the global tuberculosis epidemic the impact on florida michael lauzardo, md msc principal...
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The Global Tuberculosis EpidemicThe Global Tuberculosis EpidemicThe Impact on FloridaThe Impact on Florida
Michael Lauzardo, MD MScMichael Lauzardo, MD MScPrincipal Investigator, Southeastern National Tuberculosis CenterPrincipal Investigator, Southeastern National Tuberculosis Center
Deputy Health Officer for TB – State of FloridaDeputy Health Officer for TB – State of FloridaAssistant Professor, Div. of Pulmonary and Critical Care Medicine,Assistant Professor, Div. of Pulmonary and Critical Care Medicine,
University of Florida College of MedicineUniversity of Florida College of Medicine
DisclosureDisclosure
I, Dr. Mike Lauzardo, have no I, Dr. Mike Lauzardo, have no financial or commercial financial or commercial interests to disclose to the interests to disclose to the meeting participants.meeting participants.
Case presentation :Case presentation :The case of the wayward professorThe case of the wayward professor
RC is a 35yo woman from a country of RC is a 35yo woman from a country of high TB incidence who presented to her high TB incidence who presented to her PCP 2 years earlier c/o coughPCP 2 years earlier c/o cough
The PCP at that time placed a PPD and The PCP at that time placed a PPD and ordered a CXRordered a CXR
The PPD was 10mm and the CXR was The PPD was 10mm and the CXR was “abnormal” so she was sent to a “abnormal” so she was sent to a pulmonologistpulmonologist
Case 1:Case 1:The wayward professor continued The wayward professor continued
The pulmonologist attributed the CXR The pulmonologist attributed the CXR abnormality to BCG vaccination and the abnormality to BCG vaccination and the cough to allergies. cough to allergies.
Sputum was not obtainedSputum was not obtainedLost to follow-up for two yearsLost to follow-up for two yearsCame back to her PCP accompanied by her Came back to her PCP accompanied by her
husband “MC”, A faculty member at a husband “MC”, A faculty member at a prominent universityprominent university
Active hemoptysis in the waiting roomActive hemoptysis in the waiting room
Case 1:Case 1:“The chase begins”“The chase begins”
The PCP is very concerned about TB againThe PCP is very concerned about TB againA CXR is obtained and arrangements are A CXR is obtained and arrangements are
made to have the pt seen immediately in the made to have the pt seen immediately in the ER by a different pulmonologist ER by a different pulmonologist
They never show citing the fact that the They never show citing the fact that the husband does not think she has TBhusband does not think she has TB
The health department is notifiedThe health department is notified
CASE 1CASE 1
The pt’s husband is called at home and the The pt’s husband is called at home and the rationale and need for evaluation is rationale and need for evaluation is expressed in the carefully with their concerns expressed in the carefully with their concerns addressedaddressed
The plan was that the pt may go to the ER of The plan was that the pt may go to the ER of their choosing and will be met by me to their choosing and will be met by me to discuss the case and obtain sputumdiscuss the case and obtain sputum
Patient and husband never went but sent an Patient and husband never went but sent an impostor who came to the er with a chief impostor who came to the er with a chief complaint of “I don’t have TB”complaint of “I don’t have TB”
Case 1: Case 1: Lost to follow-upLost to follow-up
((For a little whileFor a little while))After much deliberation and legal wrangling After much deliberation and legal wrangling
the HD sent a police officer to the home to the HD sent a police officer to the home to locate the familylocate the family
The officer was informed by MC That he sent The officer was informed by MC That he sent his wife and kids away so that they would not his wife and kids away so that they would not be subject to the “conspiracy”be subject to the “conspiracy”
