Special Article
The Epidemiology of Tuberculosis among Foreign-Born Persons in the United States, 1986 to 1993
N Engl J Med 1995; 332:1071-1076April 20, 1995
- Abstract
Background
One third of the world's population is infected with Mycobacterium tuberculosis, and in the developed countries immigration is a major force that sustains the incidence of tuberculosis. We studied the effects of immigration on the epidemiology of tuberculosis and its recent resurgence in the United States.
Methods
We analyzed data from the national tuberculosis reporting system of the Centers for Disease Control and Prevention. Since 1986 reports of tuberculosis have included the patient's country of origin. Population estimates for foreign-born persons were derived from special samples from the 1980 and 1990 censuses.
Results
The proportion of persons reported to have tuberculosis who were foreign-born increased from 21.6 percent (4925 cases) in 1986 to 29.6 percent (7346 cases) in 1993. For the entire eight-year period, most foreign-born patients with tuberculosis were from Latin America (43.9 percent; 21,115 cases) and Southeast Asia (34.6 percent; 16,643 cases). Among foreign-born persons the incidence rate was almost quadruple the rate for native residents of the United States (30.6 vs. 8.1 per 100,000 person-years), and 55 percent of immigrants with tuberculosis had the condition diagnosed in their first five years in the United States.
Conclusions
Immigration has had an increasingly important effect on the epidemiology of tuberculosis in the United States. It will be difficult to eliminate tuberculosis without better efforts to prevent and control it among immigrants and greater efforts to control it in the countries from which they come.
Media in This Article
Figure 2
Correlation between State-Specific Tuberculosis Case Rates for Foreign-Born Persons and U.S.-Born Persons in the United States, 1986 to 1993.Figure 1
Number of Legal Immigrants According to Year of Admission (Bars) and Tuberculosis Case Rates for U.S.-Born (Broken Line) and Foreign-Born (Solid Line) Persons.Article Activity
- Article
The decades-long decline in the incidence of tuberculosis in the United States was reversed during the late 1980s. The resurgence continued into the current decade, and despite a 5.1 percent relative decline from 1992 to 1993, the number of reported cases in 1993 was 14 percent higher than in the nadir year of 1985.1 A limited number of studies have examined the effects of increases in immigration on the recent epidemiology of tuberculosis in the United States.2-6 A study by Powell et al. from 1977 to 1979 found that foreign-born persons accounted for 15 percent of the reported cases of tuberculosis in the 11 areas studied.2 The national surveillance data show that the proportion of diagnosed cases of active tuberculosis in which the patient was foreign-born increased from 22 percent in 1986 to almost 30 percent in 1993.1
The increasing contribution of foreign-born persons to the incidence of tuberculosis has been noted in a number of developed countries with substantial levels of immigration.7-14 However, there have been no comprehensive epidemiologic studies in the United States of the incidence rates of tuberculosis among foreign-born residents. Previous analyses have presented only frequency counts or estimates of rates for a limited number of subgroups of the foreign-born population.2-5,15 Accurate estimates of incidence rates are needed to develop cost-effective strategies for the prevention, control, and ultimate elimination of tuberculosis.16 Therefore, we have investigated the recent influence of immigration on the epidemiology of tuberculosis using data from the national reporting system for tuberculosis and from U.S. Census Bureau surveys of the foreign-born population.
Methods
Cases
All 50 states and the District of Columbia mandate the reporting of persons with clinically active tuberculosis to local or state health authorities.17 The data used in this analysis were derived from the standardized case reports forwarded to the Centers for Disease Control and Prevention (CDC) by these local or state authorities.1 Since 1986 all reports have included data on the patient's country of origin. All patients with newly diagnosed disease must be reported, regardless of their legal residency status, so long as they consider the community their home or plan to remain in the country for at least 90 days.18 The patient's legal residency status, if it is ascertained, is not forwarded to the CDC.
The U.S. Census Bureau definition was used to classify persons as foreign-born.19 Anyone born in the United States or a territory of the United States, as well as anyone born in a foreign country but having at least one American parent, was categorized as native to the United States, or U.S.-born. Persons not meeting the criteria for the native designation were considered foreign-born.
Information on the date of immigration was incomplete for 24 percent of the foreign-born persons reported as having tuberculosis. Excluding patients with incomplete information would have resulted in gross underestimations of the incidence rates. Therefore, since age and world region of origin correlated strongly with length of residence for patients with complete information, means for length of residence were imputed to those with missing dates on the basis of their ages and world regions of origin.
Population
The population estimates used in this analysis were derived from a 5 percent sample of all U.S. households surveyed as part of the censuses conducted in 1980 and 1990.20 We calculated intercensal estimates using linear interpolations between the 1980 and 1990 censuses. Estimates beyond 1990 were developed by linear extrapolation. The sampling frame for the decennial estimates contained single households as well as group quarters, including homeless shelters, correctional facilities, camps for migrant workers, and military installations. Data were collected by the U.S. Census Bureau regardless of residency status, so legal immigrants as well as undocumented persons are included in these estimates. Data on the number of legal immigrants, as well as estimates of the number of illegal immigrants and residents, were obtained from reports published by the Immigration and Naturalization Service.21
Census data may undercount certain minority subpopulations, possibly resulting in inflated disease-rate estimates for the foreign-born population.22,23 However, published estimates of census undercounts suggest that for broad population groupings on a national level the magnitude of these biases would have no substantial effect on our major findings.19,23
Regions of Origin
To obtain precise rate estimates, we categorized the foreign countries of origin in eight groups according to geography and economic development, using a scheme devised by the World Bank.24 The groups are sub-Saharan Africa; India; mainland China; other Asian countries (excluding India, China, Japan, and countries of the former Soviet Union); Latin America and the Caribbean; the Middle Eastern crescent; the formerly socialist economies of Europe, including the countries of the former Soviet Union as well as the eastern European countries with formerly communist economies; and the established market economies, including Canada, Western Europe, Australia, New Zealand, and Japan.
