INT J TUBERC LUNG DIS 15(8):1044–1049
© 2011 The Union
Missed opportunities to prevent tuberculosis in foreign-born
persons, Connecticut, 2005−2008
A. Guh,*† L. Sosa,† J. L. Hadler,† M. N. Lobato‡
* Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, † Connecticut
Department of Public Health, Hartford, Connecticut, ‡ Division of Tuberculosis Elimination, Centers for Disease Control
and Prevention, Atlanta, Georgia, USA
Correspondence to: Alice Guh, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A-31, Atlanta, GA
30329, USA. Tel: (+1) 404 639 5077. Fax: (+1) 404 639 4046. e-mail: email@example.com
Article submitted 12 August 2010. Final version accepted 23 January 2011.
SETTING: Factors that infl uence testing for latent tuber-
culosis infection (LTBI) among foreign-born persons in
Connecticut are not well understood.
OBJECTIVE: To identify predictors for LTBI testing and
challenges related to accessing health care among the
foreign-born population in Connecticut.
DESIGN: Foreign-born Connecticut residents with con-
fi rmed or suspected tuberculosis (TB) disease during
June 2005–December 2008 were interviewed regarding
health care access and immigration status. Predictors
for self-reported testing for LTBI after US entry were
RESULTS: Of 161 foreign-born persons interviewed,
48% experienced TB disease within 5 years after arrival.
One third (51/156) reported having undergone post-
a rrival testing for LTBI. Although those with established
health care providers were more likely to have reported
testing (aOR 4.49, 95%CI 1.48–13.62), only 43% of
such persons were tested. Undocumented persons, the
majority of whom lacked a provider (53%), were less
likely than documented persons to have reported testing
(aOR 0.20, 95%CI 0.06–0.67). Hispanic permanent
residents (immigrants and refugees) and visitors (per-
sons admitted temporarily) were more likely than non-
Hispanics in the respective groups to have reported test-
ing (OR 5.25, 95%CI 1.51–18.31 and OR 7.08, 95%CI
CONCLUSIONS: The self-reported rate of testing for
LTBI among foreign-born persons in Connecticut with
confi rmed or suspected TB was low and differed signifi -
cantly by ethnicity and immigration status. Strategies
are needed to improve health care access for foreign-
born persons and expand testing for LTBI, especially
among non-Hispanic and undocumented populations.
KEY WORDS: latent tuberculosis infection; immigrants;
ALTHOUGH developing countries bear the burden
of the estimated 9.3 million new tuberculosis (TB)
cases annually,1 increasing population mobility has
affected the epidemiology of TB in industrialized na-
tions such as the United States.2−5 In Connecticut,
racial and ethnic diversity is increasing, as is the
proportion of residents who are foreign-born,6,7 as
refl ected by the increased percentage of TB cases re-
ported in the foreign-born population, from 30% in
1990 to 76% in 2009.8,9 Since 2000, the TB rate in
Connecticut has been 10–15 times higher among
foreign-born persons than among US-born persons.9
To prevent and control TB among foreign-born
persons, overseas TB screening is performed as part
of the pre-immigration process for US entry.10 How-
ever, this practice is only required for immigrants seek-
ing permanent residence and for refugees; it does not
apply to US-bound persons entering temporarily (e.g.,
workers or students). Furthermore, pre-immigration
screening is intended to detect TB disease; it does
not routinely evaluate for latent TB infection (LTBI).
Whereas refugees and immigrants who have an ab-
normal chest radiograph are recommended for fur-
ther medical evaluation 30 days after their arrival in
the United States, other foreign-born persons enter-
ing temporarily are not required to undergo post-
arrival evaluation. Moreover, undocumented persons
from high TB burden countries might have less access
to health care.11,12 National guidelines, however, rec-
ommend targeted testing for LTBI among persons
who have been in the United States for ⩽5 years and
originated from countries with a high TB prevalence,13
defi ned by most TB programs as an annual rate of
⩾20 cases per 100 000 population, e.g., countries of
Asia, Africa, and Central and South America.14
To better understand factors infl uencing testing
for LTBI among foreign-born persons and to respond
to the health inequality and high TB incidence in this
population, the Connecticut Department of Public
Health (CT DPH) TB Control Program established an
S U M M A R Y
LTBI testing in foreign-born persons 1045
enhanced surveillance system for TB among foreign-
born persons in 2005. We identify predictors for self-
reported testing for LTBI and describe differences in
factors affecting health care access in this population.
