Project Title: Enhanced Surveillance to Identify Missed Opportunities for Prevention of Tuberculosis in the Foreign-Born

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.

Contact Information:
Dolly Katz, Ph.D.
Division of Tuberculosis Elimination
Centers for Disease Control and Prevention
MS E-10
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

Relative Content:

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