Statistical Analysis
All rates were adjusted for age by the direct method, with the distribution in the 10-year age intervals in 1990 used as the standard.24 Standard errors for age-adjusted rate ratios were estimated with a simple approximation to the Poisson probability distribution.25,26 We present 99 percent confidence intervals because of the design effect associated with the complex sampling procedures used to derive the population estimates.20,25,27 Pearson correlation coefficients were calculated with two-sided P values.
We used logistic regression to assess the effects of adjustment for multiple covariates other than age.28 We present the results from the model containing only main effects.29
Results
From 1986 through 1993, 195,186 persons were given a diagnosis of tuberculosis and were reported to the CDC. Only 1.2 percent of the reports had incomplete information about the country of origin or age and were excluded from our analysis. The proportion of patients reported to have tuberculosis who were classified as foreign-born increased from 21.6 percent (4925) in 1986 to 29.6 percent (7346) in 1993. The estimated rates of tuberculosis among foreign-born persons also increased (Figure 1Figure 1
Number of Legal Immigrants According to Year of Admission (Bars) and Tuberculosis Case Rates for U.S.-Born (Broken Line) and Foreign-Born (Solid Line) Persons.). From 1986 to 1989 the average annual rate in the foreign-born population was 27.1 per 100,000 persons. After 1989 the number of documented immigrants increased greatly. This increase included previously illegal long-term residents who were allowed to adjust their residency status under provisions of the Immigration Reform and Control Act of 1986. Immigrants adjusting their status were also screened for tuberculosis as part of this special admission process. From 1990 to 1993 the incidence rate of tuberculosis in the foreign-born population increased to 33.6 per 100,000. During the entire eight-year period, the overall rate in the U.S.-born population remained relatively constant at about 8.1 per 100,000.When people with tuberculosis were stratified according to age, the largest relative difference between those who were foreign-born and those who were born in the United States was evident among children less than 15 years of age (Table 1Table 1
Tuberculosis Case Rates in the United States According to Place of Birth and Demographic Variables, 1986 to 1993.). The annual rate among foreign-born children was so great that it exceeded the highest age-specific rate among native persons by 54 percent.There was substantial heterogeneity in the effect of foreign birth on the rate of tuberculosis across racial and ethnic groups. The greatest difference was noted in the Asian population, whereas there was relatively little difference in the rates between foreign-born and U.S.-born blacks or Hispanics (Table 1).
The incidence of tuberculosis in foreign-born persons residing in the western United States was almost twice the rate among foreign-born persons in the rest of the country (Table 1). In contrast, the highest rates of tuberculosis for U.S.-born persons were in the Northeast. There was little correlation between the state-specific rates for foreign-born persons and those for U.S.-born persons (Figure 2Figure 2
Correlation between State-Specific Tuberculosis Case Rates for Foreign-Born Persons and U.S.-Born Persons in the United States, 1986 to 1993.).The incidence of tuberculosis in foreign-born persons varied substantially according to the world region of origin (Table 2Table 2
Tuberculosis Case Rates According to the Length of Residence in the United States and the World Region of Origin for Foreign-Born Persons in the United States, 1986 to 1993.). People from Asian countries other than India, Japan, mainland China, and countries of the former Soviet Union had the highest rate. Of the 16,643 persons from this region with a diagnosis of tuberculosis, 92.2 percent were from five countries: the Philippines (6286 cases); Vietnam (4941); South Korea (2262); Cambodia (977); and Laos (878). Although the rate of tuberculosis was highest in those from Asia, there were more patients with tuberculosis from Latin America, and Mexico was the country of origin for 56.8 percent of the 21,115 patients from Latin America.The length of residence in the United States was strongly related to the rate of tuberculosis among foreign-born persons, with the highest rates occurring in the first five years after arrival. Overall, 55 percent of the tuberculosis cases in the foreign-born population were diagnosed in the first five years of residence in the United States. Of the 35,399 foreign-born patients whose records contained complete information on the month and year of immigration, 10,478 (29.6 percent) received diagnoses of tuberculosis less than one year after their entry into the United States. The highest average annual rate for the first five years after arrival was among persons from the other-Asian-countries region. In contrast, the rate for recent arrivals from countries with established market economies was lower than the rate for U.S.-born Americans.
We used logistic regression to adjust simultaneously for the potential confounding effects of selected demographic and geographic variables. The major determinants of risk in the foreign-born population were the region of the world from which the person emigrated and the number of years in the United States (Table 3Table 3
Age-Adjusted and Multivariable Analysis of Rate Ratios for Tuberculosis among Foreign-Born Persons in the United States According to Selected Variables, 1986 to 1993.). The rate ratio for the incidence of tuberculosis among foreign-born persons in the western United States as compared with the incidence in foreign-born persons in the rest of the country decreased substantially, from 1.7 to 1.3, after adjustment for other factors.Discussion
Recent reports from Canada, New Zealand, Britain, and western Europe have documented that immigration from nations where tuberculosis is common has been largely responsible for slowing the decrease in morbidity rates in these developed countries.7,10,11,30 In the United States, approximately 8.2 million immigrants were legally granted permanent residence from 1986 through 1993. There were 3 to 4 million illegal foreign-born residents by the early 1990s.21 Therefore, between 1980 and 1990 the foreign-born population in this country increased by over 40 percent.19 The top five countries of origin during this period were Mexico, the Philippines, Vietnam, China, and Korea.21 The tuberculosis incidence rates in these countries are 10 to 30 times greater than the rate in the United States.31 Our findings suggest that the increase in immigration during the late 1980s and early 1990s has profoundly affected the recent epidemiology of this disease in the United States.