Threatening phone calls from familyThreatening phone calls from familyHeard nothing for 6 weeks until a call from Heard nothing for 6 weeks until a call from
another state on the west coastanother state on the west coast
Case 1: Case 1: The exciting conclusion to our storyThe exciting conclusion to our story
RC was diagnosed with smear positive RC was diagnosed with smear positive cavitary TB after presenting to a local ER cavitary TB after presenting to a local ER with hemoptysis once againwith hemoptysis once again
Placed on court-ordered dot and was banned Placed on court-ordered dot and was banned from travel by the judge until therapy cleared from travel by the judge until therapy cleared her sputumher sputum
MC felt humiliated by this and immediately MC felt humiliated by this and immediately brought his children to the hd for evaluationbrought his children to the hd for evaluation—skin tests were more than 25mm—skin tests were more than 25mm
MC was evaluated with a CXR…MC was evaluated with a CXR…
The microbe is nothing… the terrain The microbe is nothing… the terrain is everythingis everything
LOUIS PASTEURLOUIS PASTEUR
Epidemiology of TB: Epidemiology of TB: Migrants and the Foreign BornMigrants and the Foreign Born
TB EpidemiologyTB Epidemiology
GLOBALGLOBAL USAUSA
Infected casesInfected cases 1.7 billion1.7 billion(33% population)(33% population)
10 million10 million(4% population)(4% population)
Case incidenceCase incidence 8-10 million/year8-10 million/year ~ 13,000/year~ 13,000/year
Case prevalenceCase prevalence 40-50 million40-50 million 20,00020,000
DeathsDeaths 1.9 million/year1.9 million/year 1,000 – 2,000/year1,000 – 2,000/year
MDRMDR Up to 15%Up to 15%(DR and Ecuador)(DR and Ecuador) < 1%< 1%
A Silent Global EpidemicA Silent Global Epidemic
One-third of the world’s population infectedOne-third of the world’s population infected
Eight million new cases of active disease per Eight million new cases of active disease per yearyear
Two to three million deaths per yearTwo to three million deaths per year
One person is newly infected every second and One person is newly infected every second and one person dies every 10 secondsone person dies every 10 seconds
Rising incidence of drug-resistant diseaseRising incidence of drug-resistant disease
Billions of dollars in lost productivityBillions of dollars in lost productivity
9m cases annually>1/3 in populous India and China
10 000 to 99 999
100 000 to 999 999
1 000 000 or more
< 1 000
1 000 to 9 999
No Estimate
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2002Stop TB DepartmentStop TB Department
Highest TB rates per capita are in Africalinked to HIV/AIDS
25 to 49
50 to 99
100 to 299
< 10
10 to 24
300 or more
No Estimate
per 100 000 population
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2002Stop TB DepartmentStop TB Department
TB cases have been rising in Africa and E Europe
0
100
200
300
400
500
1990 1992 1994 1996 1998 2000 2002 2004
Inc
ide
nc
e r
ate
(/1
00
K/y
r)
Africa - high HIV
Africa - low HIV
Eastern Europe
incidence falling
rise in incidence slowing
Stop TB DepartmentStop TB Department
TB cases falling in 6/9 regions of the world
0
50
100
150
200
1990 1992 1994 1996 1998 2000 2002 2004
Inc
ide
nc
e r
ate
(/1
00
K/y
r) SE Asia
W Pacific
Latin America
E Mediterranean
C Europe
Est Mkts
Stop TB DepartmentStop TB Department
Reported TB Cases* Reported TB Cases* United States, 1982–2007United States, 1982–2007
10,000
12,000
14,000
16,000
18,000
20,000
22,000
24,000
26,000
28,000
1983 1986 1989 1992 1995 1998 2001 2004 2007
Year
No
. of
Ca
ses
*Updated as of April 23, 2008.
TB MorbidityTB MorbidityUnited States, 2002–2007United States, 2002–2007
Year No. Rate*2002 15,056 5.22003 14,837 5.12004 14,501 4.92005 14,065 4.72006 13,754 4.62007 13,299 4.4
*Cases per 100,000, updated as of April 23, 2008.
