Tuberculosis among Newly Arrived Immigrants and Refugees in the United States.

RATIONALE U.S. health departments routinely conduct post-arrival evaluation of immigrants and refugees at risk for tuberculosis, but this important intervention has not been thoroughly studied. OBJECTIVES To assess outcomes of the post-arrival evaluation intervention. METHODS We categorized at risk immigrants and refugees as: with recent completion of treatment for pulmonary tuberculosis disease overseas (including Mexico and Canada); with suspected tuberculosis disease (chest radiograph/clinical symptoms suggestive of tuberculosis) but negative cultures overseas; or with latent tuberculosis infection diagnosed overseas. Among 2.1 million US-bound immigrants and refugees screened for tuberculosis overseas during 2013-2016, 90,737 were identified as at risk for tuberculosis. We analyzed a national dataset of these at risk immigrants and refugees, and calculated rates of tuberculosis disease for those who completed post-arrival evaluation. RESULTS Among 4,225 persons with recent completion of treatment for pulmonary tuberculosis disease overseas, 3,005 (71.1%) completed post-arrival evaluation within 1 year of arrival; of these, 22 were diagnosed with tuberculosis disease (732 cases/100,000 persons): 4 sputum culture-positive cases (133 cases/100,000 persons), 13 sputum culture-negative cases (433 cases/100,000 persons), and 5 cases with no reported sputum culture results (166 cases/100,000 persons). Among 55,938 with suspected tuberculosis disease but negative cultures overseas, 37,089 (66.3%) completed post-arrival evaluation; of these, 597 were diagnosed with tuberculosis disease (1610 cases/100,000 persons): 262 sputum culture-positive cases (706 cases/100,000 persons), 281 sputum culture-negative cases (758 cases/100,000 persons), and 54 cases with no reported sputum culture results (146 cases/100,000 persons. Among 30,574 with latent tuberculosis infection diagnosed overseas, 18,466 (60.4%) completed post-arrival evaluation; of these, 48 were diagnosed with tuberculosis disease (260 cases/100,000 persons): 11 sputum culture-positive cases (60 cases/100,000 persons), 22 sputum culture-negative cases (119 cases/100,000 persons), and 15 cases with no reported sputum culture results (81 cases/100,000 persons). Of 21,714 persons for whom treatment for latent tuberculosis infection was recommended at post-arrival evaluation, 14,977 (69.0%) initiated and 8,695 (40.0%) completed treatment. CONCLUSIONS Post-arrival evaluation of at risk immigrants and refugees can be highly effective. To optimize yield and impact of this intervention, strategies are needed to improve completion rates of post-arrival evaluation and treatment for latent tuberculosis infection.