During 1986-1997, the number of tuberculosis (TB) cases among
foreign-born persons in the United States increased by 56%, from
4,925 cases (22% of the national total) to 7,702 cases (39% of the
national total). As the percentage of reported TB cases among
foreign-born persons continues to increase, the elimination of TB
in the United States will depend increasingly on the elimination of
TB among foreign-born persons.
On May 16-17, 1997, CDC convened a working group of state and
city
TB-control program staff, as well as representatives from CDC's
Division of TB Elimination and Division of Quarantine, to outline
problems and propose solutions for addressing TB among foreign-born
persons. The Working Group on Tuberculosis Among Foreign-Born
Persons considered a) epidemiologic profiles of TB cases among
foreign-born persons, b) case finding, screening, and preventive
therapy for the foreign born, c) TB diagnosis and management for
the foreign born, d) opportunities for collaborations with
community-based organizations (CBOs) to address TB among the
foreign born, and e) TB-related training needs.
The Working Group's deliberations and the resulting
recommendations
for action by federal agencies, state and local TB-control
programs, CBOs, and private health-care providers form the basis of
this report. For each of the five topics of discussion, the group
identified key issues, problems, and constraints and suggested
solutions in the form of recommendations, which are detailed in
this report. The Working Group made the following recommendations:
The epidemiology of TB among foreign-born populations differs
considerably from area to area. To tailor TB-control efforts to
local needs, TB-control programs should develop epidemiologic
profiles to identify groups of foreign-born persons in their
jurisdictions who are at high risk for TB.
The priorities of TB control among the foreign born should be
the
same as those for control of TB among other U.S. populations --
completion of treatment by persons infected with active TB,
contact
tracing, and screening and provision of preventive therapy for
groups at high risk. Screening and preventive therapy should be
limited to areas where completion of therapy rates and
contact-tracing activities are currently adequate.
Based on local epidemiologic profiles, selective screening
should
be conducted among populations identified as being at high risk
for
TB. Screening should target groups of persons who are at the
highest risk for TB infection and disease, accessible for
screening, and likely to complete preventive therapy. The
decision
to screen for infection, disease, or both should be based on the
person's age and time in the United States, prior screening, and
locally available resources for the provision of preventive
therapy.
TB-control programs should direct efforts towards identifying
impediments to TB diagnosis and care among local foreign-born
populations, devising strategies to address these barriers, and
maximizing activities to ensure completion of treatment.
Providing TB preventive therapy and other TB-related services
for
foreign-born persons is often impeded by linguistic, cultural,
and
health-services barriers. TB-control programs can help overcome
these barriers by establishing partnerships with CBOs and by
strengthening training and education efforts. Collaborations
with
health-service CBOs should center on developing more
complementary
roles, more effective coordination of services, and better use
of
existing resources for serving the foreign born. TB-related
training should be linked to overall TB-control strategies for
the
foreign born. Training and education should be targeted to
providers, patients, and community workers.
INTRODUCTION
In 1986, CDC began collecting information on place of birth
for those persons residing in the United States who have been
reported to be infected with tuberculosis (TB). National
surveillance data for the decade that followed indicate that the
number of TB cases among persons born in other countries increased
from 4,925 in 1986 to 7,702 in 1997, and that the percentage of
foreign-born cases increased from 22% to 39% of the national total.
In Canada and several European countries, foreign-born persons now
account for more than half of TB cases. If current U.S. trends
continue through the next decade, more than half of TB cases are
likely to occur among the foreign born.
BACKGROUND
Immigration Trends
The increase in TB cases among foreign-born persons over the
past decade is partly attributable to increased immigration
(Figure_1).
The largest wave of immigration in U.S. history occurred in the
early 1900s; by 1910, 14% of all U.S. residents were foreign born.
Immigration declined during the next two decades, reached a low
during the Great Depression (1929-1939), and then gradually
increased until the mid-1980s. A peak occurred in 1986, when the
Immigration Reform and Control Act was passed and persons who had
entered the country illegally were allowed to legalize their
status. In 1996, the most recent year for which immigration figures
are available, 915,900 persons were granted permanent residence
(1). In addition, an estimated 275,000 undocumented aliens arrive
annually. In 1996, an estimated 24.6 million foreign-born persons
resided in the United States, representing 9% of the total
population (2).
Another factor in the increase in TB cases among foreign-born
persons is changing trends in countries of origin. Immigration has
been increasing from Asia and the Latin Americas, where TB rates
are 5-20 times higher than those in the United States. In 1994, 25%
of the 24 million foreign-born persons in the United States were
from Asia and 42% from Latin America, including 6 million persons
from Mexico (2). In recent years, Asian-born persons have accounted
for an increasing percentage of new immigrants; in 1995, 37% of new
arrivals were from Asia (3). After Mexico, the top two countries of
birth among immigrants in that year were the Philippines and
Vietnam.
The foreign-born population is concentrated in some areas in
the United States. Forty-three percent of such persons live in
California (34%) or New York (9%). Florida, Texas, New Jersey, and
Illinois each have 5%-8% of the total foreign-born population (2).
In 1995, two thirds of immigrants indicated California, New York,
Florida, Texas, New Jersey, and Illinois as their intended
residence at the time of immigration, and approximately one fourth
of all new immigrants indicated an intent to live in Los Angeles or
New York City (3).
Characteristics of TB Cases Among Foreign-Born Persons
The composition of TB cases among foreign-born persons
reflects immigration patterns and trends. In 1997, Mexico was the
country of origin for 22% of immigrants with TB, with the
Philippines (14%) and Vietnam (11%) the next most common countries
of birth. India, China, Haiti, and Korea each accounted for 3%-6%
of the total. Together, these seven countries accounted for two
thirds of TB cases among foreign-born persons in the United States.
As expected, most TB cases among foreign-born persons are
reported from the states with the most immigrants. In 1997, 66% of
all TB cases among foreign-born persons were reported from
California (36% of the national total), New York (15%), Texas (8%),
Florida (5%), New Jersey (4%), Illinois (3%), Washington (2%),
Massachusetts (2%), Virginia (2%), and Hawaii (2%) (Table_1).
In
1997, TB cases among foreign-born persons were examined as a
proportion of total TB cases in each state. A total of 66% of TB
cases occurred among foreign-born persons in California and 51% in
New York. Even in states with relatively few cases among the
foreign born (e.g., Minnesota and Rhode Island), approximately 60%
of TB cases in 1997 were among persons born outside the United
States.
Most TB cases among foreign-born persons are likely the result
of reactivation of remotely acquired infection, although some
transmission is probably occurring in the United States. Studies
using the restriction-fragment-length polymorphism (RFLP) technique
document transmission to the foreign born by others who are foreign
born or U.S. born (4); other studies document high percentages of
cases among the children of the foreign born (5). For all immigrant
groups, the disease risk appears highest in the first years after
U.S. arrival (Figure_2). Among some groups, the risk decreases
rapidly over time, whereas for others, it remains high for up to 20
years (6). The risk for disease among the foreign born also appears
related to chronological age and age at immigration; younger
persons and those who immigrated at younger ages are at lower risk
for subsequent infection with TB.
