ACET pushes feds to reform immigration policy
Rate increase is linked to poor screening
Concerned that TB cases in the United States among foreign born persons have increased dramatically in the past ten years, the Advisory Council for the Elimination of TB (ACET) has recommended that the U.S. Public Health Service adopt six recommendations, including changes in TB screening of immigrants and adoption of fees on immigration and visa applications.
ACET, which advises the Centers for Disease Control and Prevention on TB issues, drafted the recommendations in a letter to Secretary of Health Donna Shalala at its last meeting five months ago. The letter notes that from 1986 to 1994, the number of TB cases in the United States rose 55% among the foreign born, while the proportion of total U.S. cases among the foreign born rose from 22% to 33%. Although overall TB cases have declined in the past three years, they have increased among this population, ACET notes.
The extent of the TB problem in this country among foreign-born Hispanic patients was recently analyzed by the CDC and published in its Morbidity and Mortality Weekly Report.1 In 1995, 22% of all foreign-born TB patients in the United States were born in Mexico; these patients had 1.6 to 3.2 times higher prevalence of drug-resistant TB.
An estimated 240,000 immigrants and refugees entering the United States each year are infected with TB. And yet there is no pre-entry program that screens for dormant TB infection, ACET notes.
"Because specific federal funds exist for refugee resettlement and health programs, most health departments have been able to structure domestic TB screening and preventive programs for refugee entrants," the letter states. "However, for the larger pool of non-refugee immigrants, there are no specific funds for preventive services, nor is there a system to inform health departments about the general arrival of immigrants from high TB prevalent countries."
Burden falls on local agencies
As an example of the inadequacy of immigration screening policies, ACET described how Filipino veterans of World War II were allowed to enter the United States without TB screening, despite evidence of high rates of disease in this population. By 1992, as many as 25% of 524 cases reported in Hawaii were reported in Filipino veterans. With no federal resources to locate and screen these veterans, the burden fell to local health departments to identify and treat the scores of cases that surfaced across the United States, the letter states.
ACET also notes that current TB screening policies don’t apply to students, people seeking asylum, and permitted workers coming to the country. Moreover, screening requirements for those seeking U.S. residency status are poorly enforced.
With more than 18,000 people suspected of having TB admitted to the United State each year, ACET contends that federal funding for screening is inadequate, and state and local health departments are not providing money for tracking those immigrants. Based on a study of foreign born TB patients in Los Angeles, ACET estimates that 150 to 200 people with active TB enter the country each year without receiving appropriate medical attention.
ACET also notes that Mexico, the Philippines, and Vietnam accounted for 50% of foreign born TB cases in the United States in 1994. And yet there are few federally funded TB assistance projects in these countries.
To address these concerns, ACET recommended that the Public Health Service take the following steps:
• Develop a federal initiative to improve the tracking process of arriving "active TB suspects," and allocate resources for local jurisdictions that provide services to these entrants.
• Establish a fund for TB prevention services by placing a fee on immigration and visa applications. The funds would be distributed to state and local TB programs based on need.
• Provide state and local TB programs with adequate representation in meetings among the CDC’s Division of TB Elimination and Quarantine, the Department of State, and the Immigration and Naturalization Service to ensure that these agencies are responsive to priorities and realities of local TB programs.
• Develop effective TB control assistance in those high prevalence countries with a large immigrant population.
• Collect data on the rates of TB among legal entrants by category of entry.
Reference
1. Centers for Disease Control and Prevention. Characteristics of foreign-born hispanic patients with tuberculosis eight U.S. counties bordering Mexico. MMWR, 1996; 45:1,032-1,036.
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