National tuberculosis rates among people born in the United States did not vary substantially during the period of this study. This general stability obscures the increases in some areas, particularly urban centers with large numbers of persons infected with the human immunodeficiency virus (HIV).32 There are currently only limited national data on the proportion of patients with tuberculosis who are infected with HIV.1 Focused seroprevalence studies from tuberculosis clinics indicate that foreign-born patients from the countries that contribute the greatest number of immigrants have substantially lower rates of HIV infection than have patients born in the United States.33 These data, in combination with the legal restriction that makes HIV infection a bar to immigration to the United States, suggest there is little likelihood that HIV coinfection has contributed to recent increases in tuberculosis rates among foreign-born persons.34
The high relative rate of tuberculosis in foreign-born children indicates that there is substantial recent transmission either before or shortly after immigration.35 From our data it is difficult to determine the importance of active transmission within the foreign-born community after immigrants' arrival in the United States. However, a recent study from San Francisco using the technique of restriction-fragment–length polymorphism concluded that active tuberculosis in foreign-born persons was more likely to result from reactivation of remote infection than from recent transmission in the local community.36 The absence of correlation between state-specific disease rates for the foreign-born and those for the native population suggests that transmission to U.S.-born persons is probably not extensive.
The elevated rates among young foreign-born persons are consistent with the results of studies that report positive tuberculin-skin-test reactions in 35 to 53 percent of young foreign-born persons from Southeast Asia and Latin America.36-40 Young foreign-born persons with latent tuberculosis infections represent a growing pool of immigrants in whom active disease will continue to develop unless major efforts are mounted to screen for infection and provide treatment.6,16,41
Several factors explain the finding that the highest rates of tuberculosis among foreign-born persons occur within a few years of their arrival in the United States.3,5 First, only immigrants and refugees applying for permanent legal residence are screened for tuberculosis. Persons allowed to change their status from illegal to legal under the provisions of the Immigration Reform and Control Act of 1986 were also screened. Applicants for immigration who have abnormal screening chest radiographs as well as positive smears for acid-fast bacilli on sputum examinations must begin therapy that is effective in converting their sputum smears to negative, and each must obtain a waiver from a responsible health care provider in the United States before he or she can enter or remain in the country.34 Before implementation of the Immigration Act of 1990 (Figure 1), people with abnormal chest radiographs indicative of active tuberculosis but with negative sputum smears were also required to obtain waivers.6 However, the criteria for exclusion were liberalized to make it easier for overseas immigrants who were considered noninfectious (i.e., whose sputum smears were negative) to receive treatment in the United States. This was done to discourage such persons from receiving suboptimal treatment overseas that could promote the selection of resistant organisms.6,34
Studies in recent Southeast Asian immigrants have found that sputum smears are relatively insensitive in detecting clinically active Mycobacterium tuberculosis.6,9,42,43 There are currently no federal regulations prescribing follow-up procedures for those with suspicious chest radiographs who have negative sputum smears, although they are reported to local health departments by federal authorities. The number who are actually evaluated is unknown, since many notification forms sent to state and local health departments are never returned to the CDC (Tipple M, Division of Quarantine, CDC: personal communication). Hence, substantial numbers of persons undoubtedly enter the country with active disease but when they later come to the attention of health care workers in the United States they are counted as representing new, previously unidentified cases.3,5,6
A second factor contributing to the high rates among recent arrivals is the decreased risk of tuberculosis with lengthening time after infection.12 The annual risk of infection in many of the countries of origin is 100 to 200 times the rate in the United States.2,12,44,45 Therefore, the rate of disease among immigrants is greatest within the first few years after entry, because they are much more likely to be infected before departure than after their arrival in the United States.
Another reason for high incidence rates among recent arrivals is the more than 20 million nonimmigrant visitors and students and the estimated 200,000 undocumented immigrants who enter the United States every year.21 People in these groups do not undergo a prescribed medical evaluation before entry, and some arrive with active disease that is then diagnosed and reported in the United States. The impact of visitors and students and of undocumented residents on the rate of tuberculosis among foreign-born persons is impossible to estimate from our surveillance data. Local health departments are frequently reluctant to inquire about legal status because illegal residents with infectious disease may delay seeking care if they suspect they will be reported to immigration authorities.46
Our analyses indicate that improvements are needed in screening immigrants and refugees overseas, as well as in communicating the results of screening examinations to responsible public health and medical officials.6,16,47 Physicians in the United States who care for foreign-born persons should be aware that their patients from developing countries are at increased risk for tuberculosis even if they have been medically cleared during the legal immigration process, since that screening focuses exclusively on the identification of highly infectious persons (i.e., those whose sputum smears are positive for acid-fast bacilli). Also, programs that minimize barriers to appropriate screening and chemoprophylaxis have to be available to foreign-born residents if progress is to be made in the control of tuberculosis.6,16,41,47
Finally, recent reports document that the treatment and control of tuberculosis is one of the most cost-effective health interventions for developing countries.24,48 Future success in tuberculosis control in this country will require greater efforts by the United States, in coordination with other countries and international organizations, to upgrade the standards and quality of tuberculosis-control programs in developing countries.6,31,49 These endeavors may be most efficiently pursued in Latin America and Southeast Asia, which supply the greatest numbers of immigrants to the United States.
We are indebted to state and local tuberculosis-control officials in health departments throughout the United States who collected and reported the data used in this analysis, and to the surveillance staff at the Division of Tuberculosis Elimination, CDC, who have maintained this information over time; to Dr. Nancy Binkin from the Division of Tuberculosis Elimination for comments on early versions of the manuscript; to Dr. Margaret Tipple from the Division of Quarantine, CDC, for valuable assistance; and to Robert Pratt for his help with the computer programming.
Source Information
From the Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Rd. E-10, Atlanta, GA 30333, where reprint requests should be addressed to Dr. McKenna.
