Tougher TB Screening Needed for Some Immigrants, Report Says

A panel of the nation’s leading public health experts called Thursday for tougher tuberculosis screening of immigrants from Mexico and other countries with high rates of the infectious disease, warning that a global epidemic threatens to undercut gains at eliminating TB in the United States.

In a report on how to rid the nation of tuberculosis--by some measures the world’s leading infectious cause of death--the National Academy of Science’s Institute of Medicine recommends requiring that immigrants from Mexico, the Philippines, Vietnam and other countries with a high incidence of the disease be tested not just for active tuberculosis but to determine whether they carry the latent form of the disease.

Immigrant rights advocates immediately raised concerns about the recommendations, saying that they could lead to discrimination against certain immigrant groups. Moreover, they argued, immigration law is not the proper venue for health policy.

The incidence of tuberculosis in the United States has plummeted in the last five years. But more than 40% of all new TB cases in the country are among immigrants from countries with high rates of the disease.

Treatment Would Be Required

Although immigrants from those countries would not be denied entry to the United States if they were found to carry the latent form of the disease, they would hold special visas requiring them to undergo treatment before they could become permanent residents.

The recommendation puts the institute, a private nonprofit organization that dispenses health advice under a congressional charter, in the odd position of inserting itself into the charged immigration policy debate. Currently, people seeking immigrant visas to enter the United States must undergo screenings for HIV, active tuberculosis, various forms of mental illness and blood tests for sexually transmitted diseases. But the institute’s recommendation would add a major test and would not apply to all immigrants.

The authors of the report, who include leading infectious disease specialists from around the country, said they share many of the concerns raised by immigrant advocates. But they added that they have concluded that the benefits of such screening outweigh any pitfalls.

“We had the same concerns about saying to somebody, ‘You can’t come into the country without doing this,’ ” said Philip Hopewell, one of the report’s authors and an associate dean of San Francisco General Hospital.

“But on the other hand, immigrants are asking for a favor,” said Hopewell, who is also a professor of medicine at UC San Francisco. “They are asking for special consideration to be given to them, and those considerations carry with them some responsibilities. We came to feel that one of those responsibilities was to maintain the health of the public.”

Although the incidence of tuberculosis in the United States is at an all-time low, it is on the increase among the foreign-born living in the country, according to the report.

In 1999, just 6.4 cases per 100,000 people were detected in the United States, a decrease of 46% since 1992, according to the study. But during that same period, tuberculosis among the foreign-born living in this country increased 3%.

Overall, the proportion of TB patients among immigrants to the United States increased from 27% in 1992 to 43% in 1999, the report’s authors found. Of immigrants diagnosed with TB last year, 23% were from Mexico, and 54% lived in California, Texas, Illinois, New York and Florida--all states with significant immigrant populations.

The report recommends that all people applying for immigrant visas from countries with rates of latent tuberculosis of more than 36%, as well as those from Mexico, be required to undergo testing for the latent infection at the time they apply for visas at U.S. embassies and consulates in their countries of origin.

Tourists, students, businesspeople, academics and others planning to visit the United States on temporary visas would not be subject to the TB testing requirements.

Mexico has an incidence of latent tuberculosis of 17%--more than double that of the United States but significantly less than the 36% threshold. But the numbers of new Mexican immigrants to the United States dwarf those of any other group.

Implementing the testing would not be easy. The test itself--pricking the skin with a fine-gauge needle containing antigens of the tuberculosis virus--costs just pennies. But it takes several days for the slight rash that is indicative of the latent form of the disease to develop. That would force potential immigrants to go back and forth between the embassy and their home several times, the report said, further burdening embassies in many countries whose visa sections are already short-staffed.

The report acknowledged that screening legal immigrants will not solve the problem. Many of the roughly 7 million people with latent TB infections living in the United States are illegal immigrants, the report estimates.

Outreach Sought for High-Risk Groups

To reach those people, the report calls for increased outreach efforts in immigrant communities and among other high-risk groups, including the homeless, prison inmates, substance abusers and those infected with HIV.

The report estimates the cost to the federal government of such outreach efforts, plus the screening for new immigrants, at $280 million a year. That is triple the amount now spent. Immigrant rights advocates call the proposals unworkable.

“I can tell that they’re well meaning, but I don’t know whether their proposals are well thought out,” said Josh Bernstein, senior policy analyst at the National Immigration Law Center in Washington. “It’s troubling to single out people from certain countries. It has all sorts of discriminatory implications when you put this extra burden on them. There’s no guarantee that once they arrive, they’re actually going to be given the treatment that they need in order to satisfy the requirements.”