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Assessing the Performance of Overseas Tuberculosis Screening Programs
A Study Among US-Bound Immigrants in Vietnam
Susan A. Maloney, MD, MHSc;
Katherine L. Fielding, PhD;
Kayla F. Laserson, ScD;
Warren Jones, BS;
Nguyen Thi Ngoc Yen, MD;
Dang Quy An, MD;
Nguyen Huu Phuoc, MD;
Nguyen An Trinh, MD;
Duong Thi Cam Nhung, MD;
Vo Thi Chi Mai, MD;
M. Frank Seawright, BA;
Thomas O’Rourke, MD;
Truong Xuan Lien, MD;
Nguyen Thi Ngoc Lan, MD;
Nancy Binkin, MD, MPH;
Martin S. Cetron, MD
Arch Intern Med. 2006;166:234-240.
Background Tuberculosis cases in foreign-born persons account for more than 50% of all tuberculosis cases in the United States. The Institute of Medicine has recommended enhancing overseas screening as one measure to support tuberculosis elimination efforts. We assessed the ability of overseas tuberculosis screening (chest radiograph followed by 3 acid-fast bacilli sputum smears for persons with abnormal chest radiographs [suggestive of active tuberculosis]) to detect pulmonary tuberculosis disease among US-bound immigrants with abnormal chest radiographs.
Methods During October 1998 to October 1999, 14 098 US immigrant visa applicants were screened overseas in Vietnam. Adult applicants with abnormal chest radiographs were enrolled to assess screening test characteristics among this group using mycobacterial culture as the gold standard for pulmonary tuberculosis disease diagnosis. Risk factors for pulmonary tuberculosis disease were also evaluated.
Results Among 1179 adult applicants with abnormal chest radiographs, 82 (7.0%) had positive acid-fast bacilli smear results, and 183 (15.5%) had positive Mycobacterium tuberculosis culture results (pulmonary tuberculosis disease). The sensitivity, specificity, and positive and negative predictive values of serial acid-fast bacilli screening among this group were 34.4% (63/183), 98.1% (977/996), 76.8% (63/82), and 89.1% (977/1097), respectively. Risk factors for pulmonary tuberculosis disease included younger age (18-34 years), no history of tuberculosis or treatment, reported symptoms, and cavitation or consolidation on chest radiograph.
Conclusions The ability of current overseas screening to detect tuberculosis among immigrants with abnormal chest radiographs is low. Improved diagnostic methods, enhanced screening measures, and postmigration follow-up are essential to control tuberculosis among immigrants and support US and global tuberculosis elimination.
Author Affiliations: Divisions of Global Migration and Quarantine (Drs Maloney and Cetron and Mr Seawright) and Tuberculosis Elimination (Dr Laserson), Centers for Disease Control and Prevention, Atlanta, Ga; London School of Hygiene and Tropical Medicine, London, England (Dr Fielding); International Organization of Migration, Geneva, Switzerland (Mr Jones and Dr O’Rourke); Cho Ray Hospital (Drs Yen, An, Phuoc, Trinh, Nhung, and Mai), Institute Pasteur (Dr Lien), and Pham Ngoc Thach National Tuberculosis and Lung Disease Center (Dr Lan), Ho Chi Minh City, Vietnam; and Superioe di Sanità, Rome, Italy (Dr Binkin).
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