In Connecticut, all health care providers are required
to report to the TB Control Program any person with
TB disease, either microbiologically confi rmed or
strongly suspected based on clinical fi ndings or ra-
diographic evidence. Demographics, clinical informa-
tion and TB risk factors are obtained for each person.
Suspected TB cases become confi rmed cases if subse-
quent laboratory data and/or clinical assessment by
the treating physician support the diagnosis of TB.
Enhanced surveillance system
During June 2005–December 2008, reported foreign-
born persons (born outside the United States and its
territories) with confi rmed or suspected TB disease
were interviewed with a standard questionnaire to
assess history of testing for LTBI and treatment after
US entry, health care access and immigration status.
Interviews were conducted in person by local public
health nurses or state TB case managers during rou-
tine visits. If a nurse was unavailable, a language bar-
rier existed, or the reported person ultimately did not
have TB and no further contact was required, inter-
views were sometimes not conducted. Persons inter-
viewed were classifi ed by their entry status: permanent
residents (immigrants and refugees), visitors (persons
admitted temporarily) and undocumented immigrants
(persons entering illegally). Countries of origin were
categorized into four regions, according to the Amer-
ican Community Survey (ACS),15 as Americas, Asia,
Africa and Europe.
Population denominators by region of origin for
each year were obtained from the 2005–2008 ACS
data to calculate average annual TB case rates.15 De-
scriptive analyses were used to summarize demo-
graphic characteristics and variables of health care
access. As illegal immigration status is a known de-
terrent to TB care,11 differences in health care access
between documented and undocumented persons were
Persons interviewed who had received post-arrival
testing for LTBI as contacts of a TB case instead of
through routine screening were excluded from subse-
quent analysis. Rates for testing and treatment for
LTBI were determined. Although there is no longer
an age cut-off for receiving LTBI treatment, tubercu-
lin skin test (TST) positive, low-risk persons aged
⩾35 years were previously excluded from treatment.13
Because age might infl uence the testing rate, we chose
35 years as the reference point to assess testing for
To assess for associations between selected factors
and undergoing post-arrival testing for LTBI, odds
ratios (ORs) and 95% confi dence intervals (CIs) were
computed. Variables for which the univariate test
yielded a P value ⩽ 0.10 were introduced into a multi-
variable logistic regression model. Stratifi ed analyses
by immigration status and ethnicity were performed
to assess for differences in rates of testing for LTBI.
SAS® statistical software version 9.1.3 (SAS Institute
Inc, Cary, NC, USA) was used for analysis.
Because TB is a reportable disease in Connecti-
cut,16 this study was deemed exempt from review by
the CT DPH Human Investigations Committee and
was considered by the Centers for Disease Control
and Prevention to be routine public health practice.
Characteristics of foreign-born persons with TB
During June 2005–December 2008, 346 foreign-born
persons with suspected TB originating from 57 differ-
ent countries were reported; 228 (66%) had culture-
confi rmed disease. The TB rate was highest among
those from Africa (29.4/100 000) and Asia (26.4/
100 000), followed by those from the Americas (12.7/
100 000) and Europe (6.1/100 000).
Of 346 persons, 161 (47%) were able to be inter-
viewed. No signifi cant differences in demographics
(sex, race and region of origin) were detected between
persons interviewed and those not interviewed, ex-
cept for a higher proportion of interviewees who
were aged <35 years (52% vs. 38% among persons
not interviewed, P = 0.01) and Hispanic (38% vs.
28% among persons not interviewed, P = 0.04). Of
the 161 persons, 95 (59%) were male and 83 (52%)
were aged <35 years (range 1–88). Of 141 persons
with known entry status, 60 (43%) were permanent
residents, 48 (34%) were visitors and 33 (23%) were
Health care access and immigration status
Among the interviewed persons, 89/159 (56%) had
health insurance, 98/160 (61%) had an established
provider, and 106/153 (69%) designated an ambula-
tory care facility for their usual place of care. How-
ever, 34/153 (22%) persons had not sought medical
Among 159 persons with known year of entry, 77
(48%) were reported as TB patients within 5 years of
arrival. These persons were less likely later to have
health insurance (43% vs. 69%, P = 0.001) or an es-
tablished provider (51% vs. 71%, P = 0.01) than the
82 persons reported.
