Principal Investigator(s): Amy L. Davidow, PhD1;
Randall Reves, MD2; Dolly Katz, PhD 3
Project Dates: April 2005 - June 2007
Project Overview: In the past decade, tuberculosis (TB) in North
America has increasingly become a disease of persons born outside the U.S. and Canada.
In 2002, for the first time, TB cases among foreign born persons accounted for the
majority (51%) of cases in the United States, whereas in Canada, they have accounted
for the majority of cases since 1990. To better understand and reduce the incidence
of TB in the foreign born, the goal of the U.S. and Canada is to increase the yield
from three basic TB control activities: detecting and treating persons with active
TB to prevent further transmission; conducting contact investigations to identify
and treat contacts with latent TB infection (LTBI) or active TB disease; and,
conducting targeted testing and treatment for LTBI to prevent future TB cases among
high-risk populations. These activities have to be tailored to the special
circumstances of the foreign born, which may involve factors such as visa status,
drug resistance, social and economic hardships, linguistic barriers, and cultural
beliefs that deter diagnosis and interfere with adherence to therapy and cooperation
with contact investigations. Current national surveillance data for the U.S. and
Canada demonstrate the trend towards increasing TB morbidity among the foreign born.
These data lack the level of detail needed to identify the proportion of TB cases
that could have been prevented by improvements in each of the three basic TB control
activities. This cross-sectional, epidemiologic study of TB in the foreign born in
the United States and Canada has been developed to identify interventions that can
improve each of the three basic TB control activities and inform public health
efforts to eliminate TB among foreign born persons in the U.S. and Canada.
Objectives: The objectives of this study are to: 1) describe the
epidemiology of TB in foreign born persons in the United States and Canada; 2)
identify missed opportunities to prevent development and transmission of TB in
foreign born persons, and; 3) make recommendations for program changes at the
national, state/provincial, and local levels.
Target Audience: Local and state TB controllers; TB case managers;
primary care physicians; emergency room physicians; pharmacists; physician
assistants; nurse practitioners; institutions that could screen persons for LTBI;
members and participants of the Advisory Council for the Elimination of Tuberculosis;
members and participants of the Federal Tuberculosis Task Force; members and
participants of the National TB Controllers Association; national and local community
groups that represent foreign born persons
Methods: This study will conduct face-to-face interviews with a
random sample of approximately 1,500 foreign born persons, diagnosed with active TB
disease, between 2005-2006, and residing within any of the Tuberculosis Epidemiologic
Studies Consortium (TBESC) site jurisdictions. Epidemiologic data will be collected
to describe the steps leading to diagnosis (through screening for disease or due to
symptomatic disease), factors associated with disease onset, diagnosis and initiation
of treatment based upon timing (since arrival into the U.S. or Canada), immigration
status, country of origin, migration (within the U.S. or Canada), access/barriers to
care (including insurance coverage and cultural barriers), and treatment outcomes.
It is hypothesized that this information will shed light on missed opportunities for
prevention. Additional information will be collected from health department records,
national surveillance databases, and record linkages with CDC's Division of Global
Migration and Quarantine. Data obtained from case interviews will provide unique
epidemiologic information collected consistently from site to site. Data entry will
be done using a secure, web-based data entry system that serves several studies
developed by TBESC.
Dolly Katz, Ph.D.
Division of Tuberculosis Elimination
Centers for Disease Control and Prevention
1600 Clifton Road NE
Atlanta, Georgia 30333
Publications: Katz D, Albalak R, Wing J, Combs J. Setting the
Agenda: A new model for collaborative tuberculosis epidemiologic research.
Tuberculosis: In press
1 University of Medicine and Dentistry, New Jersey, Newark, New Jersey
2 Denver Public Health and Hospitals Authority, Denver, Colorado
3 Division of Tuberculosis Elimination, Centers for Disease Control and
Prevention, Atlanta, Georgia