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© 2005 American Public Health Association
DOI: 10.2105/AJPH.2003.019620
RESEARCH AND PRACTICE |
Francesca M. Gany, Chau Trinh-Shevrin, and Jyotsna Changrani are with the Center for Immigrant Health at the New York University School of Medicine, New York, NY.
Correspondence: Requests for reprints should be sent to Francesca Gany, MD, MS, Center for Immigrant Health, New York University School of Medicine, BCD-D-401, 550 First Ave, New York, NY 10016 (e-mail: fg12{at}nyu.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We explored an innovative strategy for targeted testing and disease management among immigrant communities at risk for tuberculosis.
Methods. Taxi drivers were recruited at an airport holding lot to undergo tuberculin skin testing (Mantoux). After receiving their test results in a location convenient for them, drivers with positive results were referred for evaluation and treatment. We conducted baseline and follow-up assessments.
Results. Of 123 drivers who participated, two thirds (82) were at high risk for tuberculosis. Seventy-eight (63%) of the 123 returned for test readings; 62% of these drivers had positive test results. All drivers with positive results received a complete physician evaluation, but 64% of those evaluated were not treated for latent TB infection. Of the untreated drivers, 37.5% were at high risk. Systemic and physician barriers (e.g., lack of knowledge, erroneous beliefs regarding vaccines) affected adherence to evaluation and treatment.
Conclusions. Targeted testing and treatment are important to the control of tuberculosis. The results of this study highlight the need for an aggressive physician educational campaign to identify latent tuberculosis infection and to tailor service delivery to meet the unique needs of foreign-born communities.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Of all infectious diseases, tuberculosis (TB) is the leading killer worldwide.1 In the United States, although TB is on the decline in US-born persons, it continues to increase in foreign-born persons. In New York City, the proportion of cases of TB that occurred in foreign-born persons increased from 17.7% in 1992 to 66% in 2001.2 Several factors are responsible for the increase, including high endemicity in immigrants’ countries of origin3,4 and lack of adequate access to health care in the United States.
A consistent shift was demonstrated in the epidemiology of TB in the United States from the late 1980s through the 1990s.5–11 Geng and colleagues8 demonstrated that more than one half of TB cases at a New York City urban hospital between 1990 and 1999 were caused by reactivation of previous infections and that the majority of these cases occurred among foreign-born persons.
Current strategies to identify persons with active cases and their close contacts are effective for US-born populations at risk for TB, but opportunities have been missed in reaching communities disproportionately burdened with latent TB infection.1 Recent immigrants from areas with a high prevalence of TB constitute a large segment of the population at risk, and targeted testing and treatment are needed for these persons.
To control TB in immigrant communities, the Center for Immigrant Health at the New York University School of Medicine implemented the Community Tuberculosis Prevention Program (CTPP). This program provides community outreach, education, screening, and case management for persons with latent TB infection. Most of the clients of the CTPP are recent immigrants who have not previously received health care in the United States. The CTPP uses creative approaches that consider the unique circumstances of immigrant communities.
The taxi driver workforce in New York City is mostly immigrant, and many of its members were born in countries where TB is endemic. The drivers face economic and cultural barriers to health care, aggravated by long working hours. They are at risk for latent TB infection and for a number of medical conditions that increase their risk for developing active TB.
John F. Kennedy International Airport is a major hub of taxi activity. Drivers await passengers in the airport central holding lot; sometimes, they wait for several hours. This waiting period is a key window of opportunity for public health intervention: an at-risk, mobile population is converted to a captive audience. We describe an opportunistic intervention to identify latent TB infection and prevent active TB in this at-risk population.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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In July 2002, the Center for Immigrant Health participated in the first health fair for taxi drivers. The health fair was held at the John F. Kennedy International Airport holding lot and was organized by the New York Taxi Workers Alliance, in association with the Asian American Network for Cancer Awareness Research and Training in New York and the Asian American Federation of New York. In general, health fairs are not a good venue in which to conduct TB screenings. The fairs are held for 1 day, and TB screening requires a second contact for reading of the test results. Adherence rates for follow-up readings are low. We devised a creative approach to reducing low return rates.
Six multilingual staff members of the Center for Immigrant Health provided TB education and screening to 123 taxi drivers. They counseled the drivers about the importance of returning for the reading of the results and provided them with verbal and written instructions regarding when and where the test readings would take place.
