Results of Screening for Tuberculosis in Foreign-born Persons Applying for Adjustment of Immigration Status

doi:10.1378/chest.103.6.1670

Chest

Volume 103, Issue 6, June 1993, Pages 1670-1674

https://doi.org/10.1378/chest.103.6.1670 Get rights and content

As part of the required screening process of illegal aliens applying for adjustment of status by the Immigration and Naturalization Service, 7,573 persons were evaluated for tuberculous infection by the Denver Department of Health and Hospitals from May 1987 through December 1988. Applicants were screened with tuberculin skin testing, chest radiographs, or both. Review of 6,520 charts that were available found that 4,840 applicants had tuberculin skin tests, of which 2,039 (42 percent) were ≥10 mm and 1,528 had further evaluation at the Denver Metro Tuberculosis Clinic. Seventy-five percent of the applicants were between the ages of 15 and 34 years, and 91 percent were from Mexico. Evidence of past or current tuberculous infection on chest radiograph was present in 273 (17 percent) and 16 (7 percent) had sputum cultures obtained that identified four new cases of active tuberculosis. Isoniazid preventive therapy (IPT) was recommended to 1,029 applicants, of whom 29 (3 percent) were 35 years of age or older; 716 (70 percent) completed at least six months of treatment. We conclude that there is a high prevalence of tuberculous infection in foreign-born persons applying for adjustment of immigration status, but a low prevalence of clinically apparent tuberculosis. This population is an excellent target for IPT, which can be achieved with good success. Proactive screening and preventive therapy is likely to significantly reduce tuberculosis reactivation and morbidity, prevent secondary infection of contacts, and be cost-effective.

(Chest 1993; 103:1670-74)

Section snippets

Applicant Eligibility and Program Guidelines

Persons applying for adjustment of status with the Immigration and Naturalization Service under the Immigration and Nationality Act and the Immigration Reform and Control Act of 1986 (Public Law 99-603) were required to undergo screening for tuberculosis among other illnesses. Negative tuberculin skin tests and/or normal chest radiographs provided for immediate clearance (with respect to tuberculous infection). A positive skin test and a normal chest radiograph called for immediate clearance

RESULTS

From May 1987 through December 1988, a total of 7,573 applicants were screened. Of these, 6,520 (86 percent) had charts that were available for review. A total of 1,528 were referred to the Denver Metro Tuberculosis Clinic. The indications for referral included positive tuberculin skin tests in 1,293 (85 percent) and abnormal chest radiographs in 235 (15 percent). The vast majority (91 percent) of applicants were from Mexico. Persons from the Middle East, Europe, Central America, Africa,

DISCUSSION

The prevalence of tuberculous infection and the effectiveness of a screening and prevention program of foreign-born persons applying for adjustment of immigration status has not been reported (to our knowledge). We found a high prevalence (42 percent) of tuberculous infection in this population, of whom 91 percent were from Mexico. Of the candidates for preventive therapy who were identified, 70 percent completed at least six months of therapy. Thus, this was a worthwhile screening program that

ACKNOWLEDGMENTS

We gratefully acknowledge Ms. Audrey Martinez for assistance with chart reviews and data collection.

REFERENCES (24)

GW Comstock
Epidemiology of tuberculosis
Am Rev Respir Dis
(1982)
Centers for Disease Control
Tuberculosis, final data-United States, 1986
MMWR
(1986)
RE Chaisson et al.
Tuberculosis in patients with the acquired immune deficiency syndrome
Am Rev Respir Dis
(1987)
CW Schieffelbein et al.
Tuberculosis control among homeless populations
Arch Intern Med
(1988)
KE Powell et al.
Tuberculosis among Indochinese refugees in the United States
JAMA
(1983)
Centers for Disease Control. Tuberculosis statistics in the United States. HHS Publication No. (CDC)89-8322,...
Colorado Governors Interagency Workgroup on IRCA. Becoming legal: a guide to the new immigration law. Colorado Refugee...
American Thoracic Society
Treatment of tuberculosis and tuberculous infection in adults and children
Am Rev Respir Dis
(1986)
Centers for Disease Control
Screening for tuberculosis and tuberculous infection in high-risk populations
MMWR
(1990)
DE Snider et al.
Tuberculosis in children
Pediatr Infect Dis
(1988)

HL Rieder et al.

Tuberculosis in the United States

JAMA

(1989)

CM Nolan et al.

The use of sputum cultures in the evaluation of immigrants classified as tuberculosis suspects

Am Rev Respir Dis

(1989)

Cited by (60)

