Correspondence
Immigrants and Tuberculosis
N Engl J Med 1995; 333:667-669September 7, 1995
- Article
To the Editor:
As a recent legal immigrant to this country, I agree with Iseman and Starke (April 20 issue)1 that “refining immigration procedures” is the better of the two alternatives they propose. However, I disagree with their suggestion that improving the screening and evaluation procedures in the immigrants' countries of origin would have a substantial impact. First, it would be almost impossible for consulates, immigration officials, and health authorities in the United States to monitor the quality of laboratories and health personnel performing the screening tests in the many countries from which immigrants come. Second and more important, corruption is a way of life in many countries, making it very easy to buy or forge test results.
A better solution would be to grant temporary legal residency to prospective immigrants and screen them for tuberculosis in the United States. The green card would eventually be issued, but only after proof of negative test results or the completion of treatment. The immigrants should pay for the testing, and those with jobs, health insurance, or other resources (probably the majority of legal immigrants) would pay for their treatments as well. It is unlikely that people applying to immigrate legally to the United States would go underground after positive testing, since they would already have shown a willingness to follow the rules and come here legally. This policy would ensure more adequate screening and a better chance of getting treatment to those who need it, and would avoid the laxity of the current system.
1 ReferencesDavid Alboukrek, M.D.
Berkshire Orthopaedic Associates, Pittsfield, MA 012011
Iseman MD ,Starke J . Immigrants and tuberculosis control. N Engl J Med 1995;332:1094-1095
Full Text | Web of Science | Medline
To the Editor:
McKenna and associates (April 20 issue),1 in describing the epidemiology of tuberculosis in foreign-born persons in the United States, make clear the obvious: tuberculosis is not contained by national boundaries.
Several categories of factors have been cited as fostering the emergence of “new” infectious diseases and contributing to the global spread of tuberculosis.2 These factors include shifts in populations, international travel, microbial adaptation (drug resistance), and commercial, technological, and industrial interactions among countries. The effect of these factors would have been minimal if effective programs were in place for the detection and treatment of patients with tuberculosis. However, because of deficiencies in public health programs and infrastructure, the effects of demographic and sociological phenomena have been magnified. These phenomena, combined with the natural history of tuberculosis, make the use of screening of new arrivals to the United States problematic as a means of reducing the incidence of tuberculosis. Such screening, as suggested by Iseman and Starke, would have a minimal effect unless much more restrictive and probably unacceptable travel and immigration policies were adopted as well.
What is required to bring about effective tuberculosis control for foreign-born persons in the United States is an effective, coordinated global tuberculosis program focusing on case detection and treatment to cure. The World Health Organization is the logical home for a coordinated strategy. However, substantially more than the $6.9 million budgeted for the Tuberculosis Programme for 1995 will be necessary to implement intensified control activities. To increase the budget it will be necessary to increase internal support from the World Health Organization and the World Health Assembly, as well as to attract funds from donor countries, such as the United States.
The other organization that has provided leadership for international tuberculosis control is the International Union against Tuberculosis and Lung Disease. Model tuberculosis programs developed by this organization have demonstrated that tuberculosis control can be applied cost effectively in very poor countries.3 The organization is in an excellent position to work collaboratively with the World Health Organization in coordinating a global tuberculosis-control strategy.
On the basis of data shown in the paper by McKenna and coworkers, the interests of the United States could be served by providing aid through the World Health Organization or the International Union against Tuberculosis and Lung Disease to tuberculosis programs in Mexico, the Philippines, Vietnam, China, and South Korea. If properly directed and coordinated, such enlightened self-interest could result in an important reduction in the incidence of tuberculosis in the United States.
3 ReferencesPhilip C. Hopewell, M.D.
San Francisco General Hospital, San Francisco, CA 941101
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
Full Text | Web of Science | Medline2
Morse SS . Factors in the emergence of infectious diseases. Emerg Infect Dis 1995;1:7-15
CrossRef | Web of Science | Medline3
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 | Medline
Author/Editor Response
The authors reply:
To the Editor: We appreciate and agree with most of Dr. Hopewell's comments about our report. However, the assumption by Dr. Hopewell that screening new arrivals will have minimal effect on reducing the incidence of tuberculosis in this country is unproved. As noted in our paper, almost 30 percent of foreign-born patients with tuberculosis have their disease diagnosed within one year after their entry into the United States. A recent evaluation of tuberculosis in immigrants in Hawaii demonstrated that 74 percent of the patients receiving that diagnosis within one year of arrival had chest radiographs consistent with active or inactive tuberculosis during their overseas physical examination. Yet they were allowed to immigrate because their sputum smears were negative (Zuber P, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention: personal communication). These data suggest that improvements in the current health screening and follow-up requirements for immigrants and refugees, including the use of preventive therapy in high-risk persons, could reduce the incidence of tuberculosis in the United States. The Centers for Disease Control and Prevention have completed an evaluation of the current screening and follow-up process for immigrants. This evaluation has resulted in a number of recommendations, which include refining the screening process, improving supervision and technical support for overseas practitioners who conduct the screening in countries with high rates of tuberculosis, and reinforcing and streamlining communication between federal, state, and local health agencies regarding immigrants to improve follow-up of suspected cases identified overseas.
