The social geography of tuberculosis: California, 1980-1992

From 1953 until 1985, annual tuberculosis incidence rates declined in the United States by an average of 5 percent annually. The steady historical decline in tuberculosis incidence rates meant that, by the early 1980's, the elimination of tuberculosis from the U.S. seemed possible for the first time. However, from a nadir in 1985, U.S. tuberculosis incidence rates increased steadily through the end of 1992.;This was a study of the tuberculosis resurgence in California during 1980-92. We used a two-segment loglinear model to describe tuberculosis incidence rate trends for the periods 1980-84 and 1985-92, and changes in trends between the two periods. Tuberculosis incidence rate trends in California declined by an average of 15.2 percent annually during 1980-84 and increased by an average of 2.4 percent annually during 1985-92. Increasing tuberculosis incidence rate trends during 1985-92 and changes in incidence rate trends for 1985-92 versus 1980-84 were most extreme for children less than 15 years of age. Modified State Economic Areas with high cross-sectional tuberculosis incidence rates experienced the most adverse changes in incidence rate trends, demonstrating that the resurgence of tuberculosis was most severe in hyperendemic areas. Modified State Economic Areas with the highest antituberculous therapy compliance rates had declining tuberculosis incidence trends during 1985-92.;This study demonstrated that the tuberculosis resurgence in California has been a remarkably global phenomenon which has affected all age, ethnic-racial groups and diverse geographic locations, but has especially affected children. Markedly increasing trends in children are an ominous sign and suggest that recent transmission of infection may have played a large role in California's tuberculosis resurgence. Immigration and the AIDS epidemic, on the other hand, appear to have played a modest role in the resurgence of tuberculosis in California.;Strategies which facilitate the development of community-based tuberculosis programs that view tuberculosis control in a context broader than simply medical treatment may be the most effective means to improve compliance with therapy and thus to prevent the continuing transmission of tuberculous infection.