Rurality and tuberculosis incidence trends in North and South Carolina, 1980 to 1992.

U.S. tuberculosis incidence rates increased steadily from 1985 through the end of 1992. Many factors have been implicated as contributors to the reversal in the historic decline of tuberculosis: the HIV epidemic, poverty and homelessness, immigration from less developed countries, and a deteriorating public health infrastructure. The purposes of this study were to demonstrate the extent of geographic variation in tuberculosis incidence rate trends in North and South Carolina and to quantify the association between aggregate-level characteristics of state economic areas and incidence rate trends. Data were obtained from the U.S. 1980 and 1990 decennial census and from the North and South Carolina health departments. In North Carolina, tuberculosis trends declined rapidly in the early 1980s, but declined much less rapidly from 1986 to 1992. In South Carolina, tuberculosis trends were nearly static during the early 1980s, but declined rapidly from 1986 to 1992. Rural and high-poverty state economic areas in South Carolina experienced especially favorable changes in tuberculosis incidence trends. South Carolina has a unique tuberculosis control program that makes widespread use of enablers, incentives, and directly observed therapy. This study demonstrates the distinct tuberculosis incidence trends that existed in two contiguous states and suggests that approaches to tuberculosis control that improve access to care may be effective in improving tuberculosis incidence trends, particularly in poor and rural areas. Strengthening tuberculosis programs may be an important strategy for controlling the current resurgence of tuberculosis in the United States.