The number of foreign-born persons in the United States with
TB infection is unknown. However, based on the World Health
Organization (WHO) estimate that one third of the world's
population is infected, more than 7 million foreign-born persons in
the United States might be at risk for reactivation of remotely
acquired infection.
PRIORITIES FOR ELIMINATING TB IN THE UNITED STATES
As the percentage of reported TB cases among foreign-born
persons continues to grow, the elimination of TB in the United
States will depend increasingly on the elimination of TB among the
foreign born. Although this factor presents challenges and requires
a flexible approach, the priorities of TB control remain the same
finding persons with active disease and ensuring completion
of treatment; b) tracing the contacts of those with active disease
and evaluating each contact's status regarding TB infection and
disease; and c) screening persons at high risk for infection,
providing preventive therapy to eligible candidates, and ensuring
completion of that preventive therapy (7).
TB Case Finding, Screening, and Preventive Therapy
In the United States, TB screening is required for a)
immigrants and refugees applying for permanent legal status and b)
persons of foreign birth (e.g., business persons, students, and
dependents) who entered the country on nonimmigrant visas and want
to adjust their immigration status to legal permanent resident.
Each year, active case finding is conducted on approximately
800,000 persons applying for long-term residence. In recent years,
approximately half have been screened overseas and half in the
United States.
Immigrants and refugees who want to enter the United States
are screened overseas by local physicians designated by U.S.
consuls. Persons with suspected TB disease are assigned a specific
classification -- Class A, B1, B2, or B3. The screening procedure
consists of initial radiologic screening for persons aged greater
than 15 years followed by sputum smear microscopy for acid-fast
bacilli (AFB) in those whose radiographs are compatible with active
TB. Persons who are AFB-smear-positive (designated Class A) must be
treated before departure. Those who are smear-negative, but whose
radiographs are compatible with active TB (Class B1) or with
inactive disease (Class B2), are referred to a health department in
the state of their intended residence for further evaluation.
(Those persons with abnormal radiographs indicating calcified
granulomas not indicative of active TB are Class B3 and are not
referred for additional evaluation.) U.S. screening practices
differ from those of other industrialized countries, which require
negative cultures.
The yield of the overseas screening process has been well
documented; 3%-14% of the approximately 6,000 Class B1 immigrants
and 0.4%-4% of the 12,000 Class B2 immigrants who enter the country
each year are infected with active TB after arrival in the United
States (8). Of those without evidence of active TB, many have
positive tuberculin skin tests and radiologic abnormalities
compatible with old TB; these persons are at high risk for
reactivation and are candidates for preventive therapy regardless
of age. A study in Seattle determined that approximately half of
Class B1 immigrants and one fourth of Class B2 immigrants were
considered candidates for preventive therapy (9). Limited
information exists concerning the practices of health departments
in pursuit of preventive therapy for these groups because, to date,
no systematic studies have been conducted on the subject.
Applicants already in the United States must be screened and
found free of infectious TB before they can adjust their
immigration status. Screening must be performed by physicians
designated as "civil surgeons" by the U.S. Department of
Justice/Immigration and Naturalization Service (INS). The procedure
consists of an initial tuberculin skin test. If the reaction size
is greater than or equal to 5 mm, a chest radiograph is required.
Persons whose results are compatible with TB must be referred to a
health department for treatment. Referral for possible preventive
therapy also is recommended for persons with skin-test reactions of
greater than or equal to 10 mm.
In contrast to the overseas program, less data are available
regarding the yield of the U.S. screening program. One program in
Denver -- where the health department physician was the
INS-appointed civil surgeon performing TB examinations -- detected
an active TB rate of 40/100,000, which was similar to the rate in
the country of origin for most of those tested. The study also
identified several candidates for preventive therapy for whom the
completion rate was higher than for candidates identified by other
means (10).
The number of foreign-born persons who are screened and
treated for TB infection through mechanisms other than formal
immigration processes is not known. Contact tracing, an important
component of the U.S. strategy for TB control, is a possible
case-finding mechanism. However, limited information is available
on the usefulness of this approach in identifying either persons
suspected of having TB or persons who are at high risk for
preventive therapy among the foreign born. A study in Seattle
documented that the yield for both the number of contacts and the
number of tuberculin-skin-test-positive contacts was higher among
the foreign born than among the U.S. born in the area, but the
study population was too small to assess the usefulness of contact
tracing as a case-finding tool among the foreign born (9).
TB-control programs have tried to identify foreign-born
preventive-therapy candidates through several other means,
including screening migrant farm laborers, school entrants, and
participants in English-as-a-second-language (ESL) programs.
However, few of these efforts have been evaluated to assess the
potential yield.
Efforts to provide screening and preventive therapy for the
foreign born are limited. Averting future cases of TB requires
linking screening programs to prevention services. However, few
resources are available to health departments for large-scale
prevention efforts for foreign-born persons. Also, persons who do
not consider themselves ill and who are from countries where TB is
regarded as a stigma might be reluctant to begin or complete
preventive therapy (11).
TB-control programs in the United States also must strive to
overcome perceptions about tuberculin-skin-test results among
persons who have been vaccinated previously against TB. Many
countries vaccinate infants with BCG (live attenuated vaccine) as
part of their TB-control programs. For those persons, tuberculin
sensitivity is highly variable and depends on the strain of BCG
used, the population vaccinated, and the recency of vaccination
because reactivity wanes over time (12). Moreover, no reliable
method exists to distinguish tuberculin reactions caused by BCG
from those caused by natural infections. Thus, some U.S.
health-care providers are reluctant to perform tuberculin skin
tests on foreign-born patients with previous BCG vaccinations
because they think that substantial reactions are likely to be
falsely positive.
Screening programs also are hindered by the unknown role of
environmental mycobacteria in other parts of the world in producing
false-positive reactions and by the cultural barriers to providing
services to persons who do not consider themselves ill and who are
from countries where TB is regarded as a stigma. Finally, the high
levels of isoniazid (INH) resistance in many countries of origin
raise questions about the usefulness of INH preventive therapy
among foreign-born populations.
TB Diagnosis
Data regarding the timeliness of TB diagnosis after the onset
of symptoms are not routinely collected for either U.S.- or
foreign-born populations. Compared with U.S.-born patients, a
higher percentage of foreign-born patients have extrapulmonary TB
only. Among foreign-born patients with pulmonary TB, the percentage
diagnosed on clinical criteria alone is higher than among U.S.-born
patients (14% versus 10%) (13).
