RESEARCH AND PRACTICE
Latent Tuberculosis Infection Screening in Foreign-Born
Populations: A Successful Mobile Clinic Outreach Model
| Jamie P. Morano, MD, MPH, Alexei Zelenev, PhD, Mary R. Walton, MHS, PA-C, R. Douglas Bruce, MD, MA, MSc, and Frederick L. Altice, MD, MA
Foreign-bom populations are at greatest risk
for having both latent tuberculosis infection
(LTBI) and developing tuberculosis (TB) dis­
ease within high-income countries and, in
2012, accounted for 63.0% of the 9951 TB
cases in the United States.1 Newly diagnosed
and reactivated TB infection among foreign-
bom individuals in the United States is cur­
rently 12 times greater (15.8 vs 1.4 cases per
100 000 population) than among US-bom
persons.1 Among foreign-bom individuals,
LTBI often reactivates within 5 to 10 years
after arrival to the United States.2'3 Undocu­
mented migrants and visitors from high-TB-
prevalence countries, however, do not undergo
routine LTBI screening and thus remain out­
side traditional health care screening and
treatment programs in primary or specialty
care settings except when they are acutely ill.3,4
Thus, identifying and treating LTBI cases
among these high-risk populations before
transforming to TB disease and resultant
transmission to others is crucial to ending the
cycle of ongoing TB infection within the United
States.
Workplace screening,4,5 mandatory criminal
justice system screening,6-8 screening for entry
into medication-assisted therapy and drug
treatment programs,9 and refugee and natu­
ralization programs10'11 have been successful
for reaching legal and domestic populations,
but innovative options are needed to target
foreign-bom populations that are not yet in­
tegrated into mainstream care.
Culturally and geographically isolated
foreign-bom groups may be overlooked espe­
cially if there is low self-perception of tuber­
culosis risk.12 Tuberculin skin testing (TST),
though imperfecL is internationally recognized
and has been shown to be a reasonably accu­
rate assessment of LTBI status in immuno­
competent adults, despite receiving previous
Bacillus Calmette-Guerin vaccine.13 Whereas
other studies have focused on traditional clinics
or statewide programs,14 we present an
1 5 0 8 | Research and Practice | Peer Reviewed | M o ra n o e t al.
Objectives. We evaluated the efficacy o f a m obile medical clinic (MMC)
screening program fo r detecting latent tuberculosis infection (LTBI) and active
tuberculosis.
Methods. A LTBI screening program in a MMC in New Haven, Connecticut,
used medical surveys to examine risk factors and tuberculin skin test (TST)
screening elig ib ility. We assessed clinically relevant correlates o f total (preva­
lent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011.
Results. Am ong 8322 individuals, 4159 (55.6%) met TST screening e lig ib ility
criteria, of which 1325 (31.9%) had TST assessed. S im ilar to LTBI prevalence
(16.8%; 779 o f 4650), newly diagnosed LTBI (25.6%; 339 o f 1325) was indepen­
dently correlated w ith being foreign-born (adjusted odds ratio [AOR] = 8.49; 95%
confidence interval [Cl] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% Cl = 1.88, 5.20),
Black (AOR = 2.16; 95% Cl = 1.31, 3.55), employed (AOR = 1.61; 95% Cl = 1.14,
2.28), and of increased age (AOR = 1.04; 95% Cl = 1.02, 1.05). Unstable housing
(AOR = 4.95; 95% Cl = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% Cl = 1.05,
2.37) were significantly correlated w ith incident LTBI, and being male, heroin
use, interpersonal violence, em ploym ent, not having health insurance, and not
com pleting high school were significantly correlated w ith prevalent LTBI.
