TB Intensive Minneapolis, Minnesota September 23-26, 2008 TB in the Foreign-Born Population: Background and Demographic Overview Marge Higgins, LSW September 24, 2008 TB in the Foreign-Born Population Background and Demographic Overview Marge Higgins, L.S.W. MDH TB Program, Refugee & Immigrant Coordinator 1
Dept. of Homeland Security Definitions U.S.A. U.S. Citizen Non-Citizen (Foreign-born) Immigrant* Non-Immigrant LPR LTR authorized employment undocumented individual student visitor on business tourist Persons fleeing from persecution refugee asylee parolee Refugee Health Program, Minnesota Department of Health *Immigrants have O/S exam (Non-Immigrants do not) Overseas TB Screening Medical History Physical Examination TST (for ages 2-14) CXR (for ages >15 and those younger with + TST) Sputum smears & cultures for those with abnormal CXR Drug susceptibility testing on positive cultures Treatment for active disease 2
Overseas Exam TB Classifications Class A TB disease and a waiver to travel Class B1 exam, history or CXR evidence of active pulmonary TB but negative AFB sputum smears and cultures or persons who have completed treatment for TB disease or persons with extrapulmonary TB Class B2 LTBI Class B3 TB Contact Note: Applicants may have more than one TB class designation. Technical Instructions for Overseas Screening are on the DGMQ website: http://www.cdc.gov/ncidod/dq Tuberculosis screening medical examination for applicants in countries with a WHO-estimated tuberculosis incidence rate <20 cases per 100,000 population. 3
Countries using the 2007 TIs Botswana Kenya (Ethiopians, Somalis, and Sudanese)* Lesotho Mexico* Mozambique Namibia Nepal (Bhutanese) Philippines* *Overseas screening sites South Africa for most MN arrivals Swaziland Tanzania (Burundian) Thailand (Burmese and Hmong refugees)* Turkey Vietnam* Estimated TB incidence rate, 2006 Estimated new TB cases (all forms) per 100 000 population No estimate 0-24 25-49 50-99 100-299 300 or more 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 2006. All rights reserved 4
Well it all depends. Where are these huddled masses coming from? 8000 7000 Primary* Refugee Arrivals to MN by Region of World 1979-2007 6000 5000 4000 3000 2000 1000 0 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Number of arrivals 2006 2007 Southeast Asia Sub-Saharan Africa Eastern Europe FSU Other Refugee Health Program, Minnesota Minnesota Department Department of Health of Health *First resettled in Minnesota 5
TB Infection* Rate Among Refugees By Region Of Origin, Minnesota, 2007 N=2,643 screened Overall TB Infection Rate 45% 1,176/2,643 Sub-Saharan Africa 50% 902/1,815 SE/East Asia 34% 230/670 Europe 29% 44/150 0% 10% 20% 30% 40% 50% 60% *Diagnosis of Latent TB infection or Suspect/Active TB disease Refugee Health Program, Minnesota Department of Health Medical Examinations Think TB! Overseas Visa TB Class Follow-up Domestic Refugee Health Assessment Adjustment of Status Health Exam by Primary Care Provider 6
Tuberculosis Cases by Method of Case Identification, Minnesota, 2003-2007 TB Contact Investigation (6%) Refugee Health Exam (5%) TB Class Exam Follow-up (2%) Presented with Symptoms (82%) Other (5%) (N = 1,067) Goals of TB Screening in Foreign Born Persons: Find and treat persons with active TB Find and treat persons with latent TB infection 7
TB in the Foreign-Born Population: Assessment of Newcomers Neal Holtan, M.D., M.P.H. Medical Director St. Paul Ramsey County Department of Public Health Screening Newcomers for TB Similar Approach for All Refugees Immigrants Adjustment of Status Non-immigrants 8
Class A and Class B Tuberculosis Class A Pulmonary TB (smear or culture positive) Completion of therapy abroad before medical clearance to travel Records of treatment are contained in CIS papers that are carried by refugees (and rarely, immigrants) If a change in immigration status is sought by persons already in US, treatment for active tuberculosis must be fully completed before application is submitted 9