By immigration status, undocumented persons were
less likely than documented persons (permanent resi-
dents and visitors) to have health insurance (21% vs.
The International Journal of Tuberculosis and Lung Disease
68%, P < 0.0001) or an established provider (45%
vs. 67%, P = 0.02); and they were more likely to
have diffi culty communicating with their provider
(36% vs. 17%, P = 0.03) and to require the use of an
interpreter (46% vs. 13%, P = 0.0001).
Testing for LTBI and missed opportunities
After excluding fi ve patients who reported testing for
LTBI as a contact of a TB case, 105/156 (67%) re-
ported not having received post-arrival testing for
LTBI and before being reported as a TB patient. By
subgroups, 55/96 (57%) with established providers,
41/60 (68%) who entered as permanent residents
and 5/9 (56%) with human immunodefi ciency virus
(HIV) infection reported not having had an evalua-
tion for LTBI.
The remaining 51/156 (33%) persons reported re-
ceiving post-arrival testing for LTBI. The median du-
ration from arrival until testing was 1 year (range 0–
10). Forty-eight persons were able to recall their TST
result, 25 (54%) of whom reported a positive result.
Only 12/25 (48%) reported completing LTBI therapy;
of the remaining 13 (52%) persons, 3 reported not
Table 1 Selected factors associated with undergoing prior testing for LTBI among foreign-born persons after entering the
Region of origin†
Dedicated TB prevention
services in city of residence
Had established provider
Usual place for care‡
Physician’s offi ce
Community or health clinic
Most common provider type‡
Used interpreter with provider‡
Diffi culty communicating with
Yes or at times
Had health insurance
Type of insurance
All other types
0.06 1.49 (0.49–4.57)0.48
* Testing for LTBI was based on self-report. This analysis excludes persons who reported having had testing for LTBI as a contact of a TB case.
† Region of origin according to American Community Survey classifi cation.15
‡ Excludes foreign-born persons without any usual place for medical care.
§ Estimate based on correction of 0.5 in cell containing zero.
¶ Includes nurse practitioners, registered nurses and physician assistants.
# Undocumented person = a person entering the United States without legal documentation; documented person = either a permanent resident (immigrant
and refugee) or a visitor (admitted to the United States on a temporary basis).
LTBI = latent TB infection; OR = odds ratio; aOR = adjusted OR; CI = confi dence interval; TB = tuberculosis.
LTBI testing in foreign-born persons 1047
receiving therapy from their providers because of prior
bacille Calmette-Guérin (BCG) vaccination, 3 could
not recall the reason for not receiving therapy, and
7 reported receiving therapy but did not complete
treatment for various reasons, including inability to
pay for medication and prior BCG vaccination.
Predictors of testing for LTBI
Having an established provider was signifi cantly as-
sociated with reporting post-arrival testing for LTBI
(adjusted OR [aOR] 4.49, 95%CI 1.48–13.62). Per-
sons were less likely to report having been tested if
they had arrived from Africa (aOR 0.11, 95%CI
0.02–0.65), Europe (aOR 0.22, 95%CI 0.05–0.94)
or Asia (aOR 0.17, 95%CI 0.06–0.50), compared
with having arrived from the Americas. Overall, un-
documented persons were less likely than documented
persons to report having been tested (aOR 0.20,
95%CI 0.06–0.67; Table 1). By specifi c entry status,
however, the proportion of permanent residents (32%)
who had self-reported post-arrival testing was not
signifi cantly different from that of visitors (46%, P =
0.14) or undocumented persons (19%, P = 0.19).