Drug Resistance
Drug-resistance rates are higher among foreign-born
populations than among the U.S. born. In a recent study of drug
resistance based on national TB surveillance data for 1993-1996,
levels of INH resistance were higher among TB patients born in
Vietnam (18.3%), the Philippines (14.7%), and Mexico (9.8%) than
among U.S.-born TB patients (6.4%) (14). Levels of resistance to
INH and rifampin for the three groups were 2.1%, 2.1%, and 1.9%,
respectively, which is similar to the rate of 2.0% for those born
in the United States. Among foreign-born TB patients from the three
countries, resistance levels were higher in new arrivals than in
long-term residents.
TB Treatment Outcomes
The outcome of TB treatment is slightly better for
foreign-born patients than for U.S.-born patients (15). Among the
foreign-born community, levels of completion vary by country of
origin, but among all the major immigrant groups, completion rates
equal or exceed those of TB cases among U.S.-born patients.
TB-HIV Coinfection
In the United States, HIV has not played a major role in TB
cases among foreign-born persons in most areas. The only exception
is persons from Haiti. Recent studies conducted in southern Florida
indicated that half of the Haitians infected with TB among those
aged 25-44 years were also HIV positive (16). The low incidence of
HIV among foreign-born persons with TB might be partly attributable
to the U.S. law prohibiting persons with HIV infection from
applying for overseas immigration (17). Also, injecting-drug use
has not emerged as a major problem among the foreign-born
population. However, areas (e.g., San Diego) that are experiencing
increasing drug use among the foreign born have noted a
corresponding increase in HIV prevalence among foreign-born TB
patients in recent years (personal communication, Kathleen Moser,
M.D., M.P.H., San Diego Department of Health, May 1997).
OVERVIEW OF THE WORKING GROUPS REPORT
Given the issues outlined previously, the Working Group on
Tuberculosis Among the Foreign Born was responsible for a)
delineating the most important policy and programmatic needs
related to TB among foreign-born persons and b) providing
recommendations for action by CDC and other federal agencies,
health departments, community-based organizations (CBOs), and
private health-care providers to enhance control efforts. The
group's deliberations centered on five topics --
epidemiologic profiles of TB cases among foreign-born persons;
case finding, screening, and preventive therapy;
diagnosis and management;
collaborations with CBOs; and
training needs.
The remainder of this report is organized around these topics,
with
discussion of key issues related to each, followed by the
recommendations of the Working Group.
DEVELOPING EPIDEMIOLOGIC PROFILES OF TB CASES AMONG FOREIGN-BORN
PERSONS
Issues
Because the characteristics of foreign-born populations and TB
cases among the foreign born differ among public health
jurisdictions in the United States, TB-control efforts must be
tailored to meet local needs. These efforts require developing
detailed epidemiologic profiles of TB cases among the foreign born.
TB-control program staff need to know the characteristics and
outcomes of foreign-born patients with TB in their jurisdictions.
They also need information on sources of medical care in
communities of the foreign born, care-seeking behaviors, delays in
seeking care, community organizations or structures with access to
specific foreign-born populations, sources of interpreter services,
and sources of culturally appropriate health information.
Recommendations for Developing Epidemiologic Profiles of TB Cases
Among Foreign-Born Persons
CDC
CDC should continue to expand data presented regarding TB cases
among foreign-born persons in annual surveillance reports (e.g.,
time person has been in the United States when TB is diagnosed).
CDC should develop guidelines to monitor disease prevalence in
each reporting jurisdiction to document the burden of disease
represented by persons entering the United States. Current TB
case
counts exclude foreign-born persons who received TB treatment
before entering the United States, even if these persons have
documented disease and require months to years of treatment
after
entry. Prevalence is an important measurement for assessing TB
program needs given the prolonged treatment courses required for
each active case. These data should be added to CDC's annual
surveillance reports.
CDC should collaborate with international and national agencies
and organizations, (e.g., the North American Chapter of the
International Union Against TB and Other Lung Diseases) as well
as
state and local health departments to develop profiles of
immigration trends and patterns at the global, national, state,
and
local levels.
CDC should help health departments use TB surveillance data to
develop profiles of TB cases among foreign-born persons in their
jurisdictions (Appendix A). CDC should develop prototype
documents
and the computer programs needed to generate routine reports at
state and local levels. CDC also can help identify and direct
health departments to other data sources, such as a) CDC's
Division
of Quarantine database on immigrants with Class B tuberculosis
and
b) INS and U.S. Bureau of Census documents and data sets that
might
be useful for certain rate calculations. (Note: Detailed
calculations at the state and local levels will not always be
feasible.)
CDC should conduct and support studies to evaluate TB
transmission, contact tracing, and source investigations among
foreign-born populations. Possible research topics include a)
the
effects and yield of contact tracing with regard to case
prevention
and completion of preventive therapy; b) TB transmission by
foreign-born patients to children; c) identification of groups
at
high risk for whom to target screening; and d) strategies to
address border issues.
Health Departments and TB-Control Programs
Heath departments should develop baseline profiles of TB cases
among foreign-born persons in their jurisdictions (Appendix A).
The
frequency of subsequent profiles and their use at the city or
county level will be governed by the number and percentage of
cases
among the foreign born. Annual profiles will be useful
management
tools for states with a high incidence of TB among persons born
in
other countries.
Although much of the information needed to generate the
epidemiologic profiles already is collected as part of the
"Reports
of Verified Cases of Tuberculosis" (RVCT), health departments in
areas with large foreign-born populations should consider
including
additional variables (e.g., whether persons were identified as
Class B1 or B2 cases on overseas screening). Information on case
designations (Class A, B1, B2, or B3) can also be used to
measure
the impact of overseas TB screening on U.S. morbidity.
As necessary, health departments should conduct special studies
to complete their epidemiologic profiles. Research could focus
on
determining who is providing health-care services to the
foreign
born; b) identifying factors that are responsible for delays in
TB
diagnosis; c) identifying obstacles to care seeking; d)
assessing
the role of managed-care organizations in the care of
foreign-born
TB patients; and e) determining the capability of local
practitioners to provide services for foreign-born populations.
Health departments should work with CDC and other agencies to
develop profiles of immigration trends and patterns at the
global,
national, and state and local levels.
CASE FINDING, SCREENING, AND PREVENTIVE THERAPY
Case Finding and Contact Tracing
Issues
Active case finding can help identify cases of TB among
foreign-born persons whose access to health-care services might be
more limited than that of persons born in the United States.
However, the yield of such case-finding efforts is influenced by
the following factors:
Screening procedures before entry into the United States.
Country or region of origin -- Immigrants from the Philippines,
Vietnam, Haiti, Korea, and sub-Saharan Africa have higher rates
of
reported TB than immigrants from other countries (6).