Tuberculosis in the U.S. Tuberculosis in the U.S. Epidemic Under ControlEpidemic Under Control
13,299 cases (4.4/100,000) in 200713,299 cases (4.4/100,000) in 2007
Fifteenth year of decline (down 3.3% from 2006)Fifteenth year of decline (down 3.3% from 2006)
98 cases (0.9%) of MDR-TB in 200798 cases (0.9%) of MDR-TB in 2007
26 states meet year 2000 elimination target26 states meet year 2000 elimination target(< 3.5/100,000)(< 3.5/100,000)
Completion of therapy exceeds 90%Completion of therapy exceeds 90%
Excess TB Morbidity – U.S. 1985 - 1992Excess TB Morbidity – U.S. 1985 - 1992Associated factorsAssociated factors
– Poor Poor infrastructure infrastructure
– HIV epidemicHIV epidemic
– ImmigrationImmigration
– Institutional Institutional transmissiontransmission
– MDR-TBMDR-TB
JAMA 1994; 272:536JAMA 1994; 272:536
TB in Foreign-BornTB in Foreign-BornUnited States 2007United States 2007
58% of total cases58% of total cases
20.7 cases/100,000 population20.7 cases/100,000 population
Rate ratioRate ratio
– 9.8 relative to US-born9.8 relative to US-born
28 states reported > 50% foreign-born cases28 states reported > 50% foreign-born cases
TB in Foreign-BornTB in Foreign-BornPercentage TB cases of foreign origin
AndorraMalta Monaco San Marino
No data
0% – 4%
5% – 19%
20% – 49%
>49%
Number of TB Cases in U.S.-Born Versus Number of TB Cases in U.S.-Born Versus Foreign-Born Persons, U.S. 1993-2003*Foreign-Born Persons, U.S. 1993-2003*
6000
8000
10000
12000
14000
16000
18000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
U.S.-born
Foreign-born
# OF CASES# OF CASES
Percentage of TB Cases AmongPercentage of TB Cases AmongForeign-Born Persons – United StatesForeign-Born Persons – United States
19931993 2003*2003*
≥ ≥ 50%50%
25 – 49 25 – 49 %%
< 25%< 25%
Countries of Birth of Foreign-born Persons Countries of Birth of Foreign-born Persons Reported with TB Reported with TB
United States, 2007United States, 2007
Mexico(24%)
Philippines(12%)
Viet Nam(7%)India
(8%)China(5%)
Haiti(2%)
Rep. Korea(2%)
OtherCountries
(39%)
Characteristics of TB Among Characteristics of TB Among MigrantsMigrants
Tuberculosis and Fear – ca. 1900Tuberculosis and Fear – ca. 1900
““Self-preservation demands radical revision of the Self-preservation demands radical revision of the definition of personal liberty…”definition of personal liberty…”
““The contagion of disease and vice fostered in The contagion of disease and vice fostered in neglected districts will spread to the prosperous neglected districts will spread to the prosperous
areas.”areas.”
““They daily traverse our pathway, entering as They daily traverse our pathway, entering as servants from contaminated huts, handling our servants from contaminated huts, handling our
children and every vestige of clothing and linen in children and every vestige of clothing and linen in our living apartments.”our living apartments.”