Of the 156 persons, 57 (37%) reported being His-
panic, all of whom originated from the Americas,
comprising 79% of foreign-born persons from that
region. Overall, Hispanics were more likely than non-
Hispanics to report having undergone post-arrival
testing for LTBI (44% vs. 26%, P = 0.02). Despite
this, Hispanics comprised 81% of all undocumented
persons. When stratifi ed by immigration status, His-
panic permanent residents and visitors were more
likely than non-Hispanics to report having under-
gone testing for LTBI (OR 5.25, 95%CI 1.51–18.31
and OR 7.08, 95%CI 1.30–38.44, respectively; Ta-
ble 2). Furthermore, Hispanic permanent residents
(60%) and visitors (80%) were more likely than un-
documented Hispanics (23%) to report having un-
dergone testing (OR 5.00, 95%CI 1.26–19.84 and
OR 13.33, 95%CI 2.21–80.51, respectively).
Similar to the situation across the United States, the
vast majority of foreign-born persons with TB in
Connecticut are from regions with high TB inci-
dence.3–5,17 Approximately half were reported as TB
patients within 5 years after arrival, underscoring the
critical importance of prompt LTBI diagnosis and
treatment.13,18 Despite high TB rates among persons
from Asia and Africa, they were less likely than those
from the Americas to report having undergone test-
ing for LTBI. In addition, undocumented persons
were less likely than documented persons to report
having undergone an evaluation for LTBI, probably
as a result of greater barriers to health care access.
Two thirds of foreign-born persons with TB did
not report having undergone testing for LTBI after
US entry, although 72% had entered as permanent
residents, had an established provider or had HIV in-
fection. Permanent residents potentially had more
opportunities than visitors and undocumented per-
sons to undergo a post-arrival medical evaluation,
yet their reported testing rate was not signifi cantly
higher. Although having a provider was a signifi cant
predictor for testing for LTBI, <50% of persons with
an established provider reported having been tested.
Furthermore, although the number of HIV-infected
foreign-born persons in our study was minimal, only
56% reported having been tested for TB, despite the
well-documented increased risk for disease among
this vulnerable population.19,20 One study revealed
that 38% of foreign-born persons experiencing TB
disease met the criteria for testing for LTBI accord-
ing to national guidelines (i.e., recent immigrant),
yet had not been tested previously and represented
missed opportunities.21 These fi ndings underscore the
need to re inforce targeted testing for LTBI guidelines
among providers who treat foreign-born persons at
Although it is unclear why documented Hispanics
were more likely than documented non-Hispanics to
report having received testing for LTBI, a substantial
proportion (41%) of the Connecticut foreign-born
population is Hispanic7 and resides in towns with
dedicated TB prevention services.15 However, given
the high TB incidence and low testing rates among
foreign-born persons from Asia and Africa, targeted
testing of these persons should be a priority.4 En-
gaging community-based organizations and identify-
ing cultural health beliefs might improve testing of
foreign-born persons from high-risk regions. As dem-
onstrated in one study, through partnerships with
community organizations and use of focus groups, a
culturally sensitive educational program was devel-
oped to reduce TB incidence among foreign-born
Vietnamese populations.22 Similarly, another study
described a community-based approach that used
bilingual, bicultural case managers who mediated
Table 2 LTBI testing rates by immigration status and Hispanic
ethnicity among foreign-born persons, Connecticut,
n (%) OR (95%CI)
9 (60) 5.25 (1.51–18.31)
10 (22) Reference
8 (80) 7.08 (1.30–38.44)
13 (36) Reference
6 (23) 4.12 (0.20–83.52)†0.56
* Testing for LTBI was based on self-report. This analysis excludes persons
who reported having undergone testing for LTBI as a contact of a TB case.
† Estimate based on correction of 0.5 in cell containing zero.
LTBI = latent tuberculosis infection; OR = odds ratio; CI = confi dence interval.
The International Journal of Tuberculosis and Lung Disease
between the medical system and immigrant commu-
nity to expand testing of targeted populations.23
Similar to other studies of TB,11,24,25 approximately
20% of foreign-born persons were undocumented.
Undocumented persons were less likely to have health
insurance or an established provider and more likely
to have diffi culty communicating with providers, all
factors that limit access to care for testing for LTBI
and, among those with TB disease, result in delayed
diagnosis, which can lead to more extensive disease
and transmission.26,27 The reduction of health care
barriers among foreign-born persons is thus critical
for enhancing TB control and will require increased
awareness and trust in systems for identifi cation and
treatment of this population. For example, in Dela-
ware, public health offi cials collaborated with the
poultry-processing industry, in which the majority of
the workforce comprises foreign-born persons who
might be undocumented, to develop an anonymized
TB tracking system that protects the identity and im-
migration status of workers.28 Two years after imple-
mentation of this system in Delaware, completion
rates for LTBI treatment of persons identifi ed had in-
creased from 48% to 64%.28 Such a system might be
useful in certain industries in Connecticut, including
casino operations and tobacco production, in which
foreign-born persons at risk for TB often work.