Length of time in the United States -- Regardless of country of
origin, immigrants who have been in the United States for less
than
5 years have higher rates of TB than immigrants who have been in
the United States greater than 5 years (6).
Current age and age at the time of U.S. entry -- Older
immigrants
have higher rates of TB disease than immigrants who are younger.
Those who enter the United States at an older age have higher
rates
than their counterparts who enter at younger ages (6).
Other factors, (e.g., return travel to the country of origin,
HIV status, living conditions, and family constellation) also can
affect contact tracing. All of these factors need to be considered
in deciding which groups, if any, should be the target of active
case-finding efforts.
Contact tracing is one form of active case finding and is an
important component of TB-control efforts in the United States,
regardless of a patient's country of origin. Although the intent
and methods of contact tracing for foreign-born persons do not
differ substantially from those for persons born in the United
States, contact investigations among foreign-born persons might
have different dynamics. For example, determining if transmission
has occurred among "close" household contacts can be difficult
because of the high background prevalence of positive tuberculin
reactions. Expanding the contact investigation to those other than
close household contacts requires additional time, effort, and
resources.
Recommendations for Case Finding and Contact Tracing
CDC
CDC should provide health departments with timely information on
Class B entrants who need evaluation. CDC should help health
departments set up monitoring systems to ensure that evaluations
of
these entrants are completed.
CDC should provide guidance and data to help health departments
determine priorities for active case finding beyond Class B1 and
B2
immigrants.
CDC should conduct and support studies and assessments of
innovative methods of case finding.
CDC should develop and disseminate measurement instruments and
other tools to help programs measure effectiveness and
prevention
effectiveness.
CDC should develop interstate communication and notification
methods for tracking TB patients who might be highly mobile and
easily lost to follow-up (e.g., asking immigrants at the time of
entry about plans for relocating).
Health Departments and TB-Control Programs
Where appropriate, health departments should develop local plans
for controlling TB among the foreign born through case finding,
screening, and preventive therapy. Emphasis should be on the
community planning role of the health department and the
implementation role of other providers in the community. The
plan
should be specific to the characteristics of TB among the
jurisdiction's foreign-born population and should include
risk assessments of TB among the foreign born, based on local
demographic and epidemiologic profiles;
data regarding expected patterns of immigration, based on
information provided by INS;
information provided by the local public health and
TB-control
programs about their structure and resources;
a list of community health centers and CBOs providing
health-care and other services to immigrant populations
provided by
local community outreach organizations; and
recommendations on case finding, contact tracing, screening,
and
preventive therapy based on recommendations of CDC and
others.
Health departments should conduct active case finding according
to the following three priorities:
Priority 1 -- Immigrants with Class A TB. Health departments
should ensure that these patients are located, evaluated, and
treated appropriately.
Priority 2 -- Immigrants with Class B1 or B2 TB. Currently, no
federal regulations exist that prescribe follow-up procedures
for
those who have suspicious chest radiographs but negative sputum
smears, although those persons are reported to state health
departments by federal authorities. The number who are actually
evaluated nationally is unknown, but in health departments where
assessments have been made, the percentage has been reported to
range from 63% to approximately 95% (8). Each state and local
TB-control program should therefore have an active process to
ensure that all Class B1 and B2 immigrants are located,
evaluated,
and treated appropriately. Programs should develop a
notification
process (e.g., timely transfer of Class B1 and B2 forms to the
health department with a prescribed "window" for action).
Priority 3 -- Other Groups at High Risk. The next priority
should
be older immigrants (especially those aged greater than 55
years),
immigrants from countries with high rates of TB, immigrants from
high-risk areas who have been in the United States less than 5
years, and/or other groups that are "producing" cases, as
documented in the epidemiologic profile.
Health departments should determine other processes for case
finding among lower-risk foreign-born persons. These will likely
center on sources of care for the foreign born and will require
fostering partnerships with those who provide such care,
including
CBOs, community clinics, community health-care providers, and
foreign-trained physicians. The health department should involve
these partners in developing and implementing the proposed plan
to
combat TB in their community. The health department's role
should
be to provide education, training, and consultation.
Health departments should ensure that the evaluation of Class B1
and B2 immigrants includes a thorough history, medical
examination,
and in many cases, a repeat chest radiograph. Evaluation of
lower-risk groups might include a) a symptom check followed by a
chest radiograph for persons with symptoms indicative of TB; b)
a
purified protein derivative (PPD) tuberculin test followed by a
chest radiograph for PPD-positive persons; or c) screening with
a
chest radiograph without symptom history or PPD testing, based
on
whether screening is to be used for both case finding and
preventive therapy or for case finding only (e.g., elderly
foreign-born persons). The most effective strategy will depend
on
the risk for disease among the population screened. Health
departments should include these strategies in their TB-control
plans.
Health departments should evaluate their case-finding strategies
and determine the operational outcomes and cost-effectiveness of
different approaches. For example, depending on the prevalence
of
TB disease among the population being screened, symptom check
and
chest radiograph screening might be more cost-effective than
performing PPD screening with chest radiographs for persons with
positive PPD results.
Contact tracing should continue according to CDC guidelines.
Health departments should systematically collect data regarding
the
outcomes of contact tracing among foreign-born populations and
evaluate the yield and effectiveness.
Health departments should use CDC-developed interstate
communication and notification methods for tracking TB patients.
Health departments should develop intrastate tracking methods.
Health departments should share information on lessons learned.
TB incidence among foreign-born persons is a fluctuating
situation
in many parts of the country. Communities that currently have
few
TB cases among the foreign born might have more in the future.
To
transfer lessons learned, programs with large numbers of recent
immigrants should systematically record their experiences with
case
finding, contact tracing, screening, preventive therapy, and
directly observed preventive therapy (DOPT) and should document
successful strategies. Regional associations could make this
topic
a formal forum at periodic meetings.
Providers
Community practitioners and physicians providing health services
to foreign-born persons from high-risk areas should have a high
degree of suspicion for anyone who is symptomatic and refer
them,
when possible, to a state TB-control clinic.
Screening and Preventive Therapy
Issues
A substantial number of foreign-born persons are from
countries where the prevalence of TB is many times higher than that
reported for the United States. CDC estimates that at least 7
million foreign-born persons in the United States are infected with
TB and that 140,000-210,000 (2%-3%) will develop disease after
immigration unless they complete a regimen of preventive treatment.
Screening and providing preventive therapy to foreign-born
persons are hindered by the large number of persons to be screened,
difficulties in diagnosis, difficulties in gaining access to
persons who should be screened, cultural and linguistic barriers,
and the perceived difficulty in interpreting tuberculin skin tests
among persons who have received BCG vaccine. In health departments
already serving large numbers of TB patients, efforts to initiate
large-scale screening programs to identify additional foreign-born
persons with TB infection might be impeded by insufficient
resources to ensure completion of preventive therapy.