Conclusions. Screening fo r TST in MMCs successfully identifies high-risk
foreign-born, Hispanic, w orking, and uninsured populations and innovatively
identifies LTBI in urban settings. (Am J Public Health. 2014;104:1508-1515. doi:
10.2105/AJPH.2014.301897)
innovative mobile medical clinic (MMC) as The Community Health Care Van (CHCV) is
a model to target “hidden” foreign-bom pop­ an MMC that provides free health care 5 days
ulations for LTBI screening. per week in 4 impoverished neighborhoods
New Haven, Connecticut the country’s in New Haven. Though at inception the pro­
fourth poorest city for its size, with a census of gram was linked to the needle and syringe
130 000, is a medium-sized urban setting in exchange program,17 it has since expanded
New England that has experienced extraordi­ over 20 years to become a vital bridge to
nary social and medical disparities including a diverse array of health and addiction treat­
a high prevalence of poverty, drug addiction, ment services that includes services for medi­
HIV/AIDS, and unemployment and is dispro­ cally underserved populations, including di­
portionately comprised of people of color, rectly administered antiretroviral therapy to
including 35.4% and 27.4% being Black or treat HIV,18-21 buprenorphine maintenance
Hispanic, respectively.15 As New Haven is an therapy,22-25 community transitional pro­
industrial city with low-paying jobs, there has grams from the criminal justice system,26-33
been an influx of foreign-bom people, now hepatitis B vaccination,34 rapid hepatitis C
officially comprising 11.6% of the population, screening,35 and other ongoing primary
with many having an undocumented residency health care programs such as screening and
status. Health care access for this group is monitoring of sexually transmitted infections,36
absent unless individuals pay directly for diabetes, and hypertension. In addition, the
fee-for-service, and concern for deportation CHCV provides outreach and intensive case
and arrest further hinders willingness to seek management services.37 Screening for LTBI
care.16 and TB disease began in 2003 to target
American Journal o f Public Health | August 2 0 1 4 , Vol 10 4, No. 8

high-risk undocumented and foreign-bom cli­
ents, as well as clients entering chug treatment
programs or homeless shelters, who were
concerned about TB infection yet were re­
luctant to seek care in traditional health care
settings for fear of deportation, prohibitive cost,
or language barriers. The LTBI screening
program shortly thereafter became successfully
incorporated into the country’s first mobile
buprenorphine maintenance therapy
program.9
M ETHO DS
We selected 2 primary outcomes: (1) we
defined total LTBI prevalence as all positive
TSTs in the study population and included any
past or present diagnosis of either TB disease
or LTBI regardless of treatment status, and (2)
we defined LTBI incidence as a subset of newly
diagnosed LTBI as part of CHCV’s new TST
screening program. The TST screening algo­
rithms were consistent with the Centers for
Disease Control and Prevention (CDC) recom­
mendation of screening for high-risk and recent
immigrant populations but also included health
care providers and those entering drug treat­
ment programs who had not been TST
screened in the previous 12 months.11 Total
prevalent LTBI reflected the total number of
persons identified with a past or current posi­
tive TST result on the CHCV as part of routine
clinical care, and newly diagnosed LTBI (LTBI
incidence) reflected the effectiveness of the
CHCV’s public health-oriented LTBI screening
program. For each of these outcomes, we
examined the independent correlates by using
standard measures used in routine clinical
practice.
S tu d y P opulation
All CHCV clients complete a standardized
medical intake survey that assesses demo­
graphic characteristics, country of origin, past
history and treatment of TB disease or LTBI,
time periods of previous TST placement and
results, screening chest x-rays (CXRs), and
medical history including HIV, pulmonary
disease, mental illness, and substance use. Un­
documented status was assessed with a unique,
confidential coding mechanism to protect
clients. Patients with positive TST (defined as
> 1 0 mm for HIV-negative individuals and > 5
August 20 1 4 , Vol 10 4, No. 8 | American Journal o f Public Health
RESEARCH AND PR A C TIC E
mm for HIV-infected individuals) underwent
World Health Organization (WHO) screening
for symptoms38 and were immediately re­
ferred for a CXR. As previously reported,
patients with symptoms or abnormal CXR re­
sults underwent sputum culture for TB disease,
and those identified with LTBI were offered 9
months of treatment of LTBI free of charge
either on the CHCV or at a local TB clinic.39
Patients eligible for TST screening included
those who either self-reported no previous TST
or who had a CDC-defined need to be screened
more than 1 year previously. Ineligibility for
TST screening included those screened within
the past year, who reported and confirmed
previous treatment of TB disease, or who had
a documented previous positive TST (with or
without isoniazid preventative therapy). Pre­
vious documented positive TST was confirmed
either by MMC medical record or by patient
history with chart review confirmation.
A nalysis
We first extracted medical information
without unique identifiers and available within
the electronic medical record from January
2003 to July 2011 into an SPSS version
18 (SPSS Inc, Chicago, EL) database and then
analyzed it with Stata IC version 12.1 (Stata-
Corp LP, College Station, TX). We selected
independent variables selected from the com­
prehensive medical intake for clinical relevance
to LTBI. As previously defined,27 patients with
stable housing reported living in one’s own
apartment, in one’s own house, or with one’s
family.40 We defined unstable housing as living
in a shelter, in a halfway house, with friends,
in a hotel, or in a public place. We classified
being married or living together as a committed
relationship. We defined no relationship status
as being divorced, separated, widowed, or
single. We defined foreign-bom by self-report
of country of birth being outside the United
States or Puerto Rico. We assessed standard­
ized measures of type, route, and frequency of
dmg use, including the 30-day time period
before TST screening, by using the dmg com­
ponent of the Addiction Severity Index.41 We
defined hazardous drinking as 4 or more
drinks daily for men and 3 or more drinks daily
for women; a “drink” was defined as equivalent
to 12 ounces of beer or 1.5 ounces of hard
liquor. We defined sex work as exchange of
Morano et at. | Peer Reviewed | Research and Practice | 1 5 0 9
sexual intercourse for money, drugs, or pro­
tection, and we defined sex solicitation by
self-report of paying money for sexual inter­
course. We defined recent incarceration and
recent emergency department visits by self-
report if such an encounter occurred within the
previous 6 months. Interpersonal violence in­
cluded anyone reporting a history of either
domestic violence or sexual assault.