Perceived barriers to completion of treatment for
LTBI among foreign-born persons also need to be ad-
dressed. More than 50% of those with a prior posi-
tive TST reported not completing LTBI treatment;
reasons provided were often based on misconcep-
tions. For example, inability to pay for medications
was a concern, although LTBI therapy is provided
free of charge by the TB Control Program. Prior BCG
vaccination was another reason for not receiving
treatment, a belief that is held even among providers,
despite studies indicating that the protective effect of
BCG over time is minimal and possibly variable,29,30
and guidelines recommending that BCG vaccination
history should not be considered when interpreting a
TST.13 Measures to overcome this barrier include ex-
panding the use of improved diagnostic tests (e.g.,
interferon-gamma release assays), which are not af-
fected by prior BCG vaccination and require only a
single patient visit.31
This study has certain limitations. As with any new
surveillance system in which underreporting might
initially occur, a lower proportion of foreign-born
persons was initially enrolled in the enhanced surveil-
lance. The results might not be representative of all
Connecticut foreign-born persons because a higher
percentage of persons interviewed were aged <35 years
and were Hispanic. Moreover, these fi ndings might
not be generalizable, as we evaluated for testing only
among persons with confi rmed or suspected TB. Al-
though we excluded persons who reported having
undergone a post-arrival TST as a contact of a case,
this information was not known for everyone who
had been tested. Furthermore, accuracy of data was
subject to recall bias and to potential miscommunica-
tion as a result of language barriers during interviews.
In addition, the outcome studied was self-reported
testing for LTBI and was not validated by medical rec-
ord review. Finally, the reasons for foreign-born per-
sons not to have undergone post-arrival testing for
LTBI (e.g., had previously treated TB) were not deter-
mined. However, because no known cases of active TB
were detected by overseas screening among foreign-
born persons arriving in Connecticut during this pe-
riod, and because reports of previous TB were rare, the
majority of foreign-born persons who had not been
tested would have met the criteria for LTBI testing.
We identifi ed several missed opportunities for testing
for LTBI in Connecticut foreign-born persons. Self-
reported rates of testing differed signifi cantly by eth-
nicity and immigration status, likely as a result of
varying degrees of TB awareness and accessibility of
health care among this population, in which undocu-
mented persons were the least likely to receive ade-
quate care. Unless a reliable process for accessing
medical care exists for all foreign-born persons and
is fully accepted by them, regardless of immigration
status, TB elimination in this population cannot be
The authors thank the following persons for their invaluable assis-
tance to this study: T Condren, M Williams, M Tate, D Orcutt and
T Christensen of the Connecticut Department of Public Health TB
Control Program; D Banach of the University of Connecticut Pub-
lic Health School; and the TB staff of Connecticut local health
The fi ndings and conclusions in this report are those of the au-
thors and do not necessarily represent the offi cial position of the
Centers for Disease Control and Prevention.
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LTBI testing in foreign-born persons i Download full-text
CONTEXTE : Les facteurs qui infl uencent les tests à la re-
cherche d’une infection tuberculeuse latente (LTBI) ne
sont pas bien connus chez les sujets du Connecticut nés
OBJECTIF : Identifi er les facteurs prédictifs des tests de
LTBI et les défi s concernant l’accès aux soins de santé
dans la population du Connecticut née à l’étranger.
SCHÉMA : Pendant la période juin 2005–décembre
2008, les résidents du Connecticut nés à l’étranger et at-
teints de la tuberculose (TB) confi rmée ou suspectée ont
été interviewés concernant leur accès aux soins de santé
et leur statut d’immigration. On a déterminé les facteurs
prédictifs de l’exécution auto-rapportée des tests de la
LTBI après l’entrée aux Etats-Unis.