As of the publication of this report, data are scarce
regarding the rate of completion of preventive therapy among
foreign-born persons with TB infection. Lack of data thwarts
efforts to evaluate the cost-effectiveness of screening and
prevention programs or to measure or predict the impact of DOPT on
completion rates, the impact of directly observed therapy (DOT) for
index cases on the preventive therapy completion rates of their
contacts, or the impact of more extensive screening programs.
Data are also lacking on the contribution of civil surgeons in
identifying candidates for preventive therapy, providing preventive
therapy to foreign-born patients, and referring patients to local
health departments for evaluation. Some physicians do not place
tuberculin-reactive foreign-born patients on preventive therapy
because the physicians attribute positive skin-test results to
prior BCG vaccination. Some foreign-born candidates might not be
started on preventive therapy because physicians find difficulty in
convincing patients of the value of this health intervention (18).
Physicians and patients have concerns about potential adverse
effects or toxicity associated with preventive therapy.
Recommendations for Screening and Preventive Therapy
CDC
Screening --
CDC should develop guidelines to help state and local
health
departments develop area-specific, cost-effective
strategies for TB
screening targeted to foreign-born populations at high risk
and
ensure that resources are targeted to areas of greatest
need.
CDC should develop guidelines for evaluating screening
programs to assess cost-effectiveness.
CDC should provide information on any national policies
related to TB screening, diagnosis, treatment, and
preventive
therapy in high-prevalence countries that are the source of
large
numbers of reported U.S. cases (e.g., Mexico, the
Philippines,
Vietnam, India, China, Haiti, and South Korea). CDC should
make
this information available to appropriate health
departments,
universities, hospitals, clinics, and private physicians to
facilitate and maximize treatment efforts.
CDC should collect and disseminate data regarding
drug-resistance prevalence and incidence by country. Data
could be
based on WHO surveys and on information generated by U.S.
states on
immigrants with TB.
CDC should conduct and support studies of screening
practices in schools, universities, ESL programs, CBOs, and
managed-care organizations. The studies should document
screening
and preventive therapy practices, the impact of the
screening
practices on case finding and disease prevention, and
cost-effectiveness.
Certain approaches might be better than others at screening
undocumented persons. CDC should ensure that screening
strategies
identify the most effective approaches without excluding or
discouraging undocumented populations from seeking TB
evaluation
and follow-up.
Community screening plans should address the differing
opinions of providers regarding interpretations of positive
tuberculin tests. CDC or the American Thoracic Society
(ATS) should
consider developing a decision algorithm to help providers
assess
the importance of BCG vaccination history among different
immigration groups and age cohorts.
Completion of Preventive Therapy --
CDC should encourage and assist health departments in
developing ongoing systems for compiling and analyzing data
regarding the completion of preventive therapy among
foreign-born
persons. CDC also should assist health departments in
analyzing the
data regarding cost-effectiveness of efforts to improve
completion
of preventive therapy among the foreign born.
CDC should conduct and support cost-effectiveness analyses
of preventive therapy program activities to establish
criteria for
program evaluation.
CDC should conduct and support studies to evaluate the
referral process between civil surgeons and health
departments for
immigration status adjustment applicants who are
TB-infected and
need evaluation for preventive therapy.
CDC should conduct and support clinical and operational
research studies to identify and replicate strategies to
increase
adherence to preventive therapy among target populations.
CDC should conduct and support studies on the effectiveness
of INH preventive therapy among populations with high
background
levels of INH resistance and the possible role of
alternative
treatments (e.g., rifampin).
CDC should conduct and support studies on TB cases
prevented
as a result of various preventive therapy strategies.
CDC should work with federal, state, and local agencies
that
award Medicaid managed-care, primary care, and other
direct-service
delivery funds to ensure that the assessment of TB
prevention
indicators are built into funding mechanisms.
CDC should collect samples of available educational
materials and consider dissemination mechanisms (e.g., a TB
Internet website). These materials should cover diagnosis
of TB
infection, the TB skin test, BCG vaccinations, and the
importance
of preventive therapy. Materials should be posted in a
full-text
English version, with a list of available translations and
sources.
Health Departments and TB-Control Programs
Screening --
Health departments should establish screening goals and
priorities. Because the number of foreign-born persons who
are
eligible for screening could be large, TB programs should
use their
epidemiologic profiles to prioritize and target screening
to groups
who are at the highest risk for TB infection, who are
accessible
for screening, and who are likely to complete preventive
therapy.
Each community's plan to combat TB among foreign-born
persons should provide recommendations for groups
identified as
screening priorities as well as recommendations for
lower-risk
groups. The role of CBOs, clinics, and other providers also
should
be specified, with recommendations for targeted programs
for health
departments.
Persons at highest risk for infection can be identified by
examining epidemiologic trends in TB disease in the
community,
results of previous or existing screening programs, and
immigration
trends. Data regarding accessibility for screening and
likelihood
of success with adherence-enhancing efforts (e.g., DOPT)
might not
be readily available. Data-gathering strategies might
include
discussions with CBO staff and providers, reviews of the
medical
literature, reviews of program data, and information
exchange with
other programs.
Based on this information, possible candidates for
screening
include a) school entrants, b) ESL students, c) migrant and
seasonal farm workers, and d) persons in occupations with
large
numbers of foreign-born persons (e.g., food handlers, hotel
staff,
and poultry industry workers). Screening might be conducted
at
schools, job sites, health departments, private providers'
offices,
or community clinics. Comprehensive screening strategies
(e.g.,
screening of all new school entrants in areas with
substantial
foreign-born populations) have the advantage of not
stigmatizing
the foreign born. Any screening program must include plans
and
resources for evaluating candidates for preventive therapy
and for
ensuring completion of therapy, if needed.
Health department staff should communicate with civil
surgeons and private providers to facilitate the evaluation
and
preventive treatment of TB-infected applicants for
immigration
adjustment. Health departments can help civil surgeons by
becoming
familiar with Technical Instructions for Medical
Examination of
Aliens in the United States, the manual used by civil
surgeons, and
by serving as a technical resource. Health departments need
to
consider whether they have the resources to provide
preventive
therapy to TB-infected adjustment applicants before
initiating such
an activity.
Health departments should evaluate their screening programs
at least annually to assess progress toward goals.
Completion of Preventive Therapy --
Health departments should ensure that plans for screening
include identifying adequate resources and a process to
ensure the
completion of preventive therapy. If sufficient resources
do not
exist to ensure completion of preventive therapy, plans for
screening should be reconsidered. In some instances, DOPT
might be
an effective strategy. However, issues of resource
allocation and
acceptance can limit its application.
Health departments should evaluate preventive therapy
programs to determine their effectiveness and impact.
