the Binational
Health Card. In 2005, Arizona TB programs referred approximately 85 individuals to CureTB or
TBNet.

Class B1/B2 Referrals
Individuals immigrating to the United States are evaluated for TB as part of the admission
process. An immigrant found to have active TB that is not infectious is classified as a Class B1.
Those with a chest x-ray that suggests a history of TB disease that is not currently active are
classified as Class B2. The state of residence for those that are suspected of having TB
infection is notified of all class B1 and B2 individuals identified. These referrals are then
forwarded to the appropriate county so that further evaluation and treatment for infection may be
pursued. In 2005, ADHS received 102 class B notifications that were forwarded to counties for
follow up.

“Meet and Greet” Program
The goal of the Arizona “Meet and Greet” program is to ensure continuity of care for individuals
being treated for TB who are being deported to Mexico. “Meet and Greets” require coordination
between the Arizona Department of Health Services (ADHS) TB Control Program, ADHS Office
of Border Health, Sonoran Health Officials, Immigration and Customs Enforcement (ICE), local
health departments, and the correctional facility or detention center that is housing the
individual. The Department initiated nine “Meet and Greets” in 2005 and five were successfully
completed.

The Tuberculosis Surveillance Report is published annually by the Arizona Department of
Health Services, Tuberculosis Control Section. All data are provisional. Report finalized on
6/29/2006 based on data available 6/12/2006.

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