New Technical Instructions for Civil Surgeons Effective May 1, 2008 Also followed abroad by CIS for refugees In US, the process is mandated by the Immigrant, Refugee, and Migrant Health Branch, Division of Global Migration and Quarantine, CDC Process applies to Adjustment of Status Examinations by Civil Surgeons Highlights of New Technical Instructions Sputum cultures for M. TB and susceptibility testing on positive cultures are required for applicants with CXR suggestive of active TB disease Applicants with Class A TB (smear or culture positive) must complete full course of treatment before clearance for travel 10
More Highlights CXR required for TST reaction of 5 mm or greater (including pregnant women) CXR now required for TST less than 5 mm (including zero) if signs/symptoms of TB or immunosuppressed individual Definitions of CXR findings suggestive of active TB are provided in the instructions TB (Class A and Class B) categories and subcategories have been changed Basic Evaluation of Class B TB Refugees Confirm with the patient any history of testing and/or treatment of TB abroad Do a review of symptoms and signs of TB 11
B Class Refugees Need Clinical Evaluations for: completeness of past treatment (if any) plausibility of prior diagnosis and treatment verification by patient of treatment (if received) efficacy of treatment (if received) Repeat the PPD in the clinic because: Skin tests can be inconsistently done and read abroad Person may have converted the PPD to positive in the interim Past false negatives from stress, poor nutrition, other illnesses and causes can occur 12
Administer TST All entrants or applicants 2 year of age and up required TST Under 2 year if contact with known case If reaction greater or equal to 5 mm, CXR required Role of QuantiFERON in TB Testing Under investigation at present Used for screening adult refugees at SPRCDPH Meets CDC Guidelines for use of QuantiFERON but not guidelines for adjustment of status 13
History of BCG CDC guidelines are to ignore Patients raise the issue of prior BCG as cause of their positive skin test Use size of PPD reaction and remoteness from BCG as discussion points with patients Advantage of using QuantiFERON Nearly all Class B refugees need a new CXR to compare with the old one. 14
Sputum smears and cultures should be done if indicated. Symptoms of TB Certain abnormalities on chest radiograph Class B1 Pulmonary, Not Treated history, exam, or CXR suggest active TB but sputum smears and cultures are negative 15
Class B1 Pulmonary TB, Treated should have culture and sensitivity results before and after treatment, CXR reports, and documentation of treatment Class B1 Extra-pulmonary treated or untreated, site of infection or suspected infection should be noted 16
Class B2 Latent TB Infection TST = or > 10 mm, CXR normal or stable Class B3 Contact Investigation TST should have been done, case contact information should be recorded, MDRTB cases signified Reaction of 5 mm or more on TST is positive 17
It is important to treat untreated latent TB infections (as originally defined or those who move into that category after further evaluation). Special Considerations in Treating Refugees and Immigrants for Latent TB Extrapulmonary disease Drug resistance Common medical problems of refugees Medical conditions pertinent to treating Latent TB 18
Extrapulmonary Disease Approaches half of TB cases in foreignborn Wide range of sites Lack of awareness among some medical providers Difficulty of establishing diagnosis Cost of diagnostic procedures Drug Resistance High in some source countries Known contacts of MDRTB cases 19
Common Medical Problems of Refugees Hypertension Diabetes Post-traumatic stress disorder Depression Intestinal parasites Medical Conditions Pertinent to Treating Latent TB Hepatitis B carrier state or chronic active hepatitis Hepatitis C Alcoholism 20
More Special Considerations in Treating Latent TB Patient education Acceptance of therapy for active or latent TB Preparation of patient for acceptance of regimen Positive attitude toward treatment on part of provider Questions or Comments? 21