Programs
should establish goals for the percentage of persons
screened who
have their skin tests read, the percentage referred for
evaluation
who are actually evaluated, the percentage recommended for
preventive therapy who actually begin therapy, and the
percentage
beginning therapy who complete that therapy. Although
formal
cost-effectiveness analyses are not necessary or feasible
for most
health departments, the cost of the program, including the
cost per
participant completing preventive therapy, should be part
of any
evaluation.
Health departments should determine the magnitude and scope
of nonadherence to preventive therapy among the
foreign-born
populations in their jurisdictions.
Health departments should ensure that culturally sensitive
and language-appropriate educational materials on TB
infection, BCG
vaccinations, skin testing, and the importance of
preventive
therapy are available to foreign-born persons at high risk
for
disease.
Health departments should collaborate with practitioners to
develop and monitor preventive therapy practices.
Health departments should undertake pilot approaches for
improving completion rates for preventive therapy among
less
adherent high-risk groups.
DIAGNOSING AND MANAGING TB
Recognizing TB
Issues
In their pursuit of health care in the United States,
foreign-born persons encounter many barriers that can impede the
recognition of TB (e.g., language and cultural differences, which
hinder communication between foreign-born patients and health-care
providers). Moreover, many foreign-born patients are unaware of how
to gain access to the health-care system. Even when they access
health care, they often are ineligible for employee-based health
insurance or Medicaid and cannot afford to purchase private
insurance.
Attitudes and behaviors can pose other impediments to the
recognition of disease among the foreign born. Because of the
social stigma of TB or cultural beliefs about disease causation,
progression, and treatment, some foreign-born persons might deny
the presence of symptoms or known disease. They might delay seeking
care even when illness is recognized because of other priorities in
their lives (e.g., securing food and shelter, job responsibilities,
and family concerns). Undocumented persons (e.g., illegal border
crossers and visa "over-stayers") might delay diagnosis and
treatment because of fear of detection and possible deportation.
Delays can result in diagnosis of disease at more advanced stages,
which translates into the possible need for hospitalization and
more expensive care, as well as prolonged periods of infectiousness
and a greater likelihood of disease transmission. Medical providers
and laboratories also can impede or delay disease recognition.
Foreign-born patients might seek care from medical providers who
are not fully aware of, or up-to-date on, the latest CDC and ATS
guidelines for TB diagnosis and treatment.
Persons of foreign origin who enter the country on
nonimmigrant visas create specific problems. Unlike immigrants and
refugees, nonimmigrant business persons, students, and dependents
are not required to be medically evaluated for TB before entering
the country. If they later want to adjust their immigration status
to that of legal permanent resident while remaining in the United
States, they are required to be screened by a civil surgeon
designated by INS. Civil surgeons have valid U.S. medical licenses
but have no other TB-related educational or training requirements
and receive no postdesignation monitoring or required continuing
education. In most areas of the country, a lack of coordination and
communication exists between civil surgeons and state and local
health departments.
Recommendations for Recognizing TB
CDC
Via direct links to INS, CDC should initiate efforts to
determine
the number of adjustment-of-status examinations conducted in
various jurisdictions and the names of civil surgeons by
jurisdiction. CDC should encourage INS to require training,
certification, and mandatory continuing education for civil
surgeons.
CDC should develop training materials for civil surgeons to
improve their ability to screen immigrants for TB infection and
disease and to make the appropriate referrals for follow-up. The
materials could be designed as self-study tools or as course
curricula for continuing education classes provided by health
departments.
CDC should conduct and support studies to identify barriers to
TB
diagnosis and care among foreign-born populations. Helpful
information could be provided through operational and behavioral
research related to access to care; knowledge and beliefs of
patients, community providers, and physicians; and other factors
related to recognition of disease among foreign-born
populations.
CDC also should consider lessons learned from medical
anthropology
research on other diseases that might be relevant to TB.
Health Departments and TB-Control Programs
Health departments should devise, identify, and implement early
disease recognition strategies that are focused on specific
foreign-born populations at high risk. Successful strategies
should
be promoted as models for other regions.
Health departments should develop ongoing educational seminars
on
TB diagnosis for private physicians, especially civil surgeons
and
physicians in the community who treat foreign-born persons.
Health departments should be encouraged to make contact with
local civil surgeons to offer training and encourage
collaboration
and referrals.
Health-care providers and health departments should not be
required to question foreign-born patients to determine if they
are
legal residents under federal immigration law.
Completing Treatment
Issues
Problems related to completion of treatment center on
nonadherence, inadequate tracking systems, information gaps, and
drug resistance. Nonadherence to treatment is a major problem in
TB-control programs worldwide. Adherence is impeded by the same
cultural and economic barriers that hinder timely diagnosis of
disease among foreign-born persons.
Tracking and communication networks also are inadequate. Some
foreign-born persons (e.g., migrant and seasonal farm workers) are
very mobile and move among countries and states and across the
U.S.-Mexico border while under treatment. Completion of treatment
in these cases is impeded by the lack of efficient tracking and
referral systems. Similarly, foreign-born patients sometimes return
to their country of origin before completion of treatment, with no
follow-up of care. Essentially no communication exists between TB
controllers in the United States and their counterparts in foreign
countries, with the exception of the U.S.-Mexico border region
where lines of communication are being established.
TB treatment is also hindered by gaps in information. U.S.
health-care providers have little information on current medical
guidelines for TB treatment and diagnosis in the developing world.
Even U.S. TB controllers are not knowledgeable about the screening
procedures and treatment regimens used in the countries of origin
for many of their foreign-born patients. In addition, scant program
data are available on the common barriers to adherence affecting
foreign-born subpopulations in the United States and even less on
the unique problems related to adherence among specific groups
within foreign-born subpopulations. Although data regarding
completion of treatment are collected via the national RVCT system,
the data have not been analyzed by subpopulation or region to help
define the scope and magnitude of adherence issues among the
foreign born.
Foreign-born patients who were treated in their home countries
pose special problems. U.S. physicians who treat foreign-born
persons with TB are rarely able to obtain medical records from
countries where the patients were treated previously. If the
records are available, the medical information is likely to be in
an unfamiliar language or format. National TB-control program
reports from countries that are sources of large numbers of TB
cases among the foreign born often lack reliable data regarding
rates of relapse, drug resistance, and completion of therapy.
Finally, because resources and infrastructure for TB-control
programs are severely limited in many foreign countries, persons
treated for TB in these countries might receive inadequate or
incomplete treatment. This puts foreign-born persons at greater
risk for disease recurrence with drug-resistant strains, which
complicates and lengthens the course of treatment. Some persons
with multiple resistant strains are chronically ill and
persistently infectious. Although the total number of these
patients with treatment-resistant TB is small, the cost associated
with their medical care is many times that of patients with
drug-susceptible disease. Treating these patients can severely
strain local health department resources, especially because
foreign-born populations are disproportionately underinsured or
uninsured.
