Manual of Travel Medicine and Health

Manual of Travel Medicine and Healt

Estimating the Impact of Newly Arrived Foreign-Born Persons on Tuberculosis in the United States

Background: Among approximately 163.5 million foreign-born persons admitted to the United States annually, only 500,000 immigrants and refugees are required to undergo overseas tuberculosis (TB) screening. It is unclear what extent of the unscreened nonimmigrant visitors contributes to the burden of foreign-born TB in the United States. Methodology/Principal Findings: We defined foreign-born persons within 1 year after arrival in the United States as ‘‘newly arrived’’, and utilized data from U.S. Department of Homeland Security, U.S. Centers for Disease Control and Prevention, and World Health Organization to estimate the incidence of TB among newly arrived foreign-born persons in the United States. During 2001 through 2008, 11,500 TB incident cases, including 291 multidrug-resistant TB incident cases, were estimated to occur among 20,989,738 person-years for the 1,479,542,654 newly arrived foreign-born persons in the United States. Of the 11,500 estimated TB incident cases, 41.6 % (4,783) occurred among immigrants and refugees, 36.6 % (4,211) among students/ exchange visitors and temporary workers, 13.8 % (1,589) among tourists and business travelers, and 7.3 % (834) among Canadian and Mexican nonimmigrant visitors without an I-94 form (e.g., arrival-departure record). The top 3 newly arrived foreign-born populations with the largest estimated TB incident cases per 100,000 admissions were immigrants and refugees from high-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of $100 cases/100,000 population/ year; 235.8 cases/100,000 admissions, 95 % confidence interval [CI], 228.3 to 243.3), students/exchange visitors an

Immigrant Arrival and Tuberculosis among Large Immigrant- and Refugee-Receiving Countries, 2005–2009

Objective. Tuberculosis control in foreign-born populations is a major public health concern for Australia, Canada, New Zealand, United Kingdom, and the United States, large immigrant- and refugee-receiving countries that comprise the Immigration and Refugee Health Working Group (IRHWG). Identifying and comparing immigration and distribution of foreign-born tuberculosis cases are important for developing targeted and collaborative interventions. Methods. Data stratified by year and country of birth from 2005 to 2009 were received from these five countries. Immigration totals, tuberculosis case totals, and multidrug-resistant tuberculosis (MDR TB) case totals from source countries were analyzed and compared to reveal similarities and differences for each member of the group. Results. Between 2005 and 2009, there were a combined 31,785,002 arrivals, 77,905 tuberculosis cases, and 888 MDR TB cases notified at the federal level in the IRHWG countries. India, China, Vietnam, and the Philippines accounted for 41.4% of the total foreign-born tuberculosis cases and 42.7% of the foreign-born MDR tuberculosis cases to IRHWG. Interpretation. Collaborative efforts across a small number of countries have the potential to yield sizeable gains in tuberculosis control for these large immigrant- and refugee-receiving countries

Optimizing Severe Acute Respiratory Syndrome Response Strategies: Lessons Learned From Quarantine

Taiwan used quarantine as 1 of numerous interventions implemented to control the outbreak of severe acute respiratory syndrome in 2003. From March 18 to July 31, 2003, 147 526 persons were placed under quarantine. Quarantining only persons with known exposure to people infected with severe acute respiratory syndrome could have reduced the number of persons quarantined by approximately 64%. Focusing quarantine efforts on persons with known or suspected exposure can greatly decrease the number of persons placed under quarantine, without substantially compromising its yield and effectiveness

Cost-Effectiveness of Screening and Treating Foreign-Born Students for Tuberculosis before Entering the United States

