Douglas Bishop, MD Zufall Health Center, Morristown, NJ
Marc Altshuler, MD Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia marc.altshuler@jefferson.edu
Kevin Scott, MD Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia
Jeffrey Panzer, MD Family and Community Medicine, Northwestern University, Erie Family Health Center, Chicago
Geoffrey Mills, MD, PhD Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia
Patrick McManus, MD Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia
The authors reported no potential conflict of interest relevant to this article.
Screen for tuberculosis Refugees have a higher prevalence of latent tuberculosis infection (LTBI) and active TB than the general US population. An estimated one-third of the world’s population has LTBI.15 Since 2002, more than 50% of all people diagnosed with TB in the United States have been born outside the country.16
Although otherwise healthy adults with LTBI have a lifetime risk of approximately 10% that it will progress to active TB,17 infants, young children, and people coinfected with HIV have a rate of progression of around 10% per year. It is imperative, therefore, that all refugees be screened for TB and treated appropriately.8,18,19
FAST TRACK
Latent tuberculosis is much more likely to progress to active TB in infants, young children, and people coinfected with HIV than in otherwise healthy adults.
Refugees are screened for active TB with a chest radiograph and possibly a sputum analysis during the OME. Because screening may take place as long as 12 months before arrival in the United States, refugees may be re-exposed to TB in the refugee camp before departure. They are not screened for LTBI before coming to the United States.11,12
Domestic screening for LTBI is complicated by routine use in many foreign countries of the Bacille Calmette-Guérin (BCG) vaccine, which can reduce the incidence of TB meningitis and disseminated TB in children, but does not protect adults against primary infection or reactivation of TB. Tuberculin skin testing using purified protein derivative, which has typically been used for screening, can render false-positive results, particularly in the context of previous BCG vaccination.
Interferon-gamma release assay (IGRA) is an alternative screening option that has been approved for use in the United States.15,20 Because the IGRA is a blood test, it eliminates interpretation errors associated with tuberculin skin testing and is not affected by BCG vaccination. IGRA testing also does not require an additional office visit.
For these reasons, we recommend screening all refugees older than 5 years with IGRAs, where available. In light of scant data and apparent differences in immune response in young children, the CDC recommends using tuberculin skin testing either alone or in conjunction with IGRA testing for all children younger than 5 years.20,21
Positive screening tests must be followed up with a chest radiograph. Perform serial sputum evaluation whenever the chest radiograph indicates potential active TB.
Everyone with latent or active TB must be treated according to CDC recommendations adapted from guidelines established by the American Thoracic Society and Infectious Diseases Society of America.22,23 For latent TB, the CDC calls for treatment with isoniazid for 9 months or rifampin for 4 months.
Patients older than 18 years should receive the adult dose of isoniazid: 5 mg/kg per day orally to a maximum daily dose of 300 mg. Children should receive 10 to 20 mg/kg per day orally to a maximum daily dose of 300 mg. Twice weekly therapy schedules are also available and commonly used for children who receive directly observed treatment in school.
The adult dosage of rifampin (for patients >15 years) is 10 mg/kg per day orally to a maximum daily dose of 600 mg; the pediatric dose is 10 to 20 mg/kg per day orally, also to a maximum daily dose of 600 mg.
Patients taking isoniazid who are pregnant or breastfeeding or have diabetes, renal failure, alcoholism, malnutrition, HIV, or a seizure disorder should receive pyridoxine (vitamin B6) supplementation to aid in preventing peripheral neuropathy, in an adult oral dose of 25 to 50 mg/d or a pediatric oral dose of 6.25 mg/d. Additional information on treating latent TB is available at http://www.cdc.gov/tb/topic/treatment/ltbi.htm.
For patients with active TB, treatment is more complex, based on the patient’s overall health. Please refer to the CDC recommendation for the treatment of active TB (http://www.cdc.gov/tb/topic/treatment/tbdisease.htm) or contact your local TB control division.
Patients may receive TB treatment from either individual medical providers or city or state health departments, depending on local capacity. In our practice, we treat LTBI in adults. The Philadelphia Department of Public Health’s TB Control Program manages LTBI in children and all suspected cases of active TB. We recommend providing everyone treated for latent or active TB with documentation of treatment completion.
Diagnose and treat problematic parasites Intestinal parasites are among the infections most often found in refugee populations.7,8,24-29 Common pathogens in untreated refugees are Ascaris lumbricoides, hookworm (Ancylostoma duodenale and Necator americanus), Schistosoma species, Strongyloides stercoralis, Trichuris trichiura, and Giardia lamblia.
FAST TRACK
Although sustained domestic transmission is unlikely, intestinal parasites may lead to growth delay, anemia, hyperinfestation syndrome and disseminated infection, and increased cancer risk.