Common Misconceptions – ca. 2008Common Misconceptions – ca. 2008TB rates among the foreign born are high due to TB rates among the foreign born are high due to
illegal immigrationillegal immigration
TB cases among the foreign-born represent TB cases among the foreign-born represent failures of overseas screeningfailures of overseas screening
Most foreign-born persons with TB are poor, Most foreign-born persons with TB are poor, unemployed, and uninsuredunemployed, and uninsured
Foreign-born persons are less adherent to Foreign-born persons are less adherent to treatmenttreatment
Characteristics TraditionallyCharacteristics TraditionallyAssociated with US-born TBAssociated with US-born TB
HomelessnessHomelessnessSubstance abuseSubstance abuseLow socioeconomic Low socioeconomic
statusstatus
Member of a Member of a minority groupminority group
Healthcare workerHealthcare workerElderlyElderly
Characteristics of Foreign-Born TB Characteristics of Foreign-Born TB Patients-Tarrant County, TexasPatients-Tarrant County, Texas
Immigration statusImmigration status
– 67 (59%) permanent67 (59%) permanent
– 28 (25%) undocumented28 (25%) undocumented
– 19 (17%) non-immigrant visitors19 (17%) non-immigrant visitors
FB TB patients significantly younger than US-FB TB patients significantly younger than US-born (mean age 38 versus 42 years)born (mean age 38 versus 42 years)
FB more likely to have primary drug resistance FB more likely to have primary drug resistance (p < .001)(p < .001)
Weis Weis et al.et al. AJRCCM 2001, 953-957 AJRCCM 2001, 953-957
Epidemiology of TBEpidemiology of TBAmong the Foreign-Born – VirginiaAmong the Foreign-Born – Virginia
840 cases (51.9% of total morbidity 1998-2001)840 cases (51.9% of total morbidity 1998-2001)– 486 (57.9%) from high burden countries486 (57.9%) from high burden countries
– 462 (55%) arrived within five years462 (55%) arrived within five years
– Younger than US-born (mean 38.9 versus 47.2 Younger than US-born (mean 38.9 versus 47.2 years)years)
– Common occupations atypical among TB patientsCommon occupations atypical among TB patients
196 cases (58% of morbidity in 2001)196 cases (58% of morbidity in 2001)– 21 different primary languages21 different primary languages
– 91 (46.4%) required interpretive services 91 (46.4%) required interpretive services
– 129 (65.8%) uninsured129 (65.8%) uninsured
Hunninghake, GM Hunninghake, GM et al.et al. AJRCCM 2003 167 (Pt 2). AJRCCM 2003 167 (Pt 2).
TB Among Foreign-BornTB Among Foreign-BornResidents, New Jersey 1994-1999Residents, New Jersey 1994-1999
2005 of 4295 cases (47%) foreign-born2005 of 4295 cases (47%) foreign-born
– FB patients resided in more affluent areas than FB patients resided in more affluent areas than US-born (p < .001)US-born (p < .001)
– More likely employed in the two years prior to More likely employed in the two years prior to diagnosis (62% versus 41% p < .001)diagnosis (62% versus 41% p < .001)
– South Asian patients more likely to be treated by South Asian patients more likely to be treated by
private MDprivate MD
Davidow, AL Davidow, AL et al.et al. Am J Public Health 2003 93:12007-1012. Am J Public Health 2003 93:12007-1012.
Patterns of TB TransmissionPatterns of TB TransmissionNew York City 1990-1999New York City 1990-1999
Clustering observed in 48% of strainsClustering observed in 48% of strainsNon-Clustering independently associated withNon-Clustering independently associated with
– Birth outside the USBirth outside the US
– Age greater than 60Age greater than 60
– Diagnosis after 1993Diagnosis after 1993
Among foreign-born persons in New York City, Among foreign-born persons in New York City, tuberculosis largely due to progression from tuberculosis largely due to progression from LTBI LTBI
Geng, EG Geng, EG et al.et al. NEJM 2002 346:1453-1458 NEJM 2002 346:1453-1458
TABLE 1. TUBERCULOSIS IN U.S.-BORN AND FOREIGN-BORN PERSONS BY TIME IN THE UNITED STATES, 2004
* Complete information for date of entry in to the United States was missing for 975 foreign-born patients with tuberculosis. Total n = 14,517. Cain Et al Am J Respir Crit Care Med Vol 175 75-79 2007
OriginOrigin Time in the United Time in the United States (States (yryr))
Cases in 2004Cases in 2004 n n
((%)%)PopulationPopulation
Case RateCase Rate
U.S. bornU.S. born —— 6,683 (46)6,683 (46) 249,424,045249,424,045 2.72.7
Foreign Foreign bornborn**
TotalTotal 7,806 (54)7,806 (54) 36,245,58236,245,582 21.521.5
11 1,620 (24)1,620 (24) 1,338,8141,338,814 121.0121.0
> 1 to > 1 to 5 5 1,767 (26)1,767 (26) 5,885,6775,885,677 30.030.0
> 5> 5 3,444 (50)3,444 (50) 29,021,09029,021,090 11.911.9
Migration to the United States and Migration to the United States and FloridaFlorida
Estimated MigrantsEstimated Migrants“Entering” the United States“Entering” the United States
Visitors without visasVisitors without visas~ 30,000,000~ 30,000,000
Non-immigrant visasNon-immigrant visas27,907,13927,907,139
Immigrants and Immigrants and refugeesrefugees411,266411,266
Undocumented Undocumented migrantsmigrants~275,000 ~275,000 ± ± ????????