Despite our differing perspectives on the potential value of an improved process for immigrant health assessment, we are in complete agreement with Dr. Hopewell that a coordinated global program of tuberculosis control is needed. In a shrinking world of increasingly mobile populations, we concur with Enarson that the strategy of tuberculosis elimination in the United States without increased attention to the global situation is nothing more than a fantasy.1 We also agree that increased financial resources are needed to support global tuberculosis-control efforts being coordinated by the World Health Organization and the International Union against Tuberculosis and Lung Disease. Indeed, we specifically stated in our report that future success in tuberculosis control in the United States will require coordination with other countries, especially those in Latin America and Southeast Asia, and with international organizations. Both technical and financial assistance from the United States will be required to ensure success.
1 ReferencesMatthew T. McKenna, M.D., M.P.H.
Eugene McCray, M.D.
Ida M. Onorato, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 303331
Enarson DA . Why not the elimination of tuberculosis? Mayo Clin Proc 1994;69:85-86
Web of Science | Medline
To the Editor:
Dr. Hopewell raises several vital issues concerning global tuberculosis control in relation to immigrants to the United States. He points out that the World Health Organization has allocated remarkably paltry resources to tuberculosis control and prevention, totally incongruous with the immense morbidity and mortality associated with this historic scourge. Analysis by the World Bank has shown that effective tuberculosis-treatment programs are among the most cost-effective public health programs in developing nations.1 Yet the budgetary commitment of the World Health Organization to tuberculosis remains low, even allowing for current fiscal constraints. Certainly, the self-interest of the United States could be responsibly served by supporting improved programming in regions whose emigrants have proved to be at high risk for tuberculosis. Notably, 80 percent of the cases among foreign-born persons in the report of the Centers for Disease Control and Prevention came from seven countries2; efforts directed to these nations would appear appropriate as a beginning.
Dr. Alboukrek describes a very pessimistic picture for health screening abroad. However, we disagree with his proposal in several respects. Although it is surely difficult with old systems to ensure high-quality services and to avert fraud, we submit that emerging high technology and information transfer allow us to improve this process substantially. Given the recent confusion and fear regarding travelers from Zaire during the outbreak of the Ebola virus, the need for prompt — if not “real time” — medical liaison between national public health authorities and foreign consulates, embassies, and airports is apparent. If reliable, good-quality radiologic services cannot be obtained locally, high-resolution radiographic images can be transferred by satellite technology used previously for surveillance from space. If such studies suggest active tuberculosis, immigration should be delayed until two or three sputum specimens, collected under monitored circumstances, are found to be negative on both smear and culture. We think it highly problematic to allow persons to come to the United States as “conditional” immigrants to undergo screening or to have treatment completed. Dr. Alboukrek suggests that these immigrants should pay for their evaluation and treatment, but this is not concordant with current public health policy in much of the United States, wherein tuberculosis care is provided free through public support. Also, this practice would result in increased numbers of persons with active pulmonary tuberculosis exposing fellow passengers on long, transoceanic flights.
René and Jean Dubos in their 1952 treatise on tuberculosis, The White Plague, commented that this disease is “the consequence of gross defects in social organization, and of errors in individual behavior.” 3 The words ring sadly true four decades later.
3 ReferencesMichael D. Iseman, M.D.
University of Colorado School of Medicine, Denver, CO 80262Jeffrey R. Starke, M.D.
Baylor University College of Medicine, Houston, TX 770301
Murray CJ ,Styblo K ,Rouillon A . Tuberculosis in developing countries: burden, intervention and cost. Bull Int Union Tuberc 1990;65:6-242
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
Full Text | Web of Science | Medline3
Dubos R, Dubos J. The white plague: tuberculosis, man and society. New Brunswick and London: Rutgers University Press, 1952.