We used the Wilcoxon rank sum test to test
differences between persons with positive
and negative TST results (Table 1), and we
used the Kruskall-Wallis test to discern dif­
ferences between groups representing newly
diagnosed LTBI (newly identified clients with
positive TSTs on the CHCV considered in­
cident LTBI) and total LTBI prevalence (all
clients with previous positive TST, including
TB disease; data not shown). To not overfit
the final multivariate regression model, we
entered covariates on bivariate analyses for
each of the 2 dependent variables significant at
P< .05 into stepwise backward and forward
multivariate logistic regressions with the final
model selected on the basis of goodness of fit
by using the Akaike information criterion. In
the instances where the data were not missing
at random (i.e., substance use), the nonresponse
predominantly reflected a negative outcome
(i.e., nonuse); in other instances where the
missing mechanism was hard to discern, we
initially tried multiple imputations but these
ultimately did not influence the results.
We calculated the marginal effects for
covariates in the multivariate logistical regres­
sion to measure if the incremental change in
probability of the outcome was associated with
the change in each of the covariates.42 Testing
for multicollinearity revealed that the estima­
tion of parameters on foreign-bom and race
variables in our final model was robust and did
not affect the final outcomes. Finally, we
performed a more specific analysis for the
top-5 countries of origin with the greatest
percentage of LTBI for both newly diagnosed
and previous LTBI compared with the United
States by using the x2 and Fisher exact test as
appropriate.
RESULTS
From January 2003 to June 2011, the
CHCV’s screening program for LTBI had
 RESEARCH AND PRACTICE

regulatory requirements (employment, entry

TABLE 1 -D e m o g ra p h ic , C lin ic a l, and Risk F actor C h ara c te ristic s o f All C lie n ts Receiving into drug treatment, etc.) and were not included
Tuberculin Skin Testing, S tra tifie d by Positive o r N egative Result: C om m unity H e a lth Care in the TST screening evaluation because they
Van M o b ile M e d ic a l C linic, New Haven, C o n n e ctic u t, 2 0 0 3 - 2 0 1 1 did not meet clinical eligibility according to CDC
recommendations.10'13 Nearly 78.0% (n = 1325)
Total Screened Total Prevalent LTBI No LTBI (All TST-)
(n - 4650), (All TST+) (n = 779), (n = 3871), of eligible patients who underwent TST
Variable No. (%) or Mean No. (%) No. (%) P returned 4 8 to 72 hours later for TST reading.
Of those TSTs read, 25.6% ( n = 339) had
Age at IS I screening, y 37.0 40.7 36.3 <.001
a positive test result; 1 of these was further
Gender
determined to have TB disease, leaving 338
Male 2585 (55.6) 481 (61.7) 2104 (54.4) <.001
cases of LTBI diagnosed by the CHCV.