- References
References
1
Expanded tuberculosis surveillance and tuberculosis morbidity -- United States, 1993
Medline2
Powell KE ,Meador MP ,Farer LS . Foreign-born persons with tuberculosis in the United States. Am J Public Health 1981;71:1223-1227
CrossRef | Web of Science | Medline3
Powell KE ,Brown ED ,Farer LS . Tuberculosis among Indochinese refugees in the United States. JAMA 1983;249:1455-1460
CrossRef | Web of Science | Medline4
Rieder HL ,Cauthen GM ,Kelly GD ,Bloch AB ,Snider DE Jr . Tuberculosis in the United States. JAMA 1989;262:385-389
CrossRef | Web of Science | Medline5
Orr P, Hershfield E. The epidemiology of tuberculosis in the foreign-born in Canada and the United States. In: Reichman LG, Hershfield ES, eds. Tuberculosis: a comprehensive international approach. New York: Marcel Dekker, 1993:531-50.
6
Tuberculosis among foreign-born persons entering the United States: recommendations of the Advisory Committee for Elimination of Tuberculosis
Medline7
Enarson DA ,Wang JS ,Dirks JM . The incidence of active tuberculosis in a large urban area. Am J Epidemiol 1989;129:1268-1276
Web of Science | Medline8
Ormerod LP . Tuberculosis screening and prevention in new immigrants, 1983-88. Respir Med 1990;84:269-271
CrossRef | Web of Science | Medline9
Orr PH ,Manfreda J ,Hershfield ES . Tuberculosis surveillance in immigrants to Manitoba. Can Med Assoc J 1990;142:453-458
Web of Science10
Raviglione MC ,Sudre P ,Rieder HL ,Spinaci S ,Kochi A . Secular trends of tuberculosis in western Europe. Bull World Health Organ 1993;71:297-306
Web of Science | Medline11
Stehr-Green JK . Tuberculosis in New Zealand, 1985-90. N Z Med J 1992;105:301-303
Medline12
Styblo K . Overview and epidemiologic assessment of the current global tuberculosis situation with an emphasis on control in developing countries. Rev Infect Dis 1989;11:Suppl 2:S339-S346
CrossRef | Medline13
Wang JS ,Allen EA ,Chao CW ,Enarson D ,Grzybowski S . Tuberculosis in British Columbia among immigrants from five Asian countries, 1982-85. Tubercle 1989;70:179-186
CrossRef | Medline14
Wang JS ,Allen EA ,Enarson DA ,Grzybowski S . Tuberculosis in recent Asian immigrants to British Columbia, Canada: 1982-1985. Tubercle 1991;72:277-283
CrossRef | Medline15
Jacobson ML ,Mercer MA ,Miller LK ,Simpson TW . Tuberculosis risk among migrant farm workers on the Delmarva peninsula. Am J Public Health 1987;77:29-32
Web of Science | Medline16
A strategic plan for the elimination of tuberculosis in the United States 17
Tuberculosis Control Laws -- United States, 1993: recommendations of the Advisory Council for the Elimination of Tuberculosis (ACET)
Medline18
Centers for Disease Control. Procedural guide: recommendations for counting reported tuberculosis cases. Atlanta: Department of Health, Education, and Welfare, 1977.
19
Bureau of the Census. 1990 Census of population: foreign-born population in the United States. Washington, D.C.: Government Printing Office, 1993.
20
1990 Census of population and housing. Public use microdata sample. Technical documentation. Washington, D.C.: Bureau of the Census, 1992.
21
Immigration and Naturalization Service. Statistical yearbook of the Immigration and Naturalization Service, 1993. Washington, D.C.: Government Printing Office, 1994.
22
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
CrossRef | Web of Science | Medline23
Fein DJ . Racial and ethnic differences in U.S. Census omission rates. Demography 1990;27:285-302
CrossRef | Web of Science | Medline24
World Bank. World development report 1993: investing in health. New York: Oxford University Press, 1993.
25
National Center for Health Statistics. Vital statistics of the United States, 1988. Vol. 2. Mortality. Part A. Technical appendix. Washington, D.C.: Government Printing Office, 1991. (DHHS publication no. (PHS) 91-1101.)
26
Clayton D, Hills M. Statistical models in epidemiology. Oxford, England: Oxford University Press, 1993.
27
Peto R . Why do we need systematic overviews of randomized trials? Stat Med 1987;6:233-244
CrossRef | Web of Science | Medline28
Kleinbaum DG, Kupper LL, Muller KE. Applied regression analysis and other multivariable methods. 2nd ed. Boston: PWS-Kent, 1988.
29
Maldonado G ,Greenland S . Simulation study of confounder-selection strategies. Am J Epidemiol 1993;138:923-936
Web of Science | Medline30
Medical Research Council Cardiothoracic Epidemiology Group
CrossRef | Web of Science | Medline31
Raviglione MC ,Snider DE Jr ,Kochi A . Global epidemiology of tuberculosis: morbidity and mortality of a worldwide epidemic. JAMA 1995;273:220-226
CrossRef | Web of Science | Medline32
Cantwell MF ,Snider DE Jr ,Cauthen GM ,Onorato IM . Epidemiology of tuberculosis in the United States, 1985 through 1992. JAMA 1994;272:535-539
CrossRef | Web of Science | Medline33
Onorato IM ,McCray E . Prevalence of human immunodeficiency virus infection among patients attending tuberculosis clinics in the United States. J Infect Dis 1992;165:87-92
CrossRef | Web of Science | Medline34
Centers for Disease Control. Technical instructions for medical examination of aliens. Atlanta: Department of Health and Human Services, 1991.