N = ~ 59,000,000N = ~ 59,000,000Status adjusters in U.S.: Status adjusters in U.S.: 679,305679,305
Source: U.S. Department of Homeland Security, 2003 (2002 data)Source: U.S. Department of Homeland Security, 2003 (2002 data)
Number of Foreign-Born Number of Foreign-Born Persons Living in the U.S.Persons Living in the U.S.
0
5
10
15
20
25
30
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 1998
Million
s of
For
eign
-Bor
n P
erso
ns
Source: Center for Immigration Studies, 2000Source: Center for Immigration Studies, 2000
Florida and Global MigrationFlorida and Global MigrationThere are 33 million foreign-born persons living There are 33 million foreign-born persons living
in the United States of whom 2.9 million (8.9%) in the United States of whom 2.9 million (8.9%) live in Florida.live in Florida.
In 2004 there were over 76.8 million visitors to In 2004 there were over 76.8 million visitors to FloridaFlorida
If Miami-Dade County’s nearly 1.2 million foreign-If Miami-Dade County’s nearly 1.2 million foreign-born residents comprised a city of their own, that born residents comprised a city of their own, that city would be among the 10 largest in the nation.city would be among the 10 largest in the nation.
Of the top 100 municipalities with the highest Of the top 100 municipalities with the highest number of foreign-born residents, 31 are in number of foreign-born residents, 31 are in Florida.Florida.
Strategies to Address the Global Strategies to Address the Global EpidemicEpidemic
FIND Diagnostics
Lessons from the history of TB Lessons from the history of TB clinical trialsclinical trials
Need to evaluate regimens, not drugsNeed to evaluate regimens, not drugs– A drug may act very differently at different A drug may act very differently at different
points in therapy (e.g., INH, PZA)points in therapy (e.g., INH, PZA)
– A drug may work differently in the setting A drug may work differently in the setting of different companion drugs (e.g., moxi)of different companion drugs (e.g., moxi)
May need to evaluate many regimens to May need to evaluate many regimens to find the optimal combination of potency, find the optimal combination of potency, tolerability, and intermittencytolerability, and intermittency
– BMRC evaluated ~ 200 regimens to come BMRC evaluated ~ 200 regimens to come up with DOTSup with DOTS
Prospects for TB drug development Prospects for TB drug development Several new drugs have very potent activity in Several new drugs have very potent activity in
animal model of TB treatment – allowing animal model of TB treatment – allowing treatment to be 2-4 monthstreatment to be 2-4 months
Several new drugs appear highly active when Several new drugs appear highly active when given 1-2 times/weekgiven 1-2 times/week
No published studies yet combining these new No published studies yet combining these new drugsdrugs
Timetable for new TB drugsTimetable for new TB drugs
Compound/product 2005 ‘06 ‘07 08 09 10 11 12 13 14 15
Moxi / gati
Diarylquinoline TCM207
Otsuka compound
Pyrrole LL3858
Nitroimidazole PA-824
Diamine SQ-109
New quinolones
II
I
I
I
I
I
D
II
I/II
I/II
I/II
I
I
D
II/III
II
II
II
I/II
I/II
PC
III
II/III
II/III
II/III
II
II
PC
III
III
III
III
II/III
II/III
I
III/NDA
III
III
III
III
III
I/II
III
III
III
III
III
II
NDA
NDA
NDA
III
III
II/III
NDA
NDA
III III III
*STOP TB Working Group
TBTC Study 27TBTC Study 27Proportion sputum culture-negative – Proportion sputum culture-negative –
moxifloxacin vs. ethambutol (both with HRZ)moxifloxacin vs. ethambutol (both with HRZ)
01020304050607080
2 4 6 8
Weeks of treatment
Sp
utum
cu
ltu
re
con
vers
ion
Moxifloxacin Ethambutol
P=0.02
P=0.003
0
1
2
3
4
5
6
7
8
9
10
0 1 2 3 4 5 6
Duration of treatment (mos.)
