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July 23, 1997, Vol 278, No. 4 >
ARTICLE | July 23, 1997

Long-term Risk of Tuberculosis Among Foreign-born Persons in the United States FREE

Patrick L. F. Zuber, MD, MPH; Matthew T. McKenna, MD, MPH; Nancy J. Binkin, MD, MPH; Ida M. Onorato, MD; Kenneth G. Castro, MD
[+] Author Affiliations

Reprints: Patrick L. F. Zuber, MD, MPH, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Rd, Mailstop E-10, Atlanta, GA 30333 (e-mail: paz0@cdc.gov).


JAMA. 1997;278(4):304-307. doi:10.1001/jama.1997.03550040060038
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Article
References

Context.  —Cases of tuberculosis (TB) in the United States have declined for 4 consecutive years, but cases among foreign-born persons account for an increasing percentage.

Objective.  —To describe the risk of tuberculosis among foreign-born persons with respect to their length of residence in the United States.

Design.  Cross-sectional analysis of national surveillance data.

Setting.  —The United States.

Patients.  —All verified TB cases reported to the Centers for Disease Control and Prevention between 1986 and 1994.

Main Outcome Measure.  —Stratum-specific incidence rates of TB by age, place of birth, length of residence, age at arrival in the United States, or combinations of these variables.

Results.  —Several groups of persons from countries with a high prevalence of TB had incidence rates higher than 20 per 100 000 person-years more than 20 years after arrival. Among long-term residents, those who arrived in the United States after their fifth birthday had incidence rates of TB 2 to 6 times higher than those of similar age who arrived before their fifth birthday. A total of 45% of the TB cases were among persons younger than 35 years and an additional 18% were among persons who arrived in the United States before their 35th birthday.

Conclusions.  —Imported Mycobacterium tuberculosis infection (active or latent) is responsible for most TB cases among foreign-born persons in the United States. Detection of active cases among recent arrivals is the main priority in these populations, but many cases were in persons who arrived in the United States before the age of 35 years that could potentially have been avoided with preventive therapy. Elimination of TB in the United States may not be feasible using available diagnostic and treatment modalities without increased efforts to address the global burden of this disease.