Female 2065 (44.4) 298 (38.3) 1767 (45.6)
Race/ethnicity
P r e v a le n t L a te n t T u b e rc u lo s is In fe c tio n
White 1268 (27.3) 97 (12.5) 1171 (30.3) <.001
In total, 7 7 9 individuals with total prevalent
Black 1858 (40.0) 288 (37.0) 1570 (40.6) .062
LTBI (previously and newly diagnosed) com­
Hispanic 1483 (31.9) 374 (48.0) 1109 (28.6) <.001
pared with those with negative TST (previously
Other 30 (2.4) 9 (1.2) 21 (0.5) .051
and newly placed) were more likely to be male
Foreign-born 808 (17.4) 372 (47.8) 436 (11.3) <.001
(61.7%), Hispanic (48.0%), foreign-bom
Undocumented immigrant 421 (9.1) 198 (25.4) 223 (5.8) <.001
(47.8%), undocumented (25.4%), and without
High-school completion 3221 (69.3) 498 (63.9) 2723 (70.3) .008
health insurance (57.9%). It was interesting
Stable housing 2643 (56.8) 444 (57.0) 2199 (56.8) .583
that clients with a negative TST reported
Committed relationship 791 (17.0) 219 (28.1) 572 (14.8) <.001
significantly more injection drug use behavior
Employed 1454 (31.3) 341 (43.8) 1113 (28.8) < .001
(24.6% vs 17.3%) and crack cocaine use
Health insurance 2853 (61.4) 328 (42.1) 2525 (65.2) < .001
(41.8% vs 29.0%) than those without LTBI
Known HIV-positive 463 (10.0) 85 (10.9) 378 (9.8) .271
(Table 1). Multivariate modeling demonstrated
Known hepatitis C-positive 658 (14.2) 101 (13.0) 557 (14.4) .369
highly significant correlations with total LTBI
Injection drug use, ever 1087 (23.4) 135 (17.3) 952 (24.6) <.001
prevalence (Table 2), including being foreign-
Injection drug use, past 30 d 347 (7.5) 37 (4.7) 310 (8.0) <.002
bom (adjusted odds ratio [AOR] = 6.27; 95%
Drug use, ever
confidence interval [Cl] = 4.92, 8.01), Hispanic
Heroin 1543 (33.2) 193 (24.8) 1350 (34.9) <.001
(AOR = 2.16; 95% C I= 1.64, 2.84), Black
Cocaine 2116 (45.5) 272 (34.9) 1844 (47.6) <.001
(AOR = 2.15; 95% C I= 1.64, 2.84), a heroin
Crack cocaine 1845 (39.7) 226 (29.0) 1619 (41.8) < .001
user (AOR= 1.34; 95% C I= 1.06, 1.69), male
Marijuana 3228 (69.4) 399 (51.2) 2829 (73.1) <.001
(AOR = 1.31; 95% Cl = 1.08, 1.59), and
Methamphetamine 234 (5.0) 25 (3.2) 209 (5.4) .011
employed (AOR = 1.26; 95% Cl = 1.03, 1.56);
Hazardous drinking 2512 (54.0) 390 (50.1) 2122 (54.8) .015
experiencing interpersonal violence (AOR =
Opioid substitution therapy, past 30 d 594 (12.8) 67 (8.6) 527 (13.6) <.001
1.33; 95% Cl = 1.05, 1.70); not having health
Emergency department visit, recent 1647 (35.4) 202 (25.9) 1445 (37.3) <.001
insurance (AOR = 1.30; 95% Cl = 1.05, 1.63);
Incarceration, recent 1114 (24.0) 120 (15.4) 994 (25.7) <.001
not completing high school (AOR = 1.26; 95%
Sex solicitation 521 (11.2) 123 (15.8) 398 (10.3) <.001
Cl = 1.04, 1.54); and increasing age (AOR =
Sex work 503 (10.8) 57 (7.3) 446 (11.5) <.001
1.04; 95% Cl = 1.03, 1.05). Similar to the
Interpersonal violence 927 (19.9) 128 (16.4) 799 (20.6) .007
model for incident LTBI, being foreign-bom
Sexually transmitted infection 1203 (25.9) 168 (21.6) 1035 (26.7) .005
contributed the greatest to prevalent LTBI with
Mental health diagnosis 1322 (28.4) 159 (20.4) 1163 (30.0) <.001
marginal effect modeling; being foreign-bom
Note. LTBI - latent tuberculosis infection; TB - tuberculosis; TST - tuberculin skin test. Percentages represent total clients by was associated with an increase in the proba­
column category and may not add to 100% because of client nonresponse. Total prevalent LTBI represents the sum of bility of having LTBI by 30% relative to being
incident LTBI (newly TST-positive) and prevalent LTBI (previously TST-positive and previously active TB).
not being foreign-bom.
Of the 372 total foreign-bom individuals
a total of 8322 unique clients, of whom 89.9% The TST positivity rate for ineligible clients with a positive TST, 34.9% (n = 130) reported
(n = 7484) completed full demographic intake who had completed screening in the past 12 having a primary care physician, and 23.7%
questionnaires (Figure 1). Of these, 55.6% m onths was 13.2% (n = 440). An additional (n = 88) reported having had a CXR before their
(n = 41 5 9 ) of individuals w ere considered 1459 individuals (17.5%) who had undergone CHCV visit in the context of general health
TST-eligible with 40 .9 % of these (n = 1699) TST screening in the previous year underwent assessment for immigration or other medical
having completed previous LTBI screening. repeat TST screening on the MMC for reason. Of the 198 total undocumented

1 5 1 0 | Research and Practice | Peer Reviewed | Morano et a/. American Journal o f Public Health | August 2 0 1 4 , Vol 10 4, No. 8

Note. T B -tu b e rc u lo s is ; TST = tuberculin skin test.
a4 5 9 ad dition al patients who did not m eet TST screening eligibility underw ent TST screening and are not reported here.