Lo
g C
FU
in
en
tire
lu
ng
Untreated
2RHZ+4RH
2RHZM+4RHM
2RMZ+4RM
Activity of moxifloxacin in combination therapy in a mouse model of TB
2.5 logs
Am J Respir Crit Care Med 2004; 164:421-6
Tackling TB in the Foreign Born:Tackling TB in the Foreign Born:Overseas ScreeningOverseas Screening
Why has impact on TBWhy has impact on TBin the foreign-born been small?in the foreign-born been small?
Possible explanationsPossible explanations
– Migration of persons with active TBMigration of persons with active TB
– Progression from LTBI to active TB following Progression from LTBI to active TB following arrival arrival to the USto the US
– Transmission of TB within foreign-born Transmission of TB within foreign-born communitiescommunities
Tackling TB in the Foreign-BornTackling TB in the Foreign-BornWhat will it take?What will it take?
Federal GovernmentFederal Government
– Support of global TB control effortsSupport of global TB control efforts
– Changes to US entry proceduresChanges to US entry procedures
State and local public health State and local public health
Community practitionersCommunity practitioners
““Ending Neglect” ChallengesEnding Neglect” ChallengesMaintain TB control – focus on foreign-bornMaintain TB control – focus on foreign-born
– Overseas screening and stateside notificationOverseas screening and stateside notification
Speed TB declineSpeed TB decline– Identify and treat latent infection (LTBI)Identify and treat latent infection (LTBI)
Develop new toolsDevelop new tools– Tests (LTBI), drugs, vaccineTests (LTBI), drugs, vaccine
Increase U.S. role in global eliminationIncrease U.S. role in global eliminationMobilize support and measure progressMobilize support and measure progress
Estimated MigrantsEstimated Migrants“Entering” the United States“Entering” the United States
Visitors without visasVisitors without visas~ 30,000,000~ 30,000,000
Non-immigrant visasNon-immigrant visas27,907,13927,907,139
Immigrants and Immigrants and refugeesrefugees411,266411,266
Undocumented Undocumented migrantsmigrants~275,000 ~275,000 ± ± ????????