35
Starke JR ,Jacobs RF ,Jereb J . Resurgence of tuberculosis in children. J Pediatr 1992;120:839-855
CrossRef | Web of Science | Medline36
Small PM ,Hopewell PC ,Singh SP , et al. The epidemiology of tuberculosis in San Francisco -- a population-based study using conventional and molecular methods. N Engl J Med 1994;330:1703-1709
Full Text | Web of Science | Medline37
Nolan CM ,Elarth AM . Tuberculosis in a cohort of southeast Asian refugees: a five-year surveillance study. Am Rev Respir Dis 1988;137:805-809
Web of Science | Medline38
Morse DL ,Hansen RE ,Grabau JC ,Cauthen G ,Redmond SR ,Hyde RW . Tuberculin conversions in Indochinese refugees: an assessment of boosting and anergy. Am Rev Respir Dis 1985;132:516-519
Web of Science | Medline39
Perez-Stable EJ ,Levin R ,Pineda A ,Slutkin G . Tuberculin skin test reactivity and conversions in United States- and foreign-born Latino children. Pediatr Infect Dis 1985;4:476-479
CrossRef | Medline40
Blum R ,Polish LB ,Tapy JM ,Catlin BJ ,Cohn DL . Results of screening for tuberculosis in foreign-born persons applying for adjustment of immigration status. Chest 1993;103:1670-1674
CrossRef | Web of Science | Medline41
Broekmans JF. Evaluation of applied strategies in low-prevalence countries. In: Reichman LB, Hershfield ES, eds. Tuberculosis: a comprehensive international approach. New York: Marcel Dekker, 1993:641-67.
42
Nolan CM ,Teklu B ,Wu R . The use of sputum cultures in the evaluation of immigrants classified as tuberculosis suspects. Am Rev Respir Dis 1989;140:996-1000
Web of Science | Medline43
Sutter RW ,Haefliger E . Tuberculosis morbidity and infection in Vietnamese in Southeast Asian refugee camps. Am Rev Respir Dis 1990;141:1483-1486
Web of Science | Medline44
Rieder HL ,Cauthen GM ,Comstock GW ,Snider DE Jr . Epidemiology of tuberculosis in the United States. Epidemiol Rev 1989;11:79-98
Web of Science | Medline45
Kochi A . The global tuberculosis situation and the new control strategy of the World Health Organization. Tubercle 1991;72:1-6
CrossRef | Medline46
Asch S ,Leake B ,Gelberg L . Does fear of immigration authorities deter tuberculosis patients from seeking care? West J Med 1994;161:373-376
Medline47
American Thoracic Society
Web of Science | Medline48
Murray CJ ,DeJonghe E ,Chum HJ ,Nyangulu DS ,Salomao A ,Styblo K . Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries. Lancet 1991;338:1305-1308
CrossRef | Web of Science | Medline49
The global challenge of tuberculosisLancet 1994;344:277-279
CrossRef | Web of Science | Medline
- Citing Articles (84)
Citing Articles
1
Jianhong Wu, Hongbin Guo. (2011) Persistent high incidence of tuberculosis among immigrants in a low-incidence country: Impact of immigrants with early or late latency. Mathematical Biosciences and Engineering 8:3, 695-709
CrossRef2
Jeffrey R. Starke, Andrea T. Cruz. 2011. Tuberculosis. , 577-600.
CrossRef3
C.A. Helbling, O. Lieger, W. Smolka, T. Iizuka, J. Kuttenberger. (2010) Primary tuberculosis of the TMJ: presentation of a case and literature review. International Journal of Oral and Maxillofacial Surgery 39:8, 834-838
CrossRef4
P.Y. Iroh Tam, A. Menon, K. Butler. (2010) A review of tuberculosis-related referrals among children in Ireland. Irish Journal of Medical Science 179:2, 251-254
CrossRef5
Claudia Hernandez, Aaron S. Cetner, J. Edward Jordan, Somchin N. Puangsuvan, June K. Robinson. (2008) Tuberculosis in the age of biologic therapy. Journal of the American Academy of Dermatology 59:3, 363-380
CrossRef6
(2008) Protecting Health Care Workers from Tuberculosis. Journal of Occupational and Environmental Medicine 50:7, 852-855
CrossRef7
Z JIA, G TANG, Z JIN, C DYE, S VLAS, X LI, D FENG, L FANG, W ZHAO, W CAO. (2008) Modeling the impact of immigration on the epidemiology of tuberculosis. Theoretical Population Biology 73:3, 437-448
CrossRef8
Guy B. Marks, Jun Bai, Sheila E. Simpson, Gregory J. Stewart, Elizabeth A. Sullivan. (2008) The incidence of tuberculosis in a cohort of South-East Asian refugees arriving in Australia 1984-94. Respirology 6:1, 71
CrossRef9
K. G. Castro. (2007) Tuberculosis Surveillance: Data for Decision-Making. Clinical Infectious Diseases 44:10, 1268-1270
CrossRef10
Prathibha Varkey, Aarti U. Jerath, Stephanie M. Bagniewski, Timothy G. Lesnick. (2007) The Epidemiology of Tuberculosis Among Primary Refugee Arrivals in Minnesota Between 1997 and 2001. Journal of Travel Medicine 14:1,
CrossRef11
Gerald F. Kominski, Sepideh Farivar Varon, Donald E. Morisky, C. Kevin Malotte, Vicki J. Ebin, Astou Coly, Chi Chiao. (2007) Costs and Cost-Effectiveness of Adolescent Compliance with Treatment for Latent Tuberculosis Infection: Results from a Randomized Trial. Journal of Adolescent Health 40:1, 61-68
CrossRef12
A. Daigeler, M. Lehnhardt, M. Helwing, L. Steinstraesser, H.-H. Homann, H.-U. Steinau, D. Druecke. (2006) Differenzialdiagnose „steriler“ phlegmonöser Entzündungen der Hand. Der Chirurg 77:11, 1040-1045
CrossRef13
Daniel P. O’Brien, Karin Leder, Elizabeth Matchett, Graham V. Brown, Joseph Torresi. (2006) Illness in Returned Travelers and Immigrants/Refugees: The 6-Year Experience of Two Australian Infectious Diseases Units. Journal of Travel Medicine 13:3, 145-152
CrossRef14
Helen M. Chun, Raymond M. Pumarejo, Michael T. Akin, Barton C. Gumpert. (2006) Thoracic Pott Disease (Tuberculous Spondylitis) Presenting as Cervical Lymphadenitis. Infectious Diseases in Clinical Practice 14:2, 76-80
CrossRef15
Óscar Sanz-Peláez, José A. Caminero-Luna, José L. Pérez-Arellano. (2006) Tuberculosis e inmigración en España. Evidencias y controversias. Medicina Clínica 126:7, 259-269
CrossRef16
Judith E. Sackoff, Melissa R. Pfeiffer, Cynthia R. Driver, Lynda S. Streett, Sonal S. Munsiff, Jack A. DeHovitz. (2006) Tuberculosis prevention for non–US-born pregnant women. American Journal of Obstetrics and Gynecology 194:2, 451-456
CrossRef17
Jeffrey R. Starke. 2006. Tuberculosis. , 581-601.