REFERENCES

1 +
Centers for Disease Control and Prevention. Tuberculosis morbidity: United States, 1996. MMWR Morb Mortal Wkly Rep. In press.
2 +
McKenna MT, McCray E, Onorato I.  The epidemiology of tuberculosis among foreign-born persons in the United States, 1986 to 1993 . N Engl J Med . 1995;;332:1071-1076.
3 +
Raviglione MC, Snider DE, Kochi A.  Global epidemiology of tuberculosis .JAMA . 1995;;273:220-226.
4 +
Binkin NJ, Zuber PLF, Wells CD, Tipple MA, Castro KG.  Overseas screening for tuberculosis among immigrants and refugees to the States: current status . Clin Infect Dis . 1996;;23:1226-1232.
5 +
Centers for Disease Control and Prevention.  Screening for tuberculosis and tuberculosis infection in high-risk populations . MMWR Morb Mortal Wkly Rep . 1995;;44( (RR-11) ):13.
6 +
Centers for Disease Control and Prevention.  Case definitions for public health surveillance . MMWR Morb Mortal Wkly Rep . 1997;;46( (RR-10) ):40-41.
7 +
Bureau of the Census. 1990 Census of Population: Foreign-born Population in the United States. Washington, DC: US Government Printing Office; 1993.
8 +
 1990 Census of Population and Housing . Public Use Microdata Sample: Technical Documentation . Washington, DC: US Bureau of the Census; 1992;.
9 +
Rothman KJ. Modern Epidemiology . Boston, Mass: Little Brown & Co Inc; 1986;.
10 +
World Bank. World Development Report, 1993: Investing in Health . New York, NY: Oxford University Press; 1993;.
11 +
Aickin M, Dunn CN, Flood TJ.  Estimation of population denominators for public health studies at the tract, gender, and age-specific level - Am J Public Health . 1991;;81:918-920.
12 +
Fein DJ.  Racial and ethnic differences in US Census omission rates . Demography . 1990;;27:285-302.
13 +
Powell KE, Brown ED, Farer LS.  Tuberculosis among Indochinese refugees in the United States . JAMA . 1983;;249:1455-1460.
14 +
Springett VH, Adams JCS, D'Costa TB, Hemming M.  Tuberculosis in immigrants in Birmingham, 1956-1957 . Br J Prev Soc Med . 1958;;12:135-140.
15 +
Springett VH.  Tuberculosis in immigrants . Lancet . 1964;;1:1091-1095.
16 +
Stevenson DK.  Tuberculosis in Pakistanis in Bradford . BMJ . 1962;;1:1382-1386.
17 +
Enarson D, Ashley MJ, Grzybowski S.  Tuberculosis in immigrants to Canada . Am Rev Respir Dis . 1979;;119:11-18.
18 +
Enarson DA, I, Sjögren I, Grzybowski S.  Tuberculosis in immigrants to Canada: incidence of tuberculosis among Scandinavian immigrants in Canada . Eur J Respir Dis . 1980;;61:139-142.
19 +
Alland D, Kalkut GE, Moss AR, et al.  Transmission of tuberculosis in New York City . N Engl J Med . 1994;;330:1710-1716.
20 +
Small PM, Hopewell PC, Singh SP, et al.  The epidemiology of tuberculosis in San Francisco . N Engl J Med . 1994;;330:1703-1709.
21 +
Friedman CR, Stoeckle MY, Kreiswirth BN, et al.  Transmission of multidrug-resistant tuberculosis in a large urban setting . Am J Respir Crit Care Med . 1995;;152:355-359.
22 +
Hopewell P, Small P, Daley C, Hahn J, Moss A, Schecter G.  Use of molecular epidemiology (ME) to plan and evaluate tuberculosis (TB) control strategies . Tuber Lung Dis . 1995;;76( (suppl 2) ):47. Abstract.
23 +
Bisgard K, Welbel S, Valway S, Woodly C, Onorato I, Pelletier A.  Tuberculosis (TB) in rural Kansas . Am J Respir Crit Care Med . 1994;;149:A703. Abstract.
24 +
Ridzon R, Kent JH, Valway SE, et al. Outbreak of drug-resistant tuberculosis in a California high school with second generation transmission. J Pediatr. In press.
25 +
Centers for Disease Control and Prevention.  Tuberculosis among foreign-born persons who had recently arrived in the United States: Hawaii, 1992-1993, and Los Angeles County, 1993 . MMWR Morb Mortal Wkly Rep . 1995;;44:703-707.
26 +
Zuber PLF, Binkin NJ, Ignacio AC, et al.  Tuberculosis screening for immigrants and refugees . Am J Respir Crit Care Med . 1996;;154:151-155.
27 +
Zuber PLF, Knowles LS, Binkin NJ, Tipple MA, Davidson PT.  Tuberculosis among foreign-born persons in Los Angeles County, 1992-1994 . Tuber Lung Dis . 1996;;77:524-530.
28 +
De Riemer K, Chin DP, Schecter GF, Reingold AL. Screening immigrantsand refugees for tuberculosis in San Francisco. Presented at 123rd meeting of the American Public Health Association; October 30, 1995; San Diego, Calif.
29 +
Willert PD, Brown E. Tuberculosis management of class B immigrants and refugees in Multnomah County, Oregon. Presented at mid year meeting of the North American Region of the International Union Against Tuberculosis and Lung Disease;March 2, 1996; Chicago, Ill.
30 +
Asch S, Leake B, Gelberg L.  Does fear of immigration authorities deter tuberculosis patients from seeking care? West J Med . 1994;;161:373-376.