Tuberculosis and immigration in Spain. Evidences and controversies
2006, Medicina Clinica
Domestic impact of tuberculosis screening among new immigrants to Ontario, Canada
2015, CMAJ
Citation Excerpt :
However, the permanent residents who were referred for and complied with postimmigration surveillance could have reduced their future risk of developing active TB if they had undergone testing and had been found to have latent TB infection, deemed eligible for and offered treatment and then completed treatment. Numerous studies have shown that fewer than 15% of immigrants at risk for latent TB infection ultimately complete preventive therapy, even in specialized clinical settings.22–25 Although we were unable to quantify the population-level impact of treating latent infection on active TB in our study, it was probably limited.
All Canadian immigrants undergo screening for tuberculosis (TB) before immigration, and selected immigrants must undergo postimmigration surveillance for the disease. We sought to quantify the domestic health impact of screening for TB in all new immigrants and to identify mechanisms to enhance effectiveness and efficiency of this screening.
We linked preimmigration medical examination records from 944 375 immigrants who settled in Ontario between 2002 and 2011 to active TB reporting data in Ontario between 2002 and 2011. Using a retrospective cohort study design, we measured birth country–specific rates of active TB detected through preimmigration screening and postimmigration surveillance. We then quantified the proportion of active TB cases among residents of Ontario born abroad that were detected through postimmigration surveillance. Using Cox regression, we identified independent predictors of active TB postimmigration.
Immigrants from 6 countries accounted for 87.3% of active TB cases detected through preimmigration screening, and 10 countries accounted for 80.4% of cases detected through postimmigration surveillance. Immigrants from countries with a TB (all-sites) incidence rate of less than 30 cases per 100 000 persons resulted in pre- and postimmigration detection of 2.4 and 0.9 cases per 100 000 immigrants, respectively. Postimmigration surveillance detected 2.6% of active TB cases in Ontario residents born abroad, and TB was detected a median of 18 days earlier in those undergoing surveillance than in those who were not referred to surveillance or who did not comply. Predictors of active TB postimmigration included radiographic markers of old TB, birth country, immigration category, location of application for residency, immune status and age.
Universal screening for TB in new immigrants has a modest impact on the domestic burden of active TB and is highly inefficient. Focusing preimmigration screening in countries with high incidence rates and revising criteria for postimmigration surveillance could increase the effectiveness and efficiency of screening.
Tuberculosis: Evidence review for newly arriving immigrants and refugees
2011, CMAJ. Canadian Medical Association Journal
Citation Excerpt :
Patients with previously treated tuberculosis or inactive tuberculosis (defined as those with latent tuberculosis infection and scarring visible on chest radiograph) are required to begin monitoring within 30 days after arrival in Canada in the Post-Landing Surveillance Program.2,10,20 There are no routine postlanding screening programs for latent tuberculosis infection for immigrants in Canada, but several programs exist (managed by different organizations) — for example, school-based screening, contact investigations, immigrant and refugee clinics, services for migrant workers and targeted screening of high-risk and undocumented migrants.106–123 The preimmigration radiographic screening and the Post-Landing Surveillance Program have relatively little effect on controlling tuberculosis in Canada.
The foreign-born population bears a disproportionate health burden from tuberculosis, with a rate of active tuberculosis 20 times that of the non-Aboriginal Canadian-born population, and could therefore benefit from tuberculosis screening programs. We reviewed evidence to determine the burden of tuberculosis in immigrant populations, to assess the effectiveness of screening and treatment programs for latent tuberculosis infection, and to identify potential interventions to improve effectiveness.
We performed a systematic search for evidence of the burden of tuberculosis in immigrant populations and the benefits and harms, applicability, clinical considerations, and implementation issues of screening and treatment programs for latent tuberculosis infection in the general and immigrant populations. The quality of this evidence was assessed and ranked using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation).
Chemoprophylaxis with isoniazid is highly efficacious in decreasing the development of active tuberculosis in people with latent tuberculosis infection who adhere to treatment. Monitoring for hepatotoxicity is required at all ages, but close monitoring is required in those 50 years of age and older. Adherence to screening and treatment for latent tuberculosis infection is poor, but it can be increased if care is delivered in a culturally sensitive manner.
Immigrant populations have high rates of active tuberculosis that could be decreased by screening for and treating latent tuberculosis infection. Several patient, provider and infrastructure barriers, poor diagnostic tests, and the long treatment course, however, limit effectiveness of current programs. Novel approaches that educate and engage patients, their communities and primary care practitioners might improve the effectiveness of these programs.
Reporting of latent TB infection among non–US-born persons adjusting their immigration status to permanent residents: An opportunity to enhance TB prevention
2022, Journal of Public Health Management and Practice
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Prevalence of latent tuberculosis (LTB) among pregnant women in a high burden setting in Sudan using interferon gamma (IFN- γ) releasing assay (IGRA)
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Chest

Clinical InvestigationsResults of Screening for Tuberculosis in Foreign-born Persons Applying for Adjustment of Immigration Status

Section snippets

Applicant Eligibility and Program Guidelines

RESULTS

DISCUSSION

ACKNOWLEDGMENTS

Epidemiology of tuberculosis

Am Rev Respir Dis

Tuberculosis, final data-United States, 1986

MMWR

Tuberculosis in patients with the acquired immune deficiency syndrome

Am Rev Respir Dis

Tuberculosis control among homeless populations

Arch Intern Med

Tuberculosis among Indochinese refugees in the United States

JAMA

Treatment of tuberculosis and tuberculous infection in adults and children

Am Rev Respir Dis

Screening for tuberculosis and tuberculous infection in high-risk populations

MMWR

Tuberculosis in children

Pediatr Infect Dis

Tuberculosis in the United States

JAMA

The use of sputum cultures in the evaluation of immigrants classified as tuberculosis suspects

Am Rev Respir Dis

Clinical Investigations
Results of Screening for Tuberculosis in Foreign-born Persons Applying for Adjustment of Immigration Status