CrossRef18
F SAUVET, I IMBERT, J MAGNIN, C SOUVIAT, J PONTIES, D LECHEVALIER. (2005) Tuberculose ostéo-articulaire et post-partum : une association fortuite ?. La Revue de Médecine Interne 26:9, 733-737
CrossRef19
E. Buiatti, D. Balzi. 2005. Migrant Studies. .
CrossRef20
Eileen Schneider, Marisa Moore, Kenneth G. Castro. (2005) Epidemiology of Tuberculosis in the United States. Clinics in Chest Medicine 26:2, 183-195
CrossRef21
Hamdan Al-Jahdali, Ziad A. Memish, Dick Menzies. (2005) The utility and interpretation of tuberculin skin tests in the Middle East. American Journal of Infection Control 33:3, 151-156
CrossRef22
Andreas Seidler, Albert Nienhaus, Roland Diel. (2005) Review of Epidemiological Studies on the Occupational Risk of Tuberculosis in Low-Incidence Areas. Respiration 72:4, 431-446
CrossRef23
A. S. Gershon, A. McGeer, A. M. Bayoumi, J. Raboud, J. Yang. (2004) Health Care Workers and the Initiation of Treatment for Latent Tuberculosis Infection. Clinical Infectious Diseases 39:5, 667-672
CrossRef24
Sarah M. Jump, Jennifer L. St. Sauver, Amy L. Weaver, Stephanie M. Bagniewski, John W. Wilson, W. Charles Huskins, Timothy R. Aksamit, W. Mark Brutinel, Marcella C. Scalcini, Irene G. Sia, Armando G. Correa, Kevin McCoy, Thomas G. Boyce. (2004) Incidence of Tuberculosis in Olmsted County, Minnesota, 1990-2001. Mayo Clinic Proceedings 79:9, 1119-1123
CrossRef25
S. M. Jump, J. L. St. Sauver, A. L. Weaver, S. M. Bagniewski, J. W. Wilson, W. C. Huskins, T. R. Aksamit, W. M. Brutinel, M. C. Scalcini, I. G. Sia, A. G. Correa, K. McCoy, T. G. Boyce. (2004) Incidence of Tuberculosis in Olmsted County, Minnesota, 1990-2001. Mayo Clinic Proceedings 79:9, 1119-1123
CrossRef26
Brian D. Gushulak, Douglas W. MacPherson. (2004) Population Mobility and Health: An Overview of the Relationships Between Movement and Population Health. Journal of Travel Medicine 11:3, 171-178
CrossRef27
Zakari Y. Aliyu. (2003) Immigration and a sneak resurgence of tuberculosis:Déjà vu. Wiener Klinische Wochenschrift 115:17-18, 611-614
CrossRef28
Hamisu M. Salihu, Robyn Spittle. (2003) Tuberculosis among foreign-born children in the State of Florida, 1993–1999: A re-emergence phase after a sustained decline?. Wiener Klinische Wochenschrift 115:17-18, 641-647
CrossRef29
A. L. Davidow, B. T. Mangura, E. C. Napolitano, L. B. Reichman. (2003) Rethinking the Socioeconomics and Geography of Tuberculosis Among Foreign-Born Residents of New Jersey, 1994-1999. American Journal of Public Health 93:6, 1007-1012
CrossRef30
Mario C. Raviglione. (2003) The TB epidemic from 1992 to 2002. Tuberculosis 83:1-3, 4-14
CrossRef31
E. Schneider, K.G. Castro. (2003) Tuberculosis trends in the United States, 1992–2001. Tuberculosis 83:1-3, 21-29
CrossRef32
Cabot, Richard C.Harris, Nancy Lee, McNeely, William F., Shepard, Jo-Anne O., Ebeling, Sally H.Ellender, Stacey M.Peters, Christine C., Tanoue, Lynn T., Mark, Eugene J., . (2003) Case 1-2003. New England Journal of Medicine 348:2, 151-161
Full Text33
Jasmer, Robert M., Nahid, Payam, Hopewell, Philip C., . (2002) Latent Tuberculosis Infection. New England Journal of Medicine 347:23, 1860-1866
Full Text34
Howard Markel, Alexandra Minna Stern. (2002) The Foreignness of Germs: The Persistent Association of Immigrants and Disease in American Society. Milbank Quarterly 80:4, 757-788
CrossRef35
Matthew Gandy, Alimuddin Zumla. (2002) The resurgence of disease: social and historical perspectives on the ‘new’ tuberculosis. Social Science & Medicine 55:3, 385-396
CrossRef36
Adelisa L. Panlilio, Dale R. Burwen, Amy B. Curtis, Pamela U. Srivastava, John Bernardo, Michela T. Catalano, Meryl H. Mendelson, Peter Nicholas, William Pagano, Carol Sulis, Ida M. Onorato, Mary E. Chamberland, . (2002) Tuberculin Skin Testing Surveillance of Health Care Personnel. Clinical Infectious Diseases 35:3, 219-227
CrossRef37
Marla J. Friedman, Nicholas Tsarouhas. (2002) An Adolescent With Hemoptysis. Pediatric Case Reviews 2:3, 159-167
CrossRef38
David H. Jacobs, Juan M. Tovar, Oliver L. Hung, Mimi Kim, Philip Ye, William K. Chiang, Lewis R. Goldfrank. (2002) Behavioral Risk Factor and Preventive Health Care Practice Survey of Immigrants in the Emergency Department. Academic Emergency Medicine 9:6, 599-608
