EFFECTIVENESS OF PROVIDING A WRITTEN REFERRAL TO NEWLY ARRIVING IMMIGRANTS AT FIRST PORT OF ENTRY ON THE COMPLETION OF U.S. TB EVALUATIONS Open Access

Abstract

Abstract

Tuberculosis (TB) remains one of the most serious infectious diseases worldwide and continues to pose a significant public health concern in the U.S. Of the 11,545 cases of TB disease reported in the U.S. in 2009, 60% were among foreign-born residents. Over the past 15 years, the percentage of TB cases in the U.S. among foreign-born individuals has doubled. A two-step process is used in the U.S. to reduce the likelihood that immigrants seeking permanent residence arrive with TB, an overseas pre-immigration examination, and a U.S.-based post-immigration TB evaluation for individuals at risk for TB disease. In 2005, 53% of immigrants with a TB classification completed their U.S. examination. Incomplete U.S. examinations represent missed opportunities for early detection and treatment of TB disease and latent TB infection. This retrospective cohort study of 398 Filipino immigrants arriving at Detroit Metropolitan Airport (DTW) with a TB classification between December 2006 and August 2007 examines whether or not the written referral used at DTW given upon U.S. entry increase the likelihood of U.S. TB evaluation completion. Of the 398 cohort immigrants, 212 (53%) completed a U.S. examination. This proportion is the same as seen in other studies. Almost no difference was found in the proportion of immigrants completing a U.S. TB evaluation between those individuals that received a written referral and those that did not ( p = .97). Results did not support use of the referral used at DTW as an effective method for increasing U.S. examination completion rates. Lack of effectiveness of the referral in this study does not however, support not providing a referral upon U.S entry. Recommendations made from this study include completing an analysis of referral methods currently used by other CDC Quarantine Stations to facilitate completion of U.S.-based TB evaluations (particularly Chicago and Honolulu), improving the current referral form used at DTW, a review of information provided to immigrants prior to departure for the U.S, and exploring the use of incentives for both public health agencies and arriving immigrants.

Table of Contents

Table of Contents
Tables...iii
Figures...iv
Chapter I: Introduction...1

Introduction and Rationale...1
Problem Statement...2
Theoretical Framework...10
Purpose Statement...12
Research Question...12
Significance Statement...12
Definition of Terms...14

Chapter II: Review of the Literature...17

Introduction...17
Public Health and Tuberculosis...19
Current Epidemiology of TB among U.S. Foreign-born Persons and U.S. TB Control Strategies...21
Impact and Effectiveness of Immigrant Health Screenings...23
Acceptability of TB Screening to Immigrants...26
Methods used to Increase Completion of Immigrant Health Screenings...28
Summary...29

Chapter III: Methods...31

Introduction...31
Population and Sample...31
Research Design...33
Procedures...33
Instrument...35
Data analysis...35
Limitations and delimitations...38

Chapter IV: Results...42

Introduction...42
Findings...42
Other Findings...49
Summary...51

Chapter V: Conclusions, Implications and Recommendations...53

Introduction...53
Summary of Study...53
Conclusion...55
Implications...56
Recommendations...57

References...61
Appendix 1: Referral Form Used at Detroit Metropolitan Airport...65
Appendix 2: Overseas Medical Examination Form DS2053...66
Appendix 3: Overseas Medical Examination Form DS3024...68
Appendix 4: Overseas Medical Screening Form DS3026...70
Appendix 5: CDC Form 75.17...72

Tables
Table 1. Algorithm for Determining if a U.S. TB Evaluation was Completed Using Answers from Returned CDC Form 75.17...36
Table 2. Demographics and Social Characteristics of Study Cohort by Referral Group...44
Table 3. Study Cohort Completion of U.S. TB Evaluation by Referral Status...47
Table 4. Demographics and Social Characteristics of Study Cohort by U.S. TB Evaluations Completed...47
Table 5. Characteristics and Demographics of Arriving Immigrants Diagnosed with Active TB Disease during Completion of U.S. TB Evaluation...50
Table 6. Comparison of the Time Interval to Completion of U.S. TB Evaluation within One Year U.S. Entry by Referral Status...51

Figures
Figure 1. Conceptual Model for Study...11
Figure 2. Annual Legal Permanent Admissions and Status Adjustments, * 1900 - 2008...18
Figure 3. Immigrants Arriving at Detroit Metropolitan Airport, Detroit, Michigan (DTW) with a B1 or B2 TB Classification between December, 2006 and August, 2007...43
Figure 4. U.S. Residence for Study Cohort (n = 398)...45
Figure 5. Completed U.S. TB Evaluations among Cohort...46
Figure 6. U.S. TB Evaluations Completed for the Seven States Receiving 20 or More Immigrant Arrivers with a TB Classification...49

About this Master's Thesis

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School	Rollins School of Public Health
Department	Career Masters of Public Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	immigrant screening TB screening tuberculosis
Committee Chair / Thesis Advisor	Cookson, Susan Temporado, Emory University
Committee Members	Palumbo, Gabriel, Centers for Disease Control and Prevention
Partnering Agencies	State or local health department (not in Georgia) CDC

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