RÉSULTATS : Sur 161 personnes nées à l’étranger qui
ont été interviewées, 48% ont souffert d’une TB dans
les 5 ans après leur arrivée. Un tiers d’entre elles (51/156)
ont signalé avoir subi un test pour LTBI après leur ar-
rivée. Bien que les personnes ayant des pourvoyeurs de
soins de santé bien déterminés aient été plus susceptibles
d’avoir signalé un test (ORaj 4,49 ; IC95% 1,48–13,62),
43% seulement d’entre elles ont fait l’objet d’un test.
Les personnes mal informées dont la majorité n’avait
pas de pourvoyeurs de soins (53%) étaient moins sus-
ceptibles que les personnes informées d’avoir signalé des
tests (ORaj 0,20 ; IC95% 0,06–0,67). Les personnes
d’origine hispanique résidents permanents (immigrants
et réfugiés) ou les visiteurs (personnes autorisées tempo-
rairement) étaient plus susceptibles d’avoir signalé un
test que les non-hispaniques dans ces deux groupes re-
spectifs (OR 5,25 ; IC95% 1,51–18,31 et OR 7,08 ;
IC95% 1,30–38,44 respectivement).
CONCLUSION : Le taux auto-rapporté des tests de la
LTBI chez les sujets du Connecticut nés à l’étranger et
at teints d’une TB confi rmée ou suspectée a été faible et
varie signifi cativement en fonction de l’ethnie et du statut
d’immigration. Des stratégies s’imposent pour améliorer
l’accès aux soins de santé pour les sujets nés à l’étranger
et pour l’extension du test de la LTBI, principalement
dans les populations non-hispaniques et mal informées.
MARCO DE REFERENCIA: No se conocen los factores
que infl uyen en la decisión de practicar la prueba de la in-
fección tuberculosa latente (LTBI) a las personas nacidas
en el extranjero que residen en el estado de Connecticut.
OBJETIVO: Defi nir las variables predictivas de realiza-
ción de la prueba de detección de la LTBI y los obstáculos
al acceso a la atención de salud en la población nacida
en el extranjero que reside en el estado de Connecticut.
MÉTODOS: Se llevaron a cabo entrevistas a los resi-
dentes de Connecticut nacidos en el extranjero que pre-
sentaban un diagnóstico confi rmado de tuberculosis (TB)
o una presunción clínica de la misma entre junio del 2005
y diciembre del 2008; las preguntas se referían a su ac-
ceso a la atención de salud y a su situación de inmi-
gración. Se determinaron las variables que permitían
predecir la autonotifi cación de la prueba diagnóstica de
LTBI después del ingreso a los Estados Unidos.
RESULTADOS: De las 161 personas nacidas en el extran-
jero que respondieron a las entrevistas, el 48% había
padecido de la TB en los primeros 5 años después de su
llegada. Un tercio (51/156), refi rieron haber tenido una
prueba de detección de LTBI después de la entrada.
Aunque fue más frecuente la notifi cación de la prueba
por las personas que contaban con un profesional de
salud asignado (aOR 4,49; IC95% 1,48–13,62), solo el
43% de estas personas recibió la prueba. Las personas
indocumentadas, que en su mayoría carecía de un profe-
sional sanitario defi nido (53%), presentaron menor pro-
babilidad que las personas con documentación de haber
recibido una prueba diagnóstica (aOR 0,20; IC95%
0,06–0,67). Los residentes permanentes de origen his-
pano (inmigrantes y refugiados) y los visitantes (perso-
nas admitidas temporalmente) notifi caron con mayor
frecuencia haber recibido la prueba que las personas
con otros orígenes en los respectivos grupos (OR 5,25;
IC95% 1,51–18,31 y OR 7,08; IC95% 1,30–38,44,
CONCLUSIONES: La tasa de autonotifi cación de una
prueba de detección de la LTBI por parte de las perso-
nas nacidas en el extranjero que residen en el estado de
Connecticut con presunción de TB o TB confi rmada fue
baja y difi rió en forma signifi cativa en función de la etnia
y la situación de inmigración. Se precisan estrategias que
mejoren el acceso a la atención de salud de las personas
nacidas en el extranjero y que amplíen la práctica de la
detección de la LTBI en las personas de origen hispano
y en las poblaciones indocumentadas.
R É S U M É
R E S U M E N