Foreign-born pulmonary tuberculosis in Washington State, 2009-2013: analysis of cases based on visa type and overseas screening status
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University of Washington Abstract Foreign-born pulmonary tuberculosis in Washington State, 2009-2013: analysis of cases based on visa type and overseas screening status Julie Tomaro Chair of the Supervisory Committee: Michael Kimerling, MD, MPH Tuberculosis (TB) disproportionately affects foreign-born persons in Washington State in the US overall. While foreign-born persons entering the US with a refugee or immigrant visa are screened for active TB disease overseas, nonimmigrant visa holder's such as those entering temporarily as students, employees or tourists do not require an overseas TB screening. Little is known about the burden of TB specifically in foreign-born persons not receiving an overseas TB screening. This retrospective cohort study is the first to analyze characteristics and risk factors associated with pulmonary TB in foreign-born persons diagnosed in Washington State who did not receive an overseas TB screening. Objective: This study sought to understand the burden of active TB disease among foreign-born persons in Washington State based on visa type and overseas screening status. It achieved this by determining the overseas TB screening status of TB cases among foreign-born individuals reported in Washington State, describing the characteristics of foreign-born cases of active TB reported in Washington State who did not receive a pre-travel overseas TB screening, and identifying opportunities for targeted interventions in the foreign-born population in Washington and the US that does not receive pre-travel overseas TB screening. Methods: The overall study cohort consisted of 592 foreign-born pulmonary TB cases diagnosed in Washington State between January 1st, 2009-December 31st, 2013. The cohort was then stratified based on overseas screening status (not screened, screened, or unknown). The sub-cohort of cases who were not screened was further stratified based on nonimmigrant visa type (student, tourist, employment, other immigration status). Descriptive and analytic analyses were performed in order to describe characteristics of the study cohort based on overseas screening status and nonimmigrant visa type. Results: Characteristics of TB among the overall study cohort include 90% being culture positive, 47% being sputum smear positive with 50% being linked to a genotyped cluster of cases, and 75% being sensitive to all TB medication. In terms of TB risk factors diabetes was found to be significantly more prevalent than other risk factors analyzed. When stratified by overseas screening status; 53% received an overseas TB screening, 22% did not have an overseas TB screening, and 25% had an unknown screening status. Significant differences were noted amongst the stratified groups for race/ethnicity, country of origin, mean age at arrival, and mean age at diagnosis. Stratification based on nonimmigrant visa type showed significant differences amongst the stratified groups for race/ethnicity, country of origin, mean age at arrival, and years between arrival and diagnosis. Conclusion: This study was able to describe the burden and characteristics of pulmonary TB disease among foreign-born persons in Washington State who did not receive overseas TB screening as well as among the entire cohort of foreign-born pulmonary TB cases. This study contributed to knowledge of the burden and characteristics of foreign-born pulmonary TB cases in Washington State, especially those without an overseas TB screening. This information helped identify opportunities for targeted interventions and policy changes to address TB in the Washington State foreign-born population. These interventions and policy change recommendations are targeted to national, state, and local government agencies as well as other stakeholder's. Interventions involving all of these levels will be needed to reach the goal of TB elimination.
- Health services