CDC History of Tuberculosis Control - Medical and Public Health ...

efugee is informed of the need to be further
evaluated for their TB and to report to the
local health department as soon as possible
after arrival. Persons with Class A TB are
required to report to the local health
department, present all medical records and
chest x-rays from overseas, and submit to the
necessary testing, isolation, and treatment
until discharged. They risk deportation
should they fail to do so. For persons having
Class B1 or B2 TB, the health department visit
is considered voluntary.
Many health departments in the United States
perform active follow-up of arrivals designated
as having Class B1 or B2 TB, on the basis of
the DQ notification. Studies conducted in the
mid-1990s by the Division of TB Elimination,
DQ, and health departments in various parts
of the country have shown from 3% to 14% of
Class B1 immigrants and refugees were
diagnosed with TB disease within one year of
their arrival; between 0.4% to 4.0% of those
with Class B2 TB were diagnosed with TB
disease within one year of arrival. Of the
remaining persons, many are high-priority
candidates for preventive therapy regardless of
their age because they are tuberculin skin test
positive with an abnormal chest x-ray
suggestive of TB disease.
The current overseas TB evaluation
procedures described above are based upon the
following three principles: 1) the requirements
apply specifically to immigrants and refugees,
as they are most likely to become permanent
US residents; 2) the procedures reduce the
importation of active infectious TB that poses
an immediate public health risk by denying
admission to persons who have positive
sputum smears; and 3) they allow those
persons with evidence of TB disease but whose
smears are negative to enter the United States,
where a more complete medical evaluation can
be performed and appropriate treatment can
be provided under supervision. Forcing
immigrants and refugees with noninfectious
TB to undergo treatment overseas could prove
TB Control at the Millennium
70
to be counter-productive, as it may be difficult
to ensure that the drug regimens are adequate,
and that applicants are regularly ingesting the
required medications. In such a scenario,
incomplete treatment as well as development
of drug resistance may be the result.
The overseas screening process for identifying
and treating TB in immigrants and refugees is
responsible for the identification of substantial
numbers of persons arriving in the United
States who have active TB. However, not all
cases in newly arrived immigrants or refugees
were identified overseas as having suspect TB,
which is in part due to several limitations of
the screening process. Although panel
physicians do function under a contractual
agreement with their respective US consulates,
they receive no formal training or certification
per se. In 1997, a training needs assessment was
performed on a sample of panel physicians in a
study undertaken by the Division of TB
Elimination and DQ. The assessment
indicated that, although 98% of panel
physicians in the sample understood which
immigrants and refugees should receive a chest
x-ray, over 60% indicated a need for training.
Presently, efforts are underway to develop selfstudy
training materials for panel physicians to
enhance their ability to diagnose and treat TB,
and to improve their ability to monitor the
performance of contracted laboratory and
radiologic services. A training plan will be
developed, and self-study materials will be
pilot-tested later this year in countries with
large numbers of persons who immigrate to
the United States and have a high TB
prevalence.
The STOP TB Initiative,
A Global Partnership
by Bess Miller, MD, MSc
Associate Director for Science, DTBE
Over the past few decades, when we have
looked at the agendas of international health