Casey Hamlet

Background: As of 2020, 71.5% of tuberculosis (TB) cases in the United States occur in foreign-born patients.1 Gaps in healthcare, congregate living conditions, are just some of the challenges that immigrants and refugees from high incidence countries face that make them especially vulnerable. The US TB-screening program mandates that immigrants 15 years and older are screened via a chest radiograph and children 2 – 14 years by TB IGRA prior to entry.2 Refugees bound for the US are screened using a similar protocol.3 However, this protocol does not apply for foreign-born students, people holding work visas, and immigrants who are undocumented.4 University Hospital (UH) in Newark, New Jersey aims to screen all foreign-born patients when they establish care. Newark has a foreign-born population (34.0%) over double the national average (13.6%), and UH sees many of these patients as it is the only public hospital in New Jersey aside from the East Orange Veterans Affairs Medical Center.5 It is important not to delay screening in order to prevent the development of TB disease; the immunocompromised, women of childbearing age who can experience TB-related pregnancy complications, and children are all at a higher risk for developing fatal TB.1 Identifying if the incidence of TB screening before entry into the US differs by the patient’s immigration status, and how quickly UH screens these patients (via QuanTIFERON-TB Gold and/or chest radiograph) once they establish care is important for disease control and detecting areas for improvement for UH.

Methods: A retrospective chart review was conducted. The medical charts of 54 TB-positive (positive QuanTIFERON-TB Gold) foreign-born adult patients seen by University Hospital between 2016 and 2023 were ultimately included and reviewed in Epic. Immigration status was categorized as citizen, permanent/conditional residents, undocumented immigrant, and refugee/evacuee. Citizen was defined as a foreign-born person who has gained US citizenship. Immigrants who fell into the permanent/conditional resident classification included green card holders, lawful permanent residents, students, and people on work visas. Undocumented immigrant was defined as an immigrant not in possession of valid immigration documentation, including using an expired visa. Refugee/evacuee was defined as a person forcibly removed or evacuated from their home country to the United States. Patients whose birth country or immigration status is not documented in their medical chart were excluded. Both immigration status and birth country were determined by reviewing previous medical notes and the “media” tab in Epic for identification documents; if either birth country or immigration status was not clearly documented in past notes or media, the patient was excluded from the study. Similarly, patients’ charts were reviewed for documentation of their tuberculosis screening status, via QuanTIFERON-TB Gold and/or chest radiograph.

Results: Qualitative data were compared using Pearson Chi-square test, and a p-value of less than 0.05 was considered significant. 35 of the 54 patients (64.8%) included in the study did not have a documented pre- arrival TB-screening (QuanTIFERON-TB Gold and/or chest radiograph) in their medical chart. A significant difference in the incidence of pre-arrival TB screening existed between citizens and undocumented immigrants (p=0.016), citizens and refugees (p=0.024), permanent/conditional residents and undocumented immigrants (p=0.027). Lastly, a significant difference existed between citizens, permanent/conditional residents and undocumented immigrants (p=0.045). Four departments at UH ordered TB-screening tests for patients: emergency medicine, internal medicine, infectious disease, and obstetrics-gynecology. Most screenings were ordered within 1 year of the patient establishing care at UH (64.8%). 22.2%% were ordered within 1-5 years, 9.3% within 5-10 years, 1.9% within 10-20 years, and 1.9% 20 or more years after the patient established care at UH.

Conclusions: In an increasingly globalized world, screening for latent tuberculosis is important, even in low-incidence countries such as the US. This study reveals that the majority of patients studied did not have a documented TB-screen in their medical chart, even if the patient was a legal immigrant. Although this study showed that the majority of TB-screening tests were ordered by University Hospital departments within one year of the patient establishing care, there are many TB-positive patients who go undiagnosed for much longer. Considering the vulnerability of this patient population to TB infection and disease, it is opportune to screen and treat these patients as soon as care is established to reduce delay in diagnosis and future costs associated with progression of disease or related complications to the patient. It is important to note that screening protocol should be confidential and non-coercive. The purpose of enhanced, standardized screening should be rooted in optimizing the patient’s wellbeing, and not used as a punitive measure or reason to deny persons entry into the US. Future research could examine the incidence of TB complications in patients whose TB-screening was delayed.