CrossRef39
M. Saraiya, S. T. Cookson, P. Tribble, B. Silk, R. Cass, S. Poonja, M. Walting, N. Howland, E. A. Paz, J. Cochran, K. S. Moser, M. J. Oxtoby, N. J. Binkin. (2002) Tuberculosis Screening Among Foreign-Born Persons Applying for Permanent US Residence. American Journal of Public Health 92:5, 826-829
CrossRef40
Joanne Kerr, Jack Elwell. (2002) Is TB in Your Curriculum?. The American Biology Teacher 64:4, 280-284
CrossRef41
Barbara J Seaworth. (2002) Multidrug-resistant tuberculosis. Infectious Disease Clinics of North America 16:1, 73-105
CrossRef42
Fred H. Linthicum. (2002) Tuberculous Otitis Media. Otology & Neurotology 23:2, 235-236
CrossRef43
Stephen E Weis, Gerry Burgess. (2002) Tuberculosis control in a border state: Treatment of the foreign-born. Infectious Disease Clinics of North America 16:1, 59-71
CrossRef44
Richard Coker, Kitty Lambregts van Weezenbeek. (2001) Mandatory screening and treatment of immigrants for latent tuberculosis in the USA: just restraint?. The Lancet Infectious Diseases 1:4, 270-276
CrossRef45
G. B. Marks, J. Bai, G. J. Stewart, S. E. Simpson, E. A. Sullivan. (2001) Effectiveness of Postmigration Screening in Controlling Tuberculosis Among Refugees: A Historical Cohort Study, 1984-1998. American Journal of Public Health 91:11, 1797-1799
CrossRef46
Nicole L. Richardson. (2001) Evaluating provider prescribing practices for the treatment of tuberculosis in Virginia, 1995 to 1998: An assessment of educational need. Journal of Continuing Education in the Health Professions 20:3, 146-155
CrossRef47
R. G. Barr, A. V. Diez-Roux, C. A. Knirsch, A. Pablos-Mendez. (2001) Neighborhood Poverty and the Resurgence of Tuberculosis in New York City, 1984-1992. American Journal of Public Health 91:9, 1487-1493
CrossRef48
Small, Peter M., Fujiwara, Paula I., . (2001) Management of Tuberculosis in the United States. New England Journal of Medicine 345:3, 189-200
Full Text49
Guy B. Marks, Jun Bai, Sheila E. Simpson, Gregory J. Stewart, Elizabeth A. Sullivan. (2001) The incidence of tuberculosis in a cohort of South-East Asian refugees arriving in Australia 1984-94. Respirology 6:1, 71-74
CrossRef50
R Figueroa-Damián. (2001) Neonatal Outcome of Children Born to Women with Tuberculosis. Archives of Medical Research 32:1, 66-69
CrossRef51
Jared Magnani, Barun Mathema, Judith Berger, Sheldon Brown, Max David, Aaron Glatt, Ferdinand Pujol, Sorana Segal-Maurer, Lee W. Riley, Barry N. Kreiswirth, Kent A. Sepkowitz. (2001) Molecular epidemiology of uberculosis among eight hospitals in New York City, 1996–1997. International Journal of Infectious Diseases 5:3, 126-132
CrossRef52
Amy L Davidow, Philip Alcabes, Michael Marmor. (2000) The Contribution of Recently Acquired Mycobacterium tuberculosis Infection to the New York City Tuberculosis Epidemic, 1989–1993. Epidemiology 11:4, 394-401
CrossRef53
KAREN SOREN, LISA SAIMAN, MATILDE IRIGOYEN, CABILIA GOMEZ-DUARTE, MOSHE J. LEVISON, DONALD J. MCMAHON. (1999) Evaluation of household contacts of children with positive tuberculin skin tests. The Pediatric Infectious Disease Journal 18:11, 949-955
CrossRef54
Edouard Pertuiset, Johann Beaudreuil, Frédéric Lioté, Anne Horusitzky, Farid Kemiche, Pascal Richette, Dominique Clerc-Wyel, Isabelle Cerf-Payrastre, Henri Dorfmann, Jacques Glowinski, Jacques Crouzet, Thomas Bardin, Olivier Meyer, Antoine Dryll, Jean-Marc Ziza, Marcel-Francis Kahn, Daniel Kuntz. (1999) Spinal Tuberculosis in Adults. Medicine 78:5, 309-320
CrossRef55
Ernesto Jaramillo. (1999) Encompassing treatment with prevention: the path for a lasting control of tuberculosis. Social Science & Medicine 49:3, 393-404
CrossRef56
Kathryn DeRiemer, Charles L. Daley, Arthur L. Reingold. (1999) Preventing Tuberculosis among HIV-Infected Persons: A Survey of Physicians' Knowledge and Practices. Preventive Medicine 28:4, 437-444
CrossRef57
Carol Dukes Hamilton. (1999) Recent developments in epidemiology, treatment, and diagnosis of tuberculosis. Current Infectious Disease Reports 1:1, 80-88
CrossRef58
Bonita T Mangura, Lee B Reichman. (1999) Periodic chest radiography: unnecessary, expensive, but still pervasive. The Lancet 353:9149, 319-320
CrossRef59
&NA;. (1998) ACOEM Guidelines for Protecting Health Care Workers Against Tuberculosis. Journal of Occupational & Environmental Medicine 40:9, 765-767