To accommodate the drivers’ working schedules and their concern that a loss in driving time represented a loss of income, the readings were held in the fire lane of a centrally located municipal hospital. The drivers drove through the lane, placed their arms out for measurement of the tuberculin skin test reaction, and, if the test result was negative, were given a letter stating the result; the drivers then drove on. The drivers who did not appear on the first day of reading were notified via their cellular telephones to return on the final day.
If the test result was positive, the drivers were individually educated on the positive test results and on the importance of treating latent TB. They (1) went to have chest radiographs taken immediately (at the municipal hospital, the Department of Health and Mental Hygiene Chest Clinic, or a private provider), as the driver’s time permitted, with appointments for follow-up at the municipal hospital chest clinic, a Department of Health and Mental Hygiene Chest Clinic, or a private provider; or (2) were given an appointment at the Department of Health and Mental Hygiene Chest Clinic for both chest radiographs and follow-up care; or (3) were given a referral for their own health care provider, if this was the driver’s preference.
All patients who began medication for latent TB infection had their cases managed to completion or termination of therapy.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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One hundred twenty-three drivers from more than 25 countries were tested for latent TB infection (Table 1
). All participants were male. Ninety-seven percent of participants had been born outside the United States. Mean length of time in the United States was 16.44 years (SD=10.85 years), but many had made multiple, prolonged visits to their countries of origin during the past 5 years. Eighty-two (67%) were at high risk for TB (risk factors= residence in the United States for <5 years, travel outside the country within the past 5 years for 
1 month, contact with a person with an active case of TB, presence of symptoms associated with TB, and coexisting medical conditions). Of the 123 drivers, approximately two thirds (82 drivers) were from Pakistan, India, Haiti, and Bangladesh. One hundred two (83%) of participants had no health insurance; only 26 (21%) drivers had a family physician. Nearly two thirds of participants had never been tested for TB.
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Of the 123 participants, 78 (63%) returned for the tuberculin skin test readings (Figure 1
). Of participants who returned, 86% had never been previously tested for TB. Seventy-six percent of returning participants were at high risk for latent TB infection and activation. Nearly 62% (48 persons) of those who returned had a positive tuberculin skin test result, representing approximately 39% of the total number of participants screened for latent TB infection. Participants with positive and negative tuberculin skin test results did not differ according to length of time in the United States.
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For 45 (94%) of the 48 tuberculin skin testpositive participants, we received complete information regarding follow-up assessments for chest radiographs, physician evaluations, and treatment status. More than two thirds (31 of 45) of the tuberculin skin test–positive participants received a chest radiograph. Twelve received a chest radiograph on the spot at the drive-by readings. More than 40% of participants who were scheduled to have a chest radiograph taken at a later date did not do so—most found this appointment inconvenient or had concerns about cost, and 1 individual was advised by his private physician that he did not need a radiograph. Of those who received a full physician evaluation, 64% (16 of 25) were advised not to start treatment for latent TB infection. Of this 64%, 37.5% (6 people) had reported coexisting medical conditions or TB exposure and were considered at high risk for TB. Nine participants were advised to start treatment for latent TB infection; 8 participants initiated treatment, and 4 (50%) completed treatment. Participants who did not complete treatment cited as reasons side effects of the medication or leaving the country for a prolonged period of time.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Targeted testing for latent TB infection is an important tool for identifying populations vulnerable to the development of TB. A targeted testing program for latent TB infection must be implemented with an effective plan to provide medication to those with positive test results.1,12,13
Initially, this screening program effectively reached a marginalized, uninsured, at-risk community. Attendance at test readings was high for this mobile, recently immigrated, medically underserved population, probably owing to the culturally sensitive design of the reading. Of importance to the taxi drivers was their mobility combined with a lack of available parking, as well as the unpredictable nature of their business. Drive-by readings addressed these needs. Drivers’ use of cellular telephones allowed us to remind them of readings; 85 (69%) of participants provided us with their cellular telephone number. Many responded to a telephone reminder and drove by the skin test reading site to receive their readings. Staff cultural competence was a necessary component of this success.
