Topics in Minority Health Tuberculosis Among Asians/Pacific Islanders - United States, 1985

In 1985, 22,201 tuberculosis cases were reported to CDC, for a rate of 9.3 cases per 100,000 U.S. population (1). Two thousand five hundred and thirty (11.4%) of the 22,170 patients for whom race was known were Asians/Pacific Islanders (2). The rate for this group was 49.6/100,000, which is 8.7 times higher than the 1985 rate of 5.7/100,000 for the white population in the United States (3).

Two thousand five hundred and twenty-five of these Asian/Pacific Islander patients resided in 330 (10.5%) of the nation's 3,138 counties (Figure 1). Of these, 1,151 (45.6%) were in California; 174 (6.9%) were in Hawaii; 164 (6.5%) were in New York; 143 (5.7%) were in Texas; 135 (5.3%) were in Illinois; and 763 (30.2%) were in 43 other states and the District of Columbia.

The country of origin was reported for 2,357 of these patients. Of these, 2,207 (93.6%) were foreign-born; this group included 643 (27.3%) from Kampuchea, Laos, and Vietnam; 595 (25.2%) from the Republic of the Philippines; 346 (14.7%) from the Republic of Korea; 226 (9.6%) from the People's Republic of China; and 397 (16.8%) from other countries. Refugees from Kampuchea, Laos, and Vietnam who arrived in the United States during the period 1975-1985 and had disease diagnosed in 1985 had an estimated incidence rate of 75.2/100,000 (572 cases among 760,900 refugees). Those who arrived in 1984 and had disease diagnosed in 1985 had an incidence rate of 310/100,000 (161 cases among approximately 52,000 refugees).

Tuberculosis developed within the first year of U.S. residency for 40.3% of all foreign-born Asians/Pacific Islanders with known date of arrival. Disease developed among an additional 8.7% within the second year of residency (Figure 2). There was little variation in this observation among the major groups of immigrants.

Because preventive therapy is indicated for all infected persons <35 years of age, analysis by age was performed. Age was known for 2,529 of the Asian/Pacific Islander patients. Of these 2,529, 1,126 (445%) were < 35 years of age when their disease was reported. Information on the date of arrival in the United States was available on 1,879 (85.1%) of the 2,207 foreign-born patients. Of these, 826 (44.0%) were < 35 years of age at the time of diagnosis in 1985. An additional 182 (9.7%) were < 35 years of age when they arrived in the United States.

Reported by: Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: From 1980 to 1985, the Asian population in the United States grew from 3.5 million to an estimated 5.1 million (2). A large proportion of today's U.S. Asian/Pacific Islander population are immigrants or refugees from areas with a high prevalence of tuberculous infection. Refugees from Kampuchea, Laos, and Vietnam are routinely screened for tuberculosis in overseas camps, and patients with active tuberculosis are required to complete a 6-month course of directly observed chemotherapy before entering the United States (4). Therapy consists of treatment with three antituberculosis drugs (isoniazid {INH}, rifampin, and ethambutol) for the full 6 months and supplemental administration of pyrazinamide during the first 2 months. The benefits of using such a fully supervised multidrug regimen are 1) a rapid reduction in infection; 2) a high rate of completion of therapy and of cure; 3) a short duration of treatment; 4) a high success rate even in the presence of initial drug resistance, which is reportedly high among this population (5); and 5) a low risk of acquired drug resistance (6).

In 1985, tuberculosis among Asians/Pacific Islanders occurred almost entirely among foreign-born persons. Almost half of all tuberculosis cases among Asians/Pacific Islanders were reported from California, and an additional one-quarter were from four other states. Nevertheless, cases have been reported from all but two states. In 1980, a large influx of refugees into the United States from Southeast Asia caused national tuberculosis morbidity to increase (7). When the number of refugees entering the United States decreased, the national trend resumed its previous decline. While the proportion of total tuberculosis cases represented by this group decreased from 5.3% for the period 1979-1980 to 2.9% in 1985, the risk of tuberculosis among refugees recently arriving from Kampuchea, Laos, and Vietnam (310/100,000) is higher than it was in 1980 (231/100,000) (7).

Nearly half of all Asians/Pacific Islanders with tuberculosis were <35 years of age. By comparison, 14% of non-Hispanic white patients with tuberculosis were < 35 (3). Furthermore, more than half of the foreign-born patients arrived in the United States when they were < 35 years of age the age group within which preventive therapy is routinely recommended for persons with tuberculous infection (8). Irrespective of country of origin, close to 50% of foreign-born Asians/Pacific Islanders with tuberculosis became ill within the first 2 years after their arrival.

These findings suggest that half of all tuberculosis cases among Asians/Pacific Islanders would be potentially preventable if refugees and immigrants were given tuberculin skin tests and offered preventive therapy according to current guidelines (8) shortly after arrival in the United States. Because noncompliance may lead to failures in preventive therapy among refugees (9), particular attention should be given to health education and other means of encouraging compliance, such as directly observed therapy (10). Because of the risk of overdosage with self-administered therapy (11), directly observed therapy should be used for refugees and immigrants with a history or suicidal tendencies. Failures in preventive therapy among Southeast Asian refugees may occur because of the high prevalent of resistance to INH in this population (6,9). For this reason, the development of alternative regimens of preventive therapy is crucial to improving disease preventive efforts among refugees and other persons from countries where infection with INH-resistant organisms is common (12).

References

1. CDC. Tuberculosis - United States, 1985 MMWR 1986;35:699-703.

2. Gardner RW, Robey B, Smith PC. Asian Americans: growth, change, and diversity. Population Bulletin 1985;40:1-43.

3. CDC. Tuberculosis in minorities United States. MMWR 1987;36:77-80.

4. CDC. Guidelines for medical examination of Indochinese refugees in Southeast Asian, Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, 1987.

5. CDC. Drug resistance among Indochinese refugees with tuberculosis. MMWR 1981;30:273-5.

6. Mitchison DA, Nunn AJ. Influence of initial drug resistance on the response to short-course chemotherapy of pulmonary tuberculosis. Am Rev Respir Dis 1986;133:423-30.

7. Powell KE, Brown ED, Farer LS. Tuberculosis among Indochinese refugees in the United States. JAMA 1986;249:1455-60.

8. American Thoracic Society, CDC. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986;134:355-63.

9. Nolan CM, Aitken ML, Earth AM, Anderson KM, Miller WT. Active tuberculosis after isoniazid chemoprophylaxis of Southeast Asian refugees. Am Rev Respir Dis 1986;133:431-6.

10. Snider DE Jr, Hutton MD. Improving patient compliance in tuberculosis treatment programs. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1988.

11. Blanchard PD, Yao JDC, McAlpine DE, Hurt RD. Isoniazid overdose in the Cambodian population of Olmsted County, Minnesota. JAMA 1986;256:3131-3.

12. Snider DE Jr, Farer LS. Preventive therapy for tuberculous infection: an intervention in need of improvement {Editorial}. Am Rev Respir Dis 1984;130:355-6.

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