FIG UR E 1 -T u b e rc u lin skin te s t scre e n in g a lgo rithm fo r la te n t tu b erculo sis in fe c tio n on the
C om m unity H e a lth C are Van m o b ile m e d ic al c lin ic (n = 7 4 8 4 ) , N ew Haven, C o n n e ctic u t,
2 0 0 3 -2 0 1 1 .
immigrants with a positive TST, 29.8% (n = 59)
self-reported having a primary care physician,
and 13.6% (n = 27) self-reported having a pre­
vious CXR screening with a minority of 40.4%
(n= 80) reporting previous TST screening be­
fore first CHCV visit Having a primary care
provider was not found to be a significant de­
terminant of either previous or newly identified
positive TST status.
Newly Diagnosed Latent Tuberculosis
Infection
Individuals with newly diagnosed LTBI (in­
cident LTBI as defined by newly TST-positive
among those who were eligible for testing)
were statistically more likely than those with­
out newly diagnosed LTBI to be male (66.4%),
Hispanic (57.2%), foreign-bom (60.5%), un­
documented (37.5%), and employed (50.4%),
and to have never injected drugs (10.0%),
and to not have had a recent emergency
department visit (73.5%). Only 16.8% (n = 57)
of the 339 individuals newly found to have
a positive TST self-reported having a primary
care doctor, and only 7.4% (n = 25) had
August 20 1 4 , Vol 1 0 4 , No. 8 | American Journal o f Public Health
RESEARCH A ND PR AC TICE
received previous CXR screening (data not
shown).
Multivariate modeling identified highly sig­
nificant correlates for incident LTBI (Table 2),
which included being foreign-bom (AOR =
8.49; 95% Cl = 5.54, 13.02), having unstable
housing (AOR = 4.95; 95% CI = 3.43, 7.14),
being Hispanic (AOR = 3.12; 95% Cl = 1.88,
5.20) or Black (AOR = 2.16; 95% Cl = 1.31,
3.55), marijuana use (AOR= 1.57; 95% CI =
1.05,2.37), and being employed (AOR = 1.61;
95% Cl = 1.14, 2.28). Hazardous drinking,
however, was inversely correlated with clients
having a newly identified positive TST (AOR =
0.64; 95% Cl = 0.47, 0.87). Marginal effect
calculation implied that being foreign-bom was
associated with an increase in probability of
being newly identified as having a positive TST
by 0.41 or, equivalently, 41.2%.
Latent Tuberculosis Infection by Country
of Origin
Foreign-bom status was confirmed to have
a large marginal effect on both TST-positive
prevalence and incidence. Countries of origin
Morano et at. | Peer Reviewed | Research and Practice | 1 5 1 1
with the most numerous foreign-bom patients
with incident LTBI identified on this MMC
were Mexico (19.2%; n = 65), Ecuador
(14.7%; n = 50), Guatemala (3.5%; n = 12),
and Jamaica (1.8%; n = 6). The United States
and Puerto Rico as a single region contributed
the largest absolute number of incident LTBI
cases at 49.0% (n= 128) because of the large
volume screened from the United States.
Nearly two thirds of newly diagnosed LTBI
cases were among foreign-bom individuals
(62.2%; n = 2 1 1 of 339), and being foreign-
bom increased one’s odds of having a positive
TST, from 4.9- to 10.1-fold (PC .001),
depending on the country of origin, based on
WHO tuberculosis prevalence category (table
not shown). Among the 779 total individuals
with a positive TST, 25.4% (n= 198) were
undocumented immigrants, and 47.8% (n =
372) were foreign-bom.
In terms of LTBI prevalence, participants
from foreign-bom countries had the greatest
likelihood of having newly identified LTBI
but were similar to the United States and
Puerto Rico in terms of absolute numbers
(50.6%; n = 394). A graphical representation
of TST-positive incidence and prevalence by
the top 5 regions of origin reveals statistically
significant greater percentage yield for identi­
fication of clients with newly diagnosed posi­
tive TST (P<.01; Figure 2).
DISCUSSION
Although other MMCs have effectively
screened for TB, one such program in Rotter­
dam, Netherlands, operational since 2002,43,44
targeted exclusively the homeless and people
who injected drugs by using chest radiographs
to detect active TB disease, but did not screen
for LTBI. By contrast, our program included
a more heterogeneous sample and assessed
clients longitudinally over a longer time period;
it focused on LTBI identification using TST and
was overrepresented by foreign-bom His-
panics, which is the predominant immigrant
population in New Haven. Although other
TB screening programs in MMCs exist do­
mestically and internationally, little peer-
reviewed data are available, and such pro­
grams typically focus on active TB case
finding through CXR screening.