N = ~ 59,000,000N = ~ 59,000,000Status adjusters in U.S.: Status adjusters in U.S.: 679,305679,305
Source: U.S. Department of Homeland Security, 2003 (2002 data)Source: U.S. Department of Homeland Security, 2003 (2002 data)
Objectives of Overseas TB ScreeningObjectives of Overseas TB ScreeningRestrict travel/entry of persons with infectious Restrict travel/entry of persons with infectious
TBTB
– Class A TB (AFB-smear positive)Class A TB (AFB-smear positive)
Identify persons with suspect TB requiring Identify persons with suspect TB requiring follow-up stateside evaluation, and notify follow-up stateside evaluation, and notify receiving jurisdictions receiving jurisdictions of US arrivalof US arrival
Current Challenges and Opportunities Current Challenges and Opportunities Quality assurance of overseas TB screeningQuality assurance of overseas TB screening
Limitations of screening algorithm Limitations of screening algorithm
– Sensitivity and specificitySensitivity and specificity
– Diagnostic tools Diagnostic tools
– Local resources Local resources
Timely state-side notification, follow-up, and Timely state-side notification, follow-up, and interventionsinterventions
Expansion of scope and underlying objectivesExpansion of scope and underlying objectives
Public HealthPublic Health
Completing Treatment – ChallengesCompleting Treatment – ChallengesCommon obstacles to completing treatment Common obstacles to completing treatment
includeinclude
– Cultural and linguistic factorsCultural and linguistic factors
– Lifestyle differencesLifestyle differences
– HomelessnessHomelessness
– Substance abuseSubstance abuse
– Patient-relatedPatient-related
– System-relatedSystem-related
Technical Instructions for Panel Technical Instructions for Panel Physicians 2007Physicians 2007
Technical Instructions for Tuberculosis Technical Instructions for Tuberculosis Screening and Treatment for Panel Screening and Treatment for Panel
PhysiciansPhysicians To prevent applicants with smear-positive To prevent applicants with smear-positive
tuberculosis from traveling to the United States, the tuberculosis from traveling to the United States, the 1991 system relies on chest radiograph findings and 1991 system relies on chest radiograph findings and sputum smears among overseas foreign national sputum smears among overseas foreign national applicants 15 years of age or older. applicants 15 years of age or older.
The 1991 system misses applicants with smear-The 1991 system misses applicants with smear-negative but culture-positive tuberculosis, as well as negative but culture-positive tuberculosis, as well as tuberculosis in applicants <15 years of age. tuberculosis in applicants <15 years of age.
Moreover, the 1991 requirements do not provide Moreover, the 1991 requirements do not provide guidance specifying the quality of treatment guidance specifying the quality of treatment applicants with tuberculosis should receive prior to applicants with tuberculosis should receive prior to travel.travel.
Changes in the 2007 Technical Changes in the 2007 Technical Instructions for Tuberculosis ScreeningInstructions for Tuberculosis Screening
Tuberculin skin tests (TST) for applicants <15 years of Tuberculin skin tests (TST) for applicants <15 years of age in countries with a World Health Organization age in countries with a World Health Organization (WHO)-estimated tuberculosis incidence rate >20 per (WHO)-estimated tuberculosis incidence rate >20 per 100,000. 100,000.
All applicants <15 years of age with TST ≥5 mm will be All applicants <15 years of age with TST ≥5 mm will be required to have a chest radiograph. required to have a chest radiograph.
Mycobacterial cultures for applicants with chest Mycobacterial cultures for applicants with chest radiographs suggestive of tuberculosis disease. radiographs suggestive of tuberculosis disease.
Treatment under a directly observed therapy (DOT) Treatment under a directly observed therapy (DOT) program. program.
Completion of treatment prior to immigrating to the Completion of treatment prior to immigrating to the United States, according to American Thoracic United States, according to American Thoracic Society/CDC/Infectious Diseases Society of America Society/CDC/Infectious Diseases Society of America guidelines. guidelines.
New TB classifications for all applicants with suspected New TB classifications for all applicants with suspected latent latent Mycobacterium tuberculosisMycobacterium tuberculosis infection and for infection and for contacts for cases of tuberculosis disease. contacts for cases of tuberculosis disease.
Tackling TB in the Foreign-BornTackling TB in the Foreign-BornWhat will it take?What will it take?
Federal governmentFederal government– Support of global TB control effortsSupport of global TB control efforts
– Changes to US entry proceduresChanges to US entry procedures
State and local public health State and local public health – Effective diagnostic and treatment servicesEffective diagnostic and treatment services
– Culturally-competent case-managementCulturally-competent case-management
Community practitionersCommunity practitioners– Efficient diagnosis and treatmentEfficient diagnosis and treatment
– Communication and advocacyCommunication and advocacy
““Give me your tired, your poor,Give me your tired, your poor,your huddled masses . . .”your huddled masses . . .”
ConclusionConclusion