The Global Tuberculosis Epidemic The Impact on Florida Michael Lauzardo, MD MSc Principal Investigator, Southeastern National Tuberculosis Center Deputy.

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