Recommendations for Completing Treatment
CDC
CDC should encourage and help state and local health departments
conduct periodic analyses of the data regarding reported TB
cases
among the foreign born to determine the magnitude and scope of
nonadherence to treatment.
CDC should support regional TB associations in facilitating
collaborations with immigrants' countries of origin.
In conjunction with INS, CDC and the model TB centers* should
develop and distribute materials in various languages for
applicants for immigration adjustment. The materials developed
should explain the TB-screening requirements for legal permanent
residency.
CDC, in conjunction with WHO, should compile
drug-resistance/drug-susceptibility data from the appropriate
countries as available and disseminate the data to jurisdictions
with large numbers of foreign-born TB patients.
Health Departments and TB-Control Programs
Health departments should identify the characteristics of the
foreign-born patients in their jurisdictions who are most likely
to
be nonadherent. They should develop approaches to address the
barriers that cause these patients to drop out before completion
of
treatment. In areas with diverse populations of foreign-born
persons, studies should be undertaken to determine problems
related
to adherence by ethnic subgroup.
Whenever possible, health departments should hire outreach
workers and case managers from the same cultural, ethnic, and
linguistic background as the patient populations they serve.
Outreach staff can familiarize patients with the local
health-care
system, ensure that patients receive the necessary examinations,
facilitate DOT, and conduct intermittent home visits for pill
counts and client interviews to help identify adherence-related
problems.
Health departments should periodically evaluate their
educational
materials on TB for foreign-born patients to ensure that the
materials are accurate, up-to-date, in agreement with the most
current CDC and ATS statements, and appropriate to the needs and
characteristics of their more recent immigrants.
Health departments should maximize their collaboration with
refugee health programs to help their patients complete
treatment.
Communication between TB controllers in the United States and
Mexico should be continued and expanded to facilitate continuity
of
medical care for TB patients who frequently move back and forth
across the border.
Health departments in jurisdictions with large numbers of
foreign-born TB patients should become familiar with the
treatment
policies and regimens of the major countries of origin. They
also
should ascertain BCG-vaccination policies and practices in those
countries.
COLLABORATING WITH CBOs
Issues
CBOs and health departments can be strong partners in efforts
to prevent and control TB among foreign-born persons who are at
high risk for the disease. However, in many communities, health
departments and relevant CBOs have little or no contact and thus
lose opportunities to maximize their effectiveness. Also, many
health-service CBOs have limited understanding of TB-related issues
and often are unable or unwilling to provide screening and
preventive therapy.
Recommendations for Collaborating with CBOs
Health Departments and TB-Control Programs
Health departments should conduct an inventory of community
organizations and resources in their jurisdictions to determine
which CBOs, community leaders, associations, and coalitions can
be
resources in the TB-control effort. The list should
differentiate
between health-service CBOs and those that cannot or do not
provide
health services. Useful sources of information might include a)
TB
outreach workers, b) members of foreign-born communities at risk
for TB, and c) directories or listings of health department and
CBO
services. If no such directories are available, health
department
staff could work with one or two CBOs to compile such a resource
for the community.
Health departments should identify the most influential
organizations for persons who are foreign born among those
listed
in any directory of resources. At a minimum, these organizations
should have substantial interactions with persons at high risk
for
TB, be effective at working in the community, and be willing to
work with the health department. Recognizing which CBOs might
contribute as partners in community TB prevention and control
efforts targeted to the foreign born is important. Examples
include
religious organizations, community action agencies, community
coalitions, vocational assistance or job programs, recognized
community leaders, professional associations, block
organizations,
health centers, student organizations, and informal community
groups.
Health departments should develop partnerships with influential
organizations and leaders and share resources to serve
communities
at risk for TB. Health department staff can
serve as sources of information about health-related issues;
help with medical referrals;
provide TB-related screening, prevention, and other medical
care
services;
provide TB-related services in CBOs or other facilities; and
work with CBOs to help newly arrived immigrants and refugees
obtain appropriate TB-related education, screening, and
follow-up.
Health departments should invite representatives of key CBOs to
serve on state and local TB advisory committees and coalitions.
CBO
representation is essential to ensure "buy-in" and to gain
community expertise in developing workable TB prevention and
control strategies.
Health departments should work with health-service CBOs to
develop more complementary roles, more effective coordination of
services, and better use of existing resources. CBO roles should
be
consistent with each organization's stated and unstated
interests,
missions, goals, and objectives. Some appropriate roles for CBOs
might be to
profile the characteristics, health beliefs, and other
attributes of the community's foreign-born population(s);
locate patients who previously have been lost to follow-up
(if
confidentiality issues can be resolved);
help provide TB-related health education to high-risk
populations;
provide outreach and screening services, with or without
financial support from the health department;
serve as a site for DOT and/or preventive therapy in close
collaboration with health department staff (e.g., a health
department might detail a staff person to provide health
education,
screening, and preventive therapy at a CBO);
identify and provide referral services;
provide and/or distribute incentives and enablers to persons
receiving treatment or preventive therapy;
enhance the credibility of health-education messages or
outreach
activities;
translate health-education or training materials; and
identify contacts abroad with whom to begin developing
relationships.
Health departments should initiate the development of
prevention-outcome measures for their communities.
TRAINING NEEDS
Issues
Some problems associated with TB among the foreign born stem from
communication barriers, cultural and cognitive dissonance between
providers and patients, and gaps in provider training. Foreign-born
patients might not know how to gain access to the health-care
system. Providing TB prevention and control services to
foreign-born persons might be impeded by linguistic, ethnic,
cultural, socioeconomic, or other differences between patients and
health workers. Foreign-born health-care providers might be
uninformed about the latest U.S. recommendations and practices
related to TB and, thus, be unable to provide optimal diagnostic
services, preventive therapy, and management to the foreign born.
TB-related training and educational efforts to support and
strengthen TB-control activities need to be linked closely to the
overall TB-control strategies for the foreign born. When
foreign-born populations are identified and health-care providers
for these populations are defined, training efforts can be
developed and implemented. Education should be targeted to
providers, patients, and community workers.
Recommendations for Training Needs
Health Departments and TB-Control Programs
Health departments should undertake training needs assessments.
These assessments should include a determination of the
practitioners' knowledge, skills, and attitudes regarding any
planned TB-control interventions. Helpful reference sources
might
include materials and recommendations from the San Francisco
Model
Center training summit scheduled for October 1998.
TB-related training and educational efforts focused on the
foreign born should reflect the educational, cultural, and
ethnic
background of the target audience and should consider the unique
characteristics of the trainees (e.g., foreign-born health-care
providers, other health-care providers who work with the
foreign-born, or foreign-born patients).
Health departments should adapt educational materials for use by
specific foreign-born populations. Adaptations should consider
language, concepts, level of comprehension, and message
delivery.
