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No. 4, 2008

International Research and Programs Branch Update

Epidemiology of TB Among Foreign-born Persons in the United States

The following is a summary of an article by Cain, Benoit, Winston, and Mac Kenzie (JAMA 2008; 300[4]: 405-12).

Rates of TB disease have declined among both U.S.-born persons and foreign-born persons, but the rate of decline has been much slower for foreign-born persons, thereby widening the disparity in TB case rates between the two. In 2006, among all TB cases in the United States, 57% occurred among foreign-born persons. We assessed the epidemiology of TB among foreign-born persons to inform approaches to enhancing TB control in this population.

We estimated that adding TB culture to overseas pre-immigration screening for U.S.-bound migrants would have prevented the importation of at most 250 TB cases per year during 2001–2006. Since approximately 7,000 TB cases occur among foreign-born persons each year, additional strategies are needed. Finding and treating latent TB infection is one such strategy; however, with over 37 million foreign-born persons living in the United States, reaching out to all of them would not be feasible. To guide these interventions, we found that the risk of TB among foreign-born persons varies based on time since U.S. entry, age at U.S. entry, and country of birth. Annual TB case rates decline with increasing time since U.S. entry, but rates never decline to the level of U.S.-born persons. Rates are highest for persons born in most countries of sub-Saharan Africa and Southeast Asia, exceeding 100 times the rate of U.S.-born persons during the first 2 years after U.S. arrival. Among foreign-born persons with TB, over half of all cases occur in persons from the highest-risk countries, which include most countries of sub-Saharan Africa and Asia. On the other hand, persons born in Canada, Western Europe, Australia and New Zealand, and Japan had low rates. A map showing the level of risk for each country is available in the full article.

To control TB in foreign-born persons and to eliminate TB in the United States, latent TB infection testing and treatment both need to be more widely implemented. Doing so would be highest yield if the populations with the highest risk of TB disease were targeted first.

For more details, please see the full article.

Cain KP, Benoit SR, Winston CA, Mac Kenzie WR. Tuberculosis among foreign-born persons in the United States. JAMA 2008; 300(4): 405-412.

—Submitted by Kevin Cain, MD
Div of TB Elimination


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