Epidemiology to Support a Proposed Policy of Latent Tuberculosis Testing and Treatment in Refugees Open Access

Abstract

Foreign-born persons have the highest rate of progression to active Tuberculosis (TB) within the first year of U.S. arrival ¹. Recent studies suggest that TB elimination goals in the U.S. (incidence of <1 case/million), will not be possible without targeting the foreign-born ². Amongst these, those especially vulnerable are refugees arriving from crowded refugee camps in countries with high TB prevalence and incidence rates, increasing the likelihood for latent Tuberculosis infection (LTBI) and progression to active TB. Currently, LTBI screening is not part of formal protocol for refugees. A cross-sectional analysis of these underserved populations was performed using pre-collected, de-identified data from the Georgia Department of Health and the Minnesota Department of Health (n = 14,141). Prevalence of LTBI in refugee populations by region of origin (Africa, Asia, Middle East, Eastern Europe, and Latin America) was determined by positive Tuberculin skin test (TST) results. Conditional logistic regression was performed conditioning on state (Minnesota and Georgia) with region of origin as the primary predictor of interest. Gender and age, as well as their interactions with region were considered as covariates. A separate analysis was performed with Georgia Department of Health data, since they provided additional health condition information. An unconditional logistic regression model was fit to determine which health indicators were associated with a positive TST. The unadjusted proportion of refugees arriving from African, Asian, Middle Eastern, Eastern European, and Latin American countries who had a positive TST upon screening in the United States was 53.6%, 35.5%, 23.7%, 42.1% and 20.8% respectively. The multivariate analysis showed that sex, age, region, and the interaction between age and region were significant predictors of a positive TST. In the Georgia data sub-analysis, it was observed that in addition to age, sex, and region, testing positive for hepatitis B surface antigen (HBsAg) and hepatitis B vaccination status were associated with a positive TST amongst refugees. Given the prevalence of LTBI in refugee populations and associated co-infections, we suggest screening and prophylactic treatment of LTBI prior to arrival in the United States.

Table of Contents

Table of Contents

Background ….. 1

Refugee Status and the Resettlement Process ….. 2

Tuberculosis Disease Process ….. 3

Tuberculosis Epidemiology in the United States ….. 5

Current United States Tuberculosis Screening Program for Refugees ….. 7

Trends in Refugee Follow-up ….. 8

Treatment Acceptance and Completion ….. 10

Further Challenges and Considerations for LTBI Treatment

and TB Prevention ….. 11

Epidemiologic Methods ….. 12

Results ….. 14

Multivariate Analysis Results ….. 16

Georgia Department of Health Data Sub-Analysis ….. 17

Discussion ….. 18

Comparative Findings ….. 18

Multivariate Analysis Discussion ….. 22

Latent Tuberculosis Prevalence and Public Health Planning ….. 23

Limitations ….. 24

Conclusions ….. 26

Tables ….. 28

Table 1: Distribution of Age, Gender, Region, and TST Status by State ….. 28

Table 2: Distribution of TST Status by Region, Mean Age, and Age Categories within Region ….. 29

Table 3a: Conditional Logistic Regression Model with Risk Factors for Latent Tuberculosis Infection Amongst Refugees Arriving in Minnesota and Georgia ….. 30

Table 3b: Conditional Logistic Regression Model with Risk Factors for Latent Tuberculosis Infection Amongst Refugees Arriving in Minnesota and Georgia Including Interaction Between Region

and Age .....31

Table 4a: Unconditional Logistic Regression Model for Georgia and Potential Health Conditions Related to TST Status ….. 32

Table 4b: Final Unconditional Logistic Regression Model for Georgia Data ….. 33

References ….. 34

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Global Epidemiology - MPH & MSPH
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Keyword	epidemiology refugee health logistic regression latent tuberculosis
Committee Chair / Thesis Advisor	Austin, Harland, Emory University
Committee Members	Coleman, Margaret, Centers for Disease Control and Prevention Division of Global Migration and Quarantine
Partnering Agencies	State or local health department (not in Georgia) Georgia state or local health department CDC

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