Health departments also should evaluate the message-delivery
tools
to assess the effectiveness of outreach efforts.
In collaboration with CBOs, health departments should provide
training to health-care providers of foreign-born groups at risk
for TB, with the goal of enhancing screening efforts, improving
case management, and increasing completion of preventive
therapy.
Possible topics include diagnosis of TB infection, the TB skin
test, preventive treatment, BCG vaccination, case reporting,
case
management, availability of TB resources, and partnership
building.
Programs also should include training in the use of interpreters
and education about cultural beliefs and practices that can
hinder
case finding, treatment, and preventive therapy (e.g., cultural
concepts about TB, BCG-vaccination use, or barriers to effective
communication with foreign-born populations). Ethnologic
research
(e.g., EthnoMed***** data) might be helpful to trainers in
gaining
a better understanding of their foreign-born constituents. To
encourage interest in and attendance at educational programs,
health departments and CBOs should consider sponsoring special
luncheon or dinner meetings, offering academic credit, and
advertising to foreign-born medical associations.
Health departments should train CBO staff who might not have a
health background but who can give PPDs and provide simple
epidemiologic data. The importance of this training should not
be
underestimated when planning collaborative efforts with CBOs.
CONCLUSION
This report presents a plan for federal, state, and local
TB-control programs to address TB among the foreign-born population
residing in the United States. Not all TB-control programs will
have the resources to implement all aspects of this plan, and some
TB-control programs will not have the same issues identified in
this report. However, these recommendations can provide assistance
in identifying programmatic gaps and in establishing priories for
a TB-control and prevention plan that will yield the greatest
positive results for foreign-born persons.
References
U.S. Department of Justice, Immigration and Naturalization
Service. Statistical yearbook of the Immigration and
Naturalization
Service, 1996. Washington D.C.: U.S. Government Printing
Office,
1997.
U.S. Census Bureau. The foreign-born population: 1996; P20-494
and PPL-59 {Internet website less than http://www.census.gov
greater than }. Washington D.C.: U.S. Census Bureau, 1998.
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the
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Wells CD, Zuber PLF, Nolan CM, Binkin NJ, and Goldberg SV.
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1997;156:573-7.
Blum RN, Polish LB, Tapy JM, Catlin BJ, Cohn DL. Results of
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* CDC funds three model TB centers -- San Francisco's Francis J.
Curry National TB Center; New York City's Charles P. Felton
National TB Center at Harlem Hospital; and Newark's New Jersey
Medical School National TB Center. These model centers provide
comprehensive and coordinated state-of-the-art diagnostic,
treatment, prevention, and patient education services for those
persons infected with TB, those suspected of being infected, their
contacts, and other persons at risk for TB.
** Sponsored by the University of Washington's Harborview Medical
Center in Seattle, EthnoMed is a database containing medical and
cultural information about refugee groups (Internet website,
.)
Table_1 Note:
To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 1. Tuberculosis cases among U.S.- and foreign-born persons -- United States, 1997
==========================================================================================================
U.S.-born Foreign-born
persons persons* Unknown
--------------- --------------- --------------
State Total cases No. % No. % No. %
----------------------------------------------------------------------------------------------------------
United States 19,851 11,898 59.9 7,702 38.8 251 1.3
Alabama 405 384 94.8 21 5.2 0 0
Alaska 78 60 76.9 18 23.1 0 0
Arizona 296 185 62.5 109 36.8 2 0.7
Arkansas 200 182 91.0 16 8.0 2 1.0
California 4,056 1,243 30.6 2,795 68.9 18 0.4
Colorado 94 43 45.7 48 51.1 3 3.2
Connecticut 128 74 57.8 54 42.2 0 0
Delaware 39 26 66.7 13 33.3 0 0
District of Columbia 110 86 78.2 17 15.5 7 6.4
Florida 1,400 988 70.6 408 29.1 4 0.3
Georgia 696 570 81.9 115 16.5 11 1.6
Hawaii 167 41 24.6 126 75.4 0 0
Idaho 15 6 40.0 9 60.0 0 0
Illinois 974 727 74.6 223 22.9 24 2.5
Indiana 168 143 85.1 24 14.3 1 0.6
Iowa 74 37 50.0 34 45.9 3 4.1
Kansas 78 42 53.8 23 29.5 13 16.7
Kentucky 198 184 92.9 14 7.1 0 0
Louisiana 406 380 93.6 23 5.7 3 0.7
Maine 21 16 76.2 5 23.8 0 0
Maryland 340 208 61.2 132 38.8 0 0
Massachusetts 268 83 31.0 185 69.0 0 0
Michigan 374 320 85.6 54 14.4 0 0
Minnesota 161 46 28.6 114 70.8 1 0.6
Mississippi 245 235 95.9 10 4.1 0 0
Missouri 248 197 79.4 51 20.6 0 0
Montana 18 15 83.3 3 16.7 0 0
Nebraska 22 11 50.0 11 50.0 0 0
Nevada 112 56 50.0 56 50.0 0 0
New Hampshire 17 8 47.1 9 52.9 0 0
New Jersey 718 379 52.8 339 47.2 0 0
New Mexico 71 51 71.8 20 28.2 0 0
New York 2,265 1,119 49.4 1,146 50.6 0 0
North Carolina 463 393 84.9 70 15.1 0 0
North Dakota 12 7 58.3 5 41.7 0 0
Ohio 286 226 79.0 59 20.6 1 0.3
Oklahoma 212 169 79.7 28 13.2 15 7.1
Oregon 161 94 58.4 67 41.6 0 0
Pennsylvania 528 399 75.6 123 23.3 6 1.1
Rhode Island 38 13 34.2 23 60.5 2 5.3
South Carolina 328 308 93.9 20 6.1 0 0
South Dakota 19 18 94.7 1 5.3 0 0
Tennessee 467 423 90.6 43 9.2 1 0.2
Texas 1,992 1,234 61.9 626 31.4 132 6.6
Utah 36 16 44.4 20 55.6 0 0
Vermont 6 4 66.7 2 33.3 0 0
Virginia 350 205 58.6 143 40.9 2 0.6
Washington 305 114 37.4 191 62.6 0 0
West Virginia 54 51 94.4 3 5.6 0 0
Wisconsin 130 78 60.0 52 40.0 0 0
Wyoming 2 1 50.0 1 50.0 0 0
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* Persons born outside the United States, American Samoa, Federated States of Micronesia,
Guam, Marshall Islands, Midway Island, Northern Mariana Islands, Puerto Rico, Republic of
Palau, U.S. Minor Outlying Islands, U.S. Miscellaneous Pacific Islands, and U.S. Virgin Islands.
Source: CDC. Reported tuberculosis in the United States, 1997. Atlanta, GA: US Department of
Health and Human Services, CDC National Center for HIV, STD, and TB Prevention, July 1998.
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