CrossRef60
David E. Griffith. (1998) MYCOBACTERIA AS PATHOGENS OF RESPIRATORY INFECTION. Infectious Disease Clinics of North America 12:3, 593-611
CrossRef61
Y Poinsignon, Z Marjanovic, P Bordon, C Georges, D Farge. (1998) Réémergence de la tuberculose et précarité socioéconomique. La Revue de Médecine Interne 19:9, 649-657
CrossRef62
Pablos-Méndez, Ariel, Raviglione, Mario C., Laszlo, Adalbert, Binkin, Nancy, Rieder, Hans L., Bustreo, Flavia, Cohn, David L., Lambregts-van Weezenbeek, Catherina S.B., Kim, Sang Jae, Chaulet, Pierre, Nunn, Paul, . (1998) Global Surveillance for Antituberculosis-Drug Resistance, 1994–1997. New England Journal of Medicine 338:23, 1641-1649
Full Text63
Sanjiv Shah, Herbert B. Tanowitz, Murray Wittner. (1998) THE ETHNIC MINORITY TRAVELER. Infectious Disease Clinics of North America 12:2, 523-541
CrossRef64
P. L. Geltman, A. F. Meyers. (1998) Immigration Reporting Laws: Ethical Dilemmas in Pediatric Practice. American Journal of Public Health 88:6, 967-968
CrossRef65
Stephen M. Ostroff, Phyllis Kozarsky. (1998) EMERGING INFECTIOUS DISEASES AND TRAVEL MEDICINE. Infectious Disease Clinics of North America 12:1, 231-241
CrossRef66
Thomas Junghanss. (1998) Asylsuchende und Fl
chtlinge: Gesundheitsversorgung einer komplexen Minderheit. Sozial- und Pr
CrossRef67
William C. Dixon, Marjeanne Collins. (1998) Screening and Chemoprophylaxis for Tuberculosis Infection in College Populations. Journal of American College Health 46:4, 171-175
CrossRef68
(1997) Perioperative air safety. Acta Anaesthesiologica Scandinavica 41, 237-250
CrossRef69
Mario C Raviglione, Christopher Dye, Sonja Schmidt, Arata Kochi. (1997) Assessment of worldwide tuberculosis control. The Lancet 350:9078, 624-629
CrossRef70
Alan R. Tait. (1997) Occupational Transmission of Tuberculosis. Anesthesia & Analgesia 85:2, 444-451
CrossRef71
Eugene McCray, Cindy M. Weinbaum, Christopher R. Braden, Ida M. Onorato. (1997) THE EPIDEMIOLOGY OF TUBERCULOSIS IN THE UNITED STATES. Clinics in Chest Medicine 18:1, 99-113
CrossRef72
M. J. GROVES. (1997) BCG. Journal of Pharmacy and Pharmacology 49:S1, 7-15
CrossRef73
Margareta Eriksson, Rutger Bennet, Niklas Danielsson. (1997) Clinical Manifestations and Epidemiology of Childhood Tuberculosis in Stockholm 1976–95. Scandinavian Journal of Infectious Diseases 29:6, 569-572
CrossRef74
Daniel P. Chin, Philip C. Hopewell. (1996) MYCOBACTERIAL COMPLICATIONS OF HIV INFECTION. Clinics in Chest Medicine 17:4, 697-711
CrossRef75
XILLA T. USSERY, SARAH E. VALWAY, MATTHEW MCKENNA, GEORGE M. CAUTHEN, EUGENE MCCRAY, IDA M. ONORATO. (1996) Epidemiology of tuberculosis among children in the United States: 1985 to 1994. The Pediatric Infectious Disease Journal 15:8, 697-704
CrossRef76
Kenyon, Thomas A., Valway, Sarah E., Ihle, Walter W., Onorato, Ida M., Castro, Kenneth G., . (1996) Transmission of Multidrug-Resistant Mycobacterium tuberculosis during a Long Airplane Flight. New England Journal of Medicine 334:15, 933-938
Full Text77
(1996) Clinical Problem-Solving: If at First You Don't Succeed. New England Journal of Medicine 334:14, 918-920
Full Text78
Friedman, Lloyd N., Williams, Michael T., Singh, Tejinder P., Frieden, Thomas R., . (1996) Tuberculosis, AIDS, and Death among Substance Abusers on Welfare in New York City. New England Journal of Medicine 334:13, 828-833
Full Text79
Cabot, Richard C.Scully, Robert E., Mark, Eugene J., McNeely, William F., Ebeling, Sally H., Mankin, H.J.Wu, H.C.. (1996) Case 9-1996. New England Journal of Medicine 334:12, 784-789
Full Text80
Laura S. Inselman. (1996) Tuberculosis in children: An update. Pediatric Pulmonology 21:2, 101-120
CrossRef81
Virginia Abernethy. (1996) Third world hospital de luxe. Population and Environment 17:3, 191-194
CrossRef82
(1995) Immigrants and Tuberculosis. New England Journal of Medicine 333:10, 667-669
Full Text83
Iseman, Michael D., , Starke, Jeffrey, . (1995) Immigrants and Tuberculosis Control. New England Journal of Medicine 332:16, 1094-1095
Full Text84
Ziv, Tal Ann, Lo, Bernard, . (1995) Denial of Care to Illegal Immigrants — Proposition 187 in California. New England Journal of Medicine 332:16, 1095-1098
Full Text
- Letters
