Evaluating Immigrants and Refugees
with Class B1 or B2 Tuberculosis
Thomas Herchline, MD
Medical Director, Public Health-Dayton & Montgomery Co
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Disclosures
• None
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Objectives
• Understand the strengths and weaknesses of
the available methods for screening for
tuberculosis in immigrants and refugees
• Recognize the epidemiology of tuberculosis
among immigrants to the US
• Review problems with drug resistance
around the world
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Tuberculosis Among US-born and ForeignBorn Persons
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Tuberculosis Among US-born and ForeignBorn Persons
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Case
• 30 yo woman from SE Asia
• In US on Immigrant visa
• Reported no symptoms
• PPD 15 mm
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AL
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Case
• AFB sputum culture grew M. tuberculosis
• Isolate INH-resistant
• Completed 6 month course of treatment
• No documented secondary cases
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Who is an Immigrant?
• An alien who has been granted the right by the
USCIS to reside permanently in the United
States and to work without restrictions in the
United States
• Includes voluntary migration for economic,
political, religious and/or social reasons
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Admissions to U.S., 2013
(Total ~ 174 million)
• Immigrants
• Refugees/Asylees
990,553
95,108
• I-94 Nonimmigrants
61,052,260
• Tourist
48,346,018
• Business
6,299,533
• Temp Worker/Family
2,996,743
• Student
1,669,225
• Exchange (J1/J2)
492,937
• In transit (just passing through) 628,711
http://www.dhs.gov/yearbook-immigration-statistics
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Source: Ohio Latino Affairs Commission, 2010
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Refugee
• Suffered past persecution, or reasonable fear of
future persecution
• Pass medical and security criteria
• Sponsor assurance
• After 1 yr, may apply for permanent resident
status
• After 5 yrs, may apply for citizenship
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Refugee Resettlement (Ohio)
Year
1983-98
1999
2001
2003
2005
2007
2010
2012
Total
22,559
1,484
1,364
656
1,549
1,581
1,987
2,301
Top Country
Russia*
Yugoslavia*
Yugoslavia
Ukraine
Somolia*
Somolia*
Bhutan
Bhutan*
Second
Vietnam
Russia
Russia
Serbia
Liberia
Burma
Iraq
Iraq
* Over 50% of resettlements in year
Ohio Dept of Jobs & Family Services, Refugee Services
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Screening for Tuberculosis
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Overseas Screening for TB
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TB Classification
Class
A
B1-Pulm
B1-EP
B2
1991
2007
Abnl CXR, +smear
Active TB
Active TB,
Abnl CXR,
not infectious
neg culture
N/A
Extra-pulm TB
TB, not
Latent TBI
clinically active
B3
CXR c/w “old TB”
TB Contact
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TB Screening
Category
1991
2007
Valid (nl/B2)
12 months
6 months
Valid (A/B1)
6 months
3 months
TST
Not used
Ages 2-14*
Smears (B1)
Sm/Cx/DST
Monitoring†
None
Monthly Cx
Contacts
None
TST (B3)
Sputums
* In countries with incidence > 20/100,000
†
During treatment for active tuberculosis
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Tuberculosis Worksheet
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Class B Follow-up
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Follow-up Instructions
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Performance of Overseas TB Screening
Program (Vietnam, 2006-07)
• 14,098 applicants
• 1179 CXR c/w active TB
• 188 culture positive
Smear
Culture
Neg
Pos
Neg
977
19
Pos
120
66
Screening with Smear:
Sens = 34% Spec = 98%
PPV = 77% NPV = 89%
Maloney, et al. Arch Intern Med 2006
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Role of Civil Surgeon
(Adjustment of Status)
• Conduct medical evaluation
• Class A diseases
• Class B diseases
• Ensure immunizations up-to-date
• Obtain consultation as necessary
• Complete I-693
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I-693 Page 5
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I-693 Page
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Foreign-born Persons Reported with TB
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Percent of Foreign-born with TB by Time of
Residence in US Prior to Diagnosis, 2003
100%
80%
60%
40%
20%
0%
Mexico
Philippines
<1 yr
Viet Nam
1- 4 yrs
All
>5 yrs
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Challenges to Screening
• Language Barriers
• Bilingual literature, interpreters
• Trust and Cultural Beliefs
• Word of mouth, education, informal
community leaders
• TB skin testing
• Requires 2 visits – incentives?
• Alternative - IGRA
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False-Positive TST Reactions
• Improper placement/interpretation
• Nontuberculous mycobacteria
• BCG vaccination
• Reactivity in BCG recipients decreases
over time
• TST result interpreted independent of
BCG status
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False-Negative TST Reactions
• Anergy
• Recent TB infection (< 10 weeks after
exposure)
• Very young age
• Live-virus vaccination (MMR, VZV)
• Overwhelming TB disease
• Improper placement/interpretation
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Interferon-gamma Release Assay
• QuantiFERON®-Gold
• FDA approved May 2, 2005
• Antigens: ESAT-6, CFP-10, mitogen, nil
• QuantiFERON® Gold-In-Tube
• FDA approved Oct 12, 2007
• Antigens: ESAT-6, CFP-10, TB7.7, mitogen, nil
• T-SPOT ®.TB
• Approved for use in U.S. 2008
• Elispot technique to quantitate cells releasing IFN-γ from whole
blood mononuclear cells, incubated with similar antigens
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Interferon-gamma Release Assays
• Results comparable to TST
• Higher sensitivity for active TB
• Higher specificity (BCG)
• Higher cost
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Summary
• TB remains an important global problem
• Foreign-born US cases now exceeds USborn cases
• Limitations on available screening methods
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An overseas medical evaluation with no
Class A or B conditions is valid for:
25% 25% 25% 25%
A. 3 months
B. 6 months
C. 12 months
ly
ef
in
ite
In
d
th
s
m
on
12
on
th
s
m
6
3
m
on
th
s
D. Indefinitely
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An immigrant presents for follow-up of Class B1 TB. The
overseas CXR is reported to show “RUL linear opacity”
(films not available for review). CXR done by you is
normal. The appropriate categories for reporting are:
25% 25% 25% 25%
bn
o
nk
)
(b
la
ow
n
rm
al
U
nk
n
Im
pr
ov
rm
al
bn
o
A
ow
n
(blank)
nk
n
D. Unknown
U
Improved
Im
pr
ov
C. Unknown
ow
n
Unknown
nk
n
B. Abnormal
U
Improved
ed
A. Abnormal
ed
US CXR compared to
Overseas CXR
A
US interpretation of
Overseas CXR
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