 RESEARCH AND PRACTICE

status that are not linked to interdiction efforts,

TABLE 2 -In d e p e n d e n t C o rrela te s o f Total Prevalen t L ate n t Tuberculosis In fe c tio n were critical to the success of the LTBI
(n = 4 6 5 0 ) and In c id e n t L a te n t Tuberculosis In fe c tio n (n = 1 3 2 5 ) W ith M u ltiv a ria te screening program, especially for previously
Logistic Regression and M a rg in a l E ffec ts M o d e lin g unscreened foreign-bom populations.
Marginal Effects (95% Cl) P
It is interesting that the decreased likelihood
Variables AOR (95% Cl) P
of newly diagnosed LTBI among those using
Total LTBI variables3 crack cocaine and taking part in hazardous
Foreign-born 6 .2 7 (4 .9 2 , 8 .0 1 ) < .0 0 1 0 .3 0 1 (0 .2 5 5 , 0 .3 5 5 6 ) < .0 0 1 drinking may not reflect low LTBI prevalence,
Hispanic 2 .1 6 (1 .6 4 , 2 .8 4 ) < .0 0 1 0 .0 9 6 (0 .0 5 9 , 0 .1 3 2 ) < .0 0 1 but more likely reflects that these high-risk
Black 2 .1 5 (1 .6 4 , 2 .8 4 ) < .0 0 1 0 .0 9 2 (0 .0 5 8 , 0 .1 2 7 ) < .0 0 1 persons may have previously interfaced with
Heroin use 1 .3 4 (1 .0 6 , 1.6 9 ) .0 1 6 0 .0 3 4 (0 .0 0 5 , 0 .0 6 2 ) .02 structural settings such as dmg treatment and
Interpersonal violence 1 .3 3 (1 .0 5 , 1.7 0 ) .02 0 .0 3 4 (0 .0 0 4 , 0 .0 6 5 ) .0 2 8 criminal justice settings where TST screenings
M ale gender 1.3 1 (1 .0 8 , 1.5 9 ) .0 0 6 0 .0 3 0 (0 .0 0 9 , 0 .0 5 1 ) .0 0 5 are routine. Furthermore, we note the high
Uninsured 1 .3 0 ( 1 .0 5 ,1 .6 3 ) .0 1 8 0 .0 3 1 (0 .0 0 5 , 0 .0 5 7 ) .021 prevalence of foreign-bom populations with
Not completing high school 1 .2 6 (1 .0 4 , 1.5 4 ) .0 2 0 .0 2 7 (-0 .0 0 4 , 0 .0 5 1 ) .0 2 4 positive TST among those not using drugs,
Employed 1 .2 6 (1 .0 3 , 1.5 6 ) .0 2 3 0 .0 2 7 (0 .0 0 3 , 0 .0 5 1 ) .0 2 8 perhaps suggesting the need to target this
Age 1 .0 4 ( 1 .0 3 ,1 .0 5 ) < .0 0 1 0 .0 0 4 (0 .0 0 3 , 0 .0 0 5 ) < .0 0 1 population more proactively. The increased
Incident LTBI variables6 association of total positive TST prevalence
Foreign-born 8 .4 9 (5 .5 4 , 1 3 .0 2 ) < .0 0 1 0 .4 1 2 (0 .3 2 6 , 0 .4 9 7 ) < .0 0 1 among heroin users similarly suggests that
Unstable housing 4 .9 5 (3 .4 3 , 7 .1 4 ) < .0 0 1 0 .2 7 9 (0 .2 1 3 , 0 .3 4 6 < .0 0 1 these individuals were previously screened in
Hispanic 3 .1 2 (1 .8 8 , 5 .2 0 ) < .0 0 1 0 .1 9 1 (0 .1 0 2 , 0 .2 8 0 ) < .0 0 1 structured settings and did not contribute to
Black 2 .1 6 (1 .3 1 , 3 .5 5 ) .0 0 2 0 .1 2 4 (0 .0 4 2 , 0 .2 1 0 ) .0 0 3 newly identified positive TSTs on the MMC.
Employed 1 .6 1 (1 .1 4 , 2 .2 8 ) .0 0 7 0 .0 7 8 (0 .1 3 6 , 0 .3 7 0 ) .0 0 9 In categorizing LTBI cases by country of
M arijuana use 1 .5 7 (1 .0 5 , 2 .3 7 ) .0 2 9 0 .0 6 9 (0 .0 2 0 , 0 .0 1 4 ) .0 2 6 origin, we were able to identify a remarkably
Age 1 .0 4 (1 .0 2 , 1 .0 5 ) < .0 0 1 0 .0 0 6 (0 .0 0 4 , 0 .0 0 8 ) < .0 0 1 high prevalence of newly diagnosed LTBI cases
Hazardous drinking 0 .6 4 (0 .4 7 , 0 .8 7 ) .0 0 4 - 0 .0 7 0 (-0 .0 2 2 , -0 .1 1 8 ) .0 0 4 from high TB disease incidence countries
Crack cocaine use 0 .5 9 (0 .3 9 , 0 .9 0 ) .0 1 5 -0 .0 7 6 (-0 .0 1 9 , -0 .1 3 3 ) .0 0 9 among foreign-bom clients. This finding high­
lights the importance of LTBI screening among
N ote. AOR = adjusted odds ratio; Cl = confidence interval; LTBI = latent tuberculosis infection.