31 +
Iseman MD, Starke J.  Immigrants and tuberculosis control . N Engl J Med . 1995;;322:1094-1095.
32 +
Ferebee SH.  Controlled chemoprophylaxis trials in tuberculosis . Adv Tuber Res . 1969;;17:28-106.
33 +
International Union Against Tuberculosis Committee on Prophylaxis.  Efficacy of various durations of isoniazid preventive therapy for tuberculosis . Bull World Health Organ . 1982;;60:555-564.
34 +
Bass JBJ, Farer LS, Hopewell PC, et al.  Treatment of tuberculosis and tuberculosis infection in adults and children . Am J Respir Crit Care Med . 1994;;149:1359-1374.
35 +
Mohle-Boetani JC, Miller B, Halpern M, et al.  School-based screening for tuberculous infection: a cost-benefit analysis . JAMA . 1995;;274:613-619.
36 +
Starke JR.  Universal screening for tuberculosis infection: school's out! JAMA . 1995;;274:652-653.
37 +
Wells CD, Zuber P, Binkin N, Nolan C. Tuberculosis case contact investigations among foreign-born and US-born patients. Presented at 45th annual Epidemic Intelligence Service Conference; April 22-26, 1996; Atlanta, Ga.
38 +
Centers for Disease Control and Prevention.  The role of BCG vaccine in the prevention and control of tuberculosis in the United States . MMWR Morb Mortal Wkly Rep . 1996;;45( (RR-4) ):8-9.
39 +
Guérin N.  BCG policies in Europe . Pediatr Pulmonol Suppl . 1995;;11:18-19.
40 +
Ballew KA, Becker DM.  Tuberculosis screening in adults who have received bacille Calmette-Guérin vaccine . South Med J . 1995;;88:1025-1030.
41 +
Immigration and Naturalization Service. Statistical Yearbook of the Immigration and Naturalization Service, 1994. Washington, DC: US Government Printing Office; 1996.
42 +
Snider DE, Caras GJ, Koplan JP.  Preventive therapy with isoniazid . JAMA . 1986;;255:1579-1583.
43 +
Rose DN, Schechter CB, Fahs MC, Silver AL.  Tuberculosis prevention . Am J Prev Med . 1988;;4:102-109.
44 +
Sterling TR, Brehm WT, Frieden TR.  Isoniazid preventive therapy in areas of high isoniazid resistance . Arch Intern Med . 1995;;155:1622-1628.
45 +
Murray CJL, Styblo K, Rouillon A.  Tuberculosis in developing countries: burden, intervention, and cost . Bull Int Union Tuber . 1990;;65:6-26.
46 +
Enarson DA.  Why not the elimination of tuberculosis? Mayo Clin Proc . 1994;;69:85-86.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Centers for Disease Control and Prevention. Tuberculosis morbidity: United States, 1996. MMWR Morb Mortal Wkly Rep. In press.
2 +
McKenna MT, McCray E, Onorato I.  The epidemiology of tuberculosis among foreign-born persons in the United States, 1986 to 1993 . N Engl J Med . 1995;;332:1071-1076.
3 +
Raviglione MC, Snider DE, Kochi A.  Global epidemiology of tuberculosis .JAMA . 1995;;273:220-226.
4 +
Binkin NJ, Zuber PLF, Wells CD, Tipple MA, Castro KG.  Overseas screening for tuberculosis among immigrants and refugees to the States: current status . Clin Infect Dis . 1996;;23:1226-1232.
5 +
Centers for Disease Control and Prevention.  Screening for tuberculosis and tuberculosis infection in high-risk populations . MMWR Morb Mortal Wkly Rep . 1995;;44( (RR-11) ):13.
6 +
Centers for Disease Control and Prevention.  Case definitions for public health surveillance . MMWR Morb Mortal Wkly Rep . 1997;;46( (RR-10) ):40-41.
7 +
Bureau of the Census. 1990 Census of Population: Foreign-born Population in the United States. Washington, DC: US Government Printing Office; 1993.
8 +
 1990 Census of Population and Housing . Public Use Microdata Sample: Technical Documentation . Washington, DC: US Bureau of the Census; 1992;.
9 +
Rothman KJ. Modern Epidemiology . Boston, Mass: Little Brown & Co Inc; 1986;.
10 +
World Bank. World Development Report, 1993: Investing in Health . New York, NY: Oxford University Press; 1993;.
11 +
Aickin M, Dunn CN, Flood TJ.  Estimation of population denominators for public health studies at the tract, gender, and age-specific level - Am J Public Health . 1991;;81:918-920.
12 +
Fein DJ.  Racial and ethnic differences in US Census omission rates . Demography . 1990;;27:285-302.
13 +
Powell KE, Brown ED, Farer LS.  Tuberculosis among Indochinese refugees in the United States . JAMA . 1983;;249:1455-1460.
14 +
Springett VH, Adams JCS, D'Costa TB, Hemming M.  Tuberculosis in immigrants in Birmingham, 1956-1957 . Br J Prev Soc Med . 1958;;12:135-140.
15 +
Springett VH.  Tuberculosis in immigrants . Lancet . 1964;;1:1091-1095.
16 +
Stevenson DK.  Tuberculosis in Pakistanis in Bradford . BMJ . 1962;;1:1382-1386.
17 +
Enarson D, Ashley MJ, Grzybowski S.  Tuberculosis in immigrants to Canada . Am Rev Respir Dis . 1979;;119:11-18.
18 +