However, the system was less successful in facilitating treatment initiation and adherence. In this study, indicated treatment was often not prescribed by the physician. Among 16 who were advised not to initiate latent TB infection treatment (out of the 25 participants who received a full physician evaluation), 37% met Centers for Disease Control and Prevention guidelines for treatment because of risk factors for activation.5 This outcome underscores the need for a more aggressive latent TB infection educational campaign for medical providers who serve high-risk communities.
For taxi drivers, time is money. Long work schedules significantly affected adherence to medication regimens, as did the requirement of scheduled appointments. Opting to meet an appointment instead of accepting a fare directly translates into a loss of income. Although the targeted testing was conducted in a convenient manner, the clinic system is less convenient for taxi drivers. Programs that target immigrants, an important risk group, need a flexible appointment system that accounts for the unique work circumstances of immigrants.
Treatment completion rates for latent tuberculosis infection in the United States are low. The Centers for Disease Control and Prevention found that in major urban areas, the overall therapy completion rate is 57%. Among those who were eligible for therapy, the completion rate was 44%.1
TB control in the US immigrant population is essential, yet many large, highly visible, and well-defined foreign-born communities are not reached by traditional public health efforts. Tailoring service delivery to the unique needs of foreign-born populations is necessary to prevent and control TB.
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Acknowledgments |
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The Community Tuberculosis Prevention Program is funded by the New York City Department of Health and Mental Hygiene.
We would like to thank Mike Lee and Jessica Lee for their assistance in preparation of the article.
Human Participant Protection
Institutional review board approval was obtained from New York University School of Medicine.
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Footnotes |
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Peer Reviewed
F.M. Gany is the principal investigator of the Community Tuberculosis Prevention Program. F.M. Gany originated the study and supervised all aspects of its implementation. C. Trinh-Shevrin assisted with the study and the data analysis. J. Changrani assisted with the study, synthesized analyses, and edited the article. All of the authors helped conceptualize the study, interpret findings, and review drafts of the article.
Accepted for publication January 23, 2004.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. Institute of Medicine. Ending Neglect: The Elimination of Tuberculosis in the United States. Washington, DC: National Academy Press; 2000.
2. New York City Department of Health Tuberculosis Control Program. Tuberculosis in New York City, 2001: Information Summary. New York, NY: New York City Department of Health; 2002.
3. Alland D, Kalkut GE, Moss AR, et al. Transmission of tuberculosis in New York City: an analysis by DNA fingerprinting and conventional epidemiologic methods. N Engl J Med. 1994;330:1710–1716.
4. Frieden TR, Fujiwara PI, Washko RM, et al. Tuberculosis in New York City—turning the tide. N Engl J Med. 1995;333:229–233.
5. Centers for Disease Control and Prevention. Recommendations for prevention and control of tuberculosis among foreign-born persons. MMWR Morb Mortal Wkly Rep. 1998;47(RR-16):1–19.[Medline]
6. Chin DP, DeRiemer K, Small PM, et al. Differences in contributing factors to tuberculosis incidence in US-born and foreign-born persons. Am J Respir Crit Care Med. 1998;158:1797–1803.
7. Davidoff AL, Marmor M, Alcabes P. Geographic diversity in tuberculosis trends and directly observed therapy, New York City, 1991 to 1994. Am J Respir Crit Care Med. 1997;156:1495–1500.
8. Geng E, Kreiswirth B, Driver C, et al. Changes in the transmission of tuberculosis in New York City from 1990 to 1999. N Engl J Med. 2002;346:1453–1458.
9. Liu Z, Shilkret KL, Tranotti J, et al. Distinct trends in tuberculosis morbidity among foreign-born and US-born persons in New Jersey, 1986 through 1995. Am J Public Health. 1998;88:1064–1067.
10. McKenna MT, McCray E, Jones JL, et al. The fall after the rise: tuberculosis in the United States, 1991 through 1994. Am J Public Health. 1998;88:1059–1063.
11. Talbot EA, Moore M, McCray E, et al. Tuberculosis among foreign-born persons in the United States, 1993–1998. JAMA. 2000;284:2894–2900.
12. American Thoracic Society and Centers for Disease Control and Prevention. Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med. 2000;161:S221–S247
13. New York City Department of Health. Testing and Treatment for Latent Tuberculosis Infection. New York, NY: New York City Department of Health; 2000.
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