<div><p>Introduction</p><p>The Centers for Disease Control and Prevention is considering implementation of overseas medical screening of student-visa applicants to reduce the numbers of active tuberculosis cases entering the United States.</p><p>Objective</p><p>To evaluate the costs, cases averted, and cost-effectiveness of screening for, and treating, tuberculosis in United States-bound students from countries with varying tuberculosis prevalence.</p><p>Methods</p><p>Costs and benefits were evaluated from two perspectives, combined and United States only. The combined perspective totaled overseas and United States costs and benefits from a societal perspective. The United States only perspective was a domestic measure of costs and benefits. A decision tree was developed to determine the cost-effectiveness of tuberculosis screening and treatment from the combined perspective.</p><p>Results</p><p>From the United States only perspective, overseas screening programs of Chinese and Indian students would prevent the importation of 157 tuberculosis cases annually, and result in $2.7 million in savings. From the combined perspective, screening programs for Chinese students would cost more than$2.8 million annually and screening programs for Indian students nearly $440,000 annually. From the combined perspective, the incremental cost for each tuberculosis case averted by screening Chinese and Indian students was$22,187 and $15,063, respectively. Implementing screening programs for German students would prevent no cases in most years, and would result in increased costs both overseas and in the United States. The domestic costs would occur because public health departments would need to follow up on students identified overseas as having an elevated risk of tuberculosis.</p><p>Conclusions</p><p>Tuberculosis screening and treatment programs for students seeking long term visas to attend United States schools would reduce the number of tuberculosis cases imported. Implementing screening in high-incidence countries could save the United States millions of dollars annually; however there would be increased costs incurred overseas for students and their families.</p></div

Cost per Case Averted from Being Imported into the U.S. when Comparing Two Programs for Treating TB in Foreign-Born Student-Visa Applicants.

<p>TB = Tuberculosis; U.S. = United States</p><p>A- Derived by dividing the additional costs with overseas screening by the cases prevented from being imported into the United States;</p><p>B-Includes costs for treating imported TB cases in the U.S. with no overseas screening;</p><p>C-Includes overseas costs incurred while screening for and treating TB overseas, screening high risk students in the U.S., and treatment of active TB cases occurring in the U.S. after implementing overseas screening and treatment</p><p>Cost per Case Averted from Being Imported into the U.S. when Comparing Two Programs for Treating TB in Foreign-Born Student-Visa Applicants.</p

Cases of TB Diagnosed among Foreign-Born Student-Visa Applicants.

<p>U.S. = United States; TB = Tuberculosis</p><p>A-Class B-1 indicates those who have an abnormal chest radiograph, signs and symptoms of TB, or known HIV infection during overseas screening;</p><p>B-All cases assumed to be imported into U.S. in absence of screening</p><p>Cases of TB Diagnosed among Foreign-Born Student-Visa Applicants.</p

Overseas Parameters in Cost-Effectiveness Model Comparing Programs for Screening and Treating TB in Foreign-Born Student Visa-Applicants.

<p>NA = Not applicable because no cases were detected in German students; TB = Tuberculosis</p><p>A-Suspected TB includes those with abnormal chest radiograph, signs and symptoms of TB, or known HIV infection, and these persons undergo three sputum smears and cultures;</p><p>B-Reflects the proportion seen in the low incidence countries of France and Canada;</p><p>C-Calculated by multiplying number in cohort times % suspected TB times % active disease among those with suspected TB;</p><p>D-Based upon data submitted by panel physicians in China;</p><p>E-Initial TB screening consists of chest radiograph and part of physical examination;</p><p>F-costs not available for German students because the modeled results indicate that no cases would be detected in German students</p><p>Overseas Parameters in Cost-Effectiveness Model Comparing Programs for Screening and Treating TB in Foreign-Born Student Visa-Applicants.</p

Estimates of incident cases of TB and MDR-TB among newly arrived immigrants and refugees in the United States, 2001–2008.^*

<p>*Newly arrived immigrants and refugees are those who have resided in the United States for up to 1 year after their arrival.</p>†<p>The number of person-years is the same as the number of admissions, since immigrants and refugees are assumed to stay in the United States for at least 1 year after their arrival.</p>‡<p>See the <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032158#s2" target="_blank">Methods</a> Section for details of the estimations.</p>§<p>Values are World Health Organization estimates for 2008.</p>¶<p>Countries are listed in descending order, according to the estimated number of TB incident cases. Country of citizenship is assumed to be the same as country of birth for immigrants and refugees.</p>#<p>The values for China include those for Hong Kong, Macau, and Taiwan.</p