Enarson DA, I, Sjögren I, Grzybowski S.  Tuberculosis in immigrants to Canada: incidence of tuberculosis among Scandinavian immigrants in Canada . Eur J Respir Dis . 1980;;61:139-142.
19 +
Alland D, Kalkut GE, Moss AR, et al.  Transmission of tuberculosis in New York City . N Engl J Med . 1994;;330:1710-1716.
20 +
Small PM, Hopewell PC, Singh SP, et al.  The epidemiology of tuberculosis in San Francisco . N Engl J Med . 1994;;330:1703-1709.
21 +
Friedman CR, Stoeckle MY, Kreiswirth BN, et al.  Transmission of multidrug-resistant tuberculosis in a large urban setting . Am J Respir Crit Care Med . 1995;;152:355-359.
22 +
Hopewell P, Small P, Daley C, Hahn J, Moss A, Schecter G.  Use of molecular epidemiology (ME) to plan and evaluate tuberculosis (TB) control strategies . Tuber Lung Dis . 1995;;76( (suppl 2) ):47. Abstract.
23 +
Bisgard K, Welbel S, Valway S, Woodly C, Onorato I, Pelletier A.  Tuberculosis (TB) in rural Kansas . Am J Respir Crit Care Med . 1994;;149:A703. Abstract.
24 +
Ridzon R, Kent JH, Valway SE, et al. Outbreak of drug-resistant tuberculosis in a California high school with second generation transmission. J Pediatr. In press.
25 +
Centers for Disease Control and Prevention.  Tuberculosis among foreign-born persons who had recently arrived in the United States: Hawaii, 1992-1993, and Los Angeles County, 1993 . MMWR Morb Mortal Wkly Rep . 1995;;44:703-707.
26 +
Zuber PLF, Binkin NJ, Ignacio AC, et al.  Tuberculosis screening for immigrants and refugees . Am J Respir Crit Care Med . 1996;;154:151-155.
27 +
Zuber PLF, Knowles LS, Binkin NJ, Tipple MA, Davidson PT.  Tuberculosis among foreign-born persons in Los Angeles County, 1992-1994 . Tuber Lung Dis . 1996;;77:524-530.
28 +
De Riemer K, Chin DP, Schecter GF, Reingold AL. Screening immigrantsand refugees for tuberculosis in San Francisco. Presented at 123rd meeting of the American Public Health Association; October 30, 1995; San Diego, Calif.
29 +
Willert PD, Brown E. Tuberculosis management of class B immigrants and refugees in Multnomah County, Oregon. Presented at mid year meeting of the North American Region of the International Union Against Tuberculosis and Lung Disease;March 2, 1996; Chicago, Ill.
30 +
Asch S, Leake B, Gelberg L.  Does fear of immigration authorities deter tuberculosis patients from seeking care? West J Med . 1994;;161:373-376.
31 +
Iseman MD, Starke J.  Immigrants and tuberculosis control . N Engl J Med . 1995;;322:1094-1095.
32 +
Ferebee SH.  Controlled chemoprophylaxis trials in tuberculosis . Adv Tuber Res . 1969;;17:28-106.
33 +
International Union Against Tuberculosis Committee on Prophylaxis.  Efficacy of various durations of isoniazid preventive therapy for tuberculosis . Bull World Health Organ . 1982;;60:555-564.
34 +
Bass JBJ, Farer LS, Hopewell PC, et al.  Treatment of tuberculosis and tuberculosis infection in adults and children . Am J Respir Crit Care Med . 1994;;149:1359-1374.
35 +
Mohle-Boetani JC, Miller B, Halpern M, et al.  School-based screening for tuberculous infection: a cost-benefit analysis . JAMA . 1995;;274:613-619.
36 +
Starke JR.  Universal screening for tuberculosis infection: school's out! JAMA . 1995;;274:652-653.
37 +
Wells CD, Zuber P, Binkin N, Nolan C. Tuberculosis case contact investigations among foreign-born and US-born patients. Presented at 45th annual Epidemic Intelligence Service Conference; April 22-26, 1996; Atlanta, Ga.
38 +
Centers for Disease Control and Prevention.  The role of BCG vaccine in the prevention and control of tuberculosis in the United States . MMWR Morb Mortal Wkly Rep . 1996;;45( (RR-4) ):8-9.
39 +
Guérin N.  BCG policies in Europe . Pediatr Pulmonol Suppl . 1995;;11:18-19.
40 +
Ballew KA, Becker DM.  Tuberculosis screening in adults who have received bacille Calmette-Guérin vaccine . South Med J . 1995;;88:1025-1030.
41 +
Immigration and Naturalization Service. Statistical Yearbook of the Immigration and Naturalization Service, 1994. Washington, DC: US Government Printing Office; 1996.
42 +
Snider DE, Caras GJ, Koplan JP.  Preventive therapy with isoniazid . JAMA . 1986;;255:1579-1583.
43 +
Rose DN, Schechter CB, Fahs MC, Silver AL.  Tuberculosis prevention . Am J Prev Med . 1988;;4:102-109.
44 +
Sterling TR, Brehm WT, Frieden TR.  Isoniazid preventive therapy in areas of high isoniazid resistance . Arch Intern Med . 1995;;155:1622-1628.
45 +
Murray CJL, Styblo K, Rouillon A.  Tuberculosis in developing countries: burden, intervention, and cost . Bull Int Union Tuber . 1990;;65:6-26.
46 +
Enarson DA.  Why not the elimination of tuberculosis? Mayo Clin Proc . 1994;;69:85-86.

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