Prevention of tuberculosis in older adults in the United States: obstacles and opportunities.

BACKGROUND Persons ≥65 are a growing proportion of the US population and are at increased risk for tuberculosis disease. The objective of the study was to examine rates and identify risk factors for tuberculosis among older adults in the United States. METHODS Average rates and rate ratios for tuberculosis by age group, race/ethnicity, country of birth, calendar year, and long-term care facility residence were calculated using Centers for Disease Control and Prevention tuberculosis case reports and Census Bureau data. RESULTS Older adults accounted for 21.9% of tuberculosis cases in the United States between 1993 and 2008. Average yearly tuberculosis rates over sixteen years were 10.9 per 100 000 (95% confidence interval [CI], 10.8-11.0) in older adults compared with 7.3 per 100 000 (95% CI, 7.3-7.4) in persons aged 21-64 (rate ratio [RR], 1.5; 95% CI, 1.5-1.5). Among older adults, tuberculosis rates increased with age from 9.6 per 100 000 in persons aged 65-74 to 14.2 per 100 000 in persons aged ≥85 years. Older persons at higher risk for tuberculosis include men (RR, 2.1; 95% CI, 2.1-2.2), American Indians/Alaska Natives (RR 3.6; 95% CI, 3.4-3.9), those in long-term care facilities (RR 2.3; 95% CI, 2.2-2.3), and the foreign-born (RR 5.1; 95% CI, 5.0-5.2). CONCLUSIONS Elimination of tuberculosis in the United States will require addressing the substantial burden of disease among older persons, especially men, non-whites, long-term care facility residents, and foreign-born persons. Use of interferon-γ release assay testing may help prioritize persons with greatest need for treatment of latent tuberculosis infection, as new shorter and less toxic regimens make latent tuberculosis treatment in older adults more attractive.