3Akaike information criterion = 3 2 2 8 .7 1 ; Pearson's x 2 * 0 .0 7 5 4 . foreign-bom immigrants from high TB preva­
bAkaike information criterion = 1 0 6 9 .7 3 ; Pearson’s x 2 ■ 0 .0 5 1 . lence countries, recognizing that WHO only
reports TB disease and not LTBI prevalence
and incidence worldwide. Important in
Domestically, the greatest incidence of TB LTBI testing and return rates, however, may TB-control programs is the use of TB pre­
disease is among foreign-bom persons from reflect a bias as many clients may have re­ ventive therapy among those with LTBI, espe­
Asia and Africa.45 In New Haven, however, the quired TST for work, school, or dmg treat­ cially foreign-bom persons. A 9-month course
foreign-bom populations screened by the ment programs. of isoniazid preventive therapy for those with
CHCV were largely of Hispanic origin, which The CHCV mobile screening program serves LTBI is fraught with numerous adherence and
may reflect both the inner city’s demographics as an important, ongoing public health inter­ completion challenges. Newer approaches to
and the strong community referral factor vention with more than a quarter (25.6%) of all reduce LTBI treatment duration to 12 weekly
within the local Hispanic community by the eligible clients resulting in newly diagnosed doses of combined isoniazid with rifapentine
CHCV’s Spanish-speaking bicultural staff. A cases of LTBI, which confirms the success of for those without HIV is promising, though cost
longstanding community presence by this pro­ the LTBI screening program that targets high- and implementation challenges remain, espe­
gram has been previously described for TB risk populations that may not access traditional cially in the setting of current national dmg
screening programs by creating community- health care settings, evidenced by the low shortages.50
based trust and referral networks for both TB proportion having a primaiy physician. Estab­
screening and treatment where financial in­ lished linkages to the statewide TB control Limitations
centives are not provided.46 program enabled those with LTBI to receive Though these findings are compelling for
Moreover, among a population with a large further treatment, free of charge, through pro­ scaling up LTBI screening domestically, this
number of undocumented immigrants, sub­ vision of free CXR and laboratoiy testing and study is not without limitations. First, among
stance misusers, and hazardous alcohol provision of isoniazid preventive therapy for 4159 individuals who were considered TST-
drinkers, more than three quarters (78.0%) interested clients.39 Such proactive public eligible, only 40.9% of these (1699 of 4159)
returned for TST readings, higher than re­ health programs that target foreign-bom pop­ had a TST placed and 31.9% overall (13 2 5 of
ports elsewhere.47-49 The high acceptance of ulations, especially those with undocumented 4159) followed through with TST reading.

1 5 1 2 | Research and Practice | Peer Reviewed | Morano et al. American Journal o f Public Health | August 2 0 1 4 , Vol 10 4, No. 8
 RESEARCH AND PRACTICE

populations. As the Affordable Care Act in­

creases health insurance coverage for many
Americans, it will fail to do so among the many
who are likeliest to develop TB disease (e.g.,
newly arrived and undocumented immigrants)
and facilitate transmission to others. Lack of
supplemental community-based health care
programs may undermine current public
health efforts unless immigration reform is
achieved. Public health authorities should
consider MMCs as an effective method to
promote screening of at-risk, vulnerable
populations for LTBI and thus provide inno­
vative outreach that can further reduce TB
disease among foreign-bom and vulnerable
populations. ■

(n = 3196) (n = 5 1 1) <n = 51) (n = 225) (n=40) (n = 141)

About the Authors
Country Jamie P. Morano, Alexei Zelenev, Mary R. Walton.
R. Douglas Bruce, and Frederick L. Altice are with the Yale
N ote. LTBI - la t e n t tu b e r c u lo s is in fe c tio n . P u e rto R ic o is s h o w n s e p a ra te ly b e c a u s e i t h a s s ig n ific a n tly h ig h e r in c id e n c e a n d School o f Medicine, Department o f Infectious Diseases, Yale
p re v a le n c e t h a n t h e U S m a in la n d . N e w ly d ia g n o s e d LTBI ( in c id e n t LTBI = n e w T S T -p o s itiv e ) p lu s p r e v a le n t LTBI ( p r e v io u s TST- University AID S Program, New Haven, CT. R. D. Bruce
p o s itiv e ) e q u a ls t o t a l p r e v a le n t LTBI ( a ll T S T -p o s itiv e ). and F. L. Altice are also affiliated with the Yale School o f
aP < . 0 1 f o r n e w ly d ia g n o s e d LTBI f o r a ll fo re ig n c o u n tr ie s c o m p a r e d w ith U n ite d S ta te s . Public Health, Division o f Epidemiology o f Microbial
V < .0 1 f o r p re v io u s ly d ia g n o s e d LTBI f o r M e x ic o , J a m a ic a , a n d E c u a d o r c o m p a r e d w ith th e U n ite d S ta te s ; P < .1 7 f o r P u e rto Diseases, New Haven. F. L. Altice is also associated with the
R ic o a n d G u a te m a la c o m p a r e d w ith th e U n ite d S ta te s . Centre o f Excellence in Research in AIDS, University of
Malaya, Kuala Lumpur, Malaysia.
FIGURE 2 —Newly diagnosed and previously diagnosed latent tuberculosis infection by Correspondence should be sent to Jamie P. Morano, MD,
US-born and top-4 foreign-born countries of origin. MPH, Yale University A ID S Program, 13 5 College St,
Suite 323, New Haven, C T 0 6 5 1 0 (e-mail: jpmorano@
alumni.princeton.edu). Reprints can be ordered at
http://www.ajph.org by clicking the "Reprints" link.
This article was accepted January 15, 2014.
This low LTBI completion percentage reflects, public health departments that have limited
in part, a calculation bias in estimating budgets. Contributors
TST-eligible patients within subgroups in J. P. Morano was responsible for writing, editing, bio-
our population who may not necessarily C o n c lu s io n s statistical analysis, table and graphic creation, and in­
terfacing with the Yale institutional review board.
need yearly screens (e.g., 1-time drug treat­ Latent tuberculosis infection in high-income A. Zelenev provided key biostatistical expertise supervi­
ment program entry). Nonetheless, among countries such as the United States has the sion and interpretation for database merging and anal­
those targeted for LTBI screening, follow greatest prevalence and incidence among ysis. M. Walton and R. D. Bruce interviewed clients,
interpreted skin test and chest x-ray results, evaluated
through was 78%. Methods that could in­ foreign-bom populations, many of whom are positive skin test reactors, prescribed treatment, and
crease LTBI screening, such as enhanced missed through current screening guidelines followed individual clients for completion of therapy.
community outreach, educational initiatives, and within traditional health care settings. F. L. Altice, as current clinical director of the mobile
health clinic, was responsible for study design, sustaining
and mobile health technologies should be Screening initiatives such as on the CHCV’s the tuberculosis screening program, writing, and critical
considered.51 mobile medical clinic provides an innovative article review. All authors critically reviewed the pro­
Second, previous positive TST screening strategy to improve TB detection and promote tocol and article for publication.
relied on self-report, but previous studies sug­ public health to reduce TB disease. The CHCV,
gest that self-reported TST-positive status has a confidential, free health care venue for both Acknowledgments
This project was supported by the National Institutes on
a high predictive value positive rate associated documented and undocumented foreign-bom Drug Abuse for Career Development (F. L. Altice: K24
with the inflammatory skin reaction observed individuals provides an alternative to current DA017072) and Research (F. L. Altice: ROl DA13805,
after testing. Last, we did not use LTBI traditional health care settings. Such low ROl DAO 17059) and The National Institutes of Allergy
and Infectious Diseases 0- P. Morano: T32 A1007517).
screening strategies that deploy a 1-time threshold and grassroots programs are effective We thank Angel Ojeda, Rolo Lopez, and Elizabeth
serum interferon-y release assay, which in detecting both newly and previously known Roessler of the Community Health Care Van at the Yale
performs only slightly better than TST in LTBI, and findings here reflect high uptake University School of Medicine for their extensive and
sustained daily clinical field work in screening and
predicting future TB disease.52 Such strategies utilization by not only underserved foreign- treating clients for latent tuberculosis; Paula Dellamura
remain cost-prohibitive for many MMCs and bom populations but also by high-risk US-bom who coordinated key editorial sessions and project

August 20 1 4 , Vol 10 4, No. 8 | American Journal o f Public Health M o ra n o e t al. | Peer Reviewed | Research and Practice | 1 5 1 3

deadlines; Ruthanne Marcus, MPH, PhD, as associate
director of Yale Clinical Research for her facilitation and
dedication to the project; and Lisandra Estremera for
database expertise and client questionnaire management
Human Participant Protection
This retrospective analysis of clinical data was reviewed
and approved by the Yale University School of Medicine
Institutional Review Board Human Investigations
Committee.
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