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Tuberculosis Questions and Answers for Hmong Community Leaders
and Service Providers
||Tuberculosis Questions and Answers for Hmong Community
Leaders and Service Providers
- Are refugees tested for infectious diseases, such
as tuberculosis, prior to coming to the United States?
- Is tuberculosis an infectious and contagious disease
that can be treated?
- What is drug-resistant tuberculosis? Can people
with drug-resistant tuberculosis be treated?
- Can people be vaccinated against tuberculosis?
- What is the difference between tuberculosis disease
and latent tuberculosis infection?
- What is the U.S. policy regarding tuberculosis
testing for people who are coming to the United States?
- Should anyone who comes in contact with refugees
be tested for tuberculosis?
- Should people who have been living in substandard
housing for several years be tested or retested for tuberculosis?
- A few years ago, CDC established a National Action
Plan to Combat Multidrug-Resistant Tuberculosis. Is this program
still active? Are there funds available to treat refugees who
are no longer eligible for medical assistance? Are there efforts
to educate the Hmong community or to enlist their support in assisting
their relatives in following drug treatment regiments?
- How has the Federal Government organized itself
to respond to the problem of tuberculosis in the Hmong refugees?
- Please describe the current CDC tuberculosis
prevention program available through the United States.
1. Are refugees tested for
infectious diseases, such as tuberculosis, prior to coming to the
U.S. migrant health screening policy focuses on migrants planning
to establish permanent U.S. residence, namely immigrants and refugees.
All immigrants and refugees migrating to the United States are required
to have a medical screening examination overseas, which is performed
by physicians or physician groups appointed by the local U.S. embassy.
The mandated medical examination focuses primarily on detecting
diseases determined to be inadmissible conditions for the purposes
of visa eligibility. These diseases include certain serious infectious
diseases such as infectious tuberculosis, human immunodeficiency
virus infection, syphilis and other sexually transmitted infections,
and infectious Hansen’s disease (leprosy).
The objectives of the screening are to identify and treat diseases
of public health importance, both to improve the health of newly
arriving citizens and to prevent potential disease transmission
in both host and receiving communities. The screening process also
includes notification of state and local U.S. health departments
about refugees arriving to their jurisdiction to ensure appropriate
follow-up evaluation and treatment. Early investment in the health
needs of refugees and other migrants facilitates the migration process,
improves migrant health and decreases associated morbidity and mortality,
avoids long-term health resource and social costs, and protects
global public health. Over 400,000 immigrants and refugees are medically
screened before arrival in the United States annually; immigrants
comprise approximately 90% of arrivals, and refugees close to 10%.
2. Is tuberculosis an
infectious and contagious disease that can be treated?
Tuberculosis (also known as “TB”) is an infectious disease caused
by germs that are spread from person to person through the air.
Tuberculosis usually affects the lungs, but it can also affect other
parts of the body, such as the brain, the kidneys, or the spine.
A person with tuberculosis can die if they do not get treatment.
Tuberculosis disease can be cured by taking several drugs for 6
to 12 months. It is very important that people who have tuberculosis
disease finish the medicine, and take the drugs exactly as prescribed.
If they stop taking the drugs too soon, they can become sick again;
if they do not take the drugs correctly, the germs that are still
alive may become resistant to those drugs. Tuberculosis that is
resistant to drugs is harder and more expensive to treat. In some
situations, staff of the local health department meet regularly
with patients who have tuberculosis to watch them take their medications.
This is called directly observed therapy (DOT). DOT helps the patient
complete treatment in the least amount of time.
3. What is drug-resistant
tuberculosis? Can people with drug-resistant tuberculosis be treated?
Multidrug-resistant tuberculosis (MDR TB) (i.e. , tuberculosis
resistant to at least isoniazid and rifampin—the two most important
drugs used to treat tuberculosis) presents difficult treatment problems.
Treatment must be individualized and based on the patient’s medication
history and drug resistance studies. Unfortunately, adequate data
are not available on the effectiveness of various regimens and the
necessary duration of treatment for patients with organisms resistant
to both isoniazid and rifampin. Moreover, many of these patients
also have resistance to other first-line drugs (e.g. , ethambutol
and streptomycin). Because of the poor outcome in such cases, it
is preferable to give at least three, but often as many as four
to six new drugs to which the organism is susceptible. This regimen
should be continued for a total of 18 to 24 months. MDR TB drugs
should be given using a daily regimen under directly observed therapy
(DOT). Intermittent administration of medications is generally not
possible in treatment of MDR TB.
4. Can people be vaccinated
BCG is a vaccine for tuberculosis disease that is used in many
countries to prevent deaths and severe TB in children. In places
where TB is not common, such as the United States, BCG use is not
generally recommended. BCG vaccination does not completely prevent
people from getting tuberculosis. It may also cause a positive tuberculin
skin test and make it difficult to diagnose latent TB. However,
persons who have been vaccinated with BCG can be given a
tuberculin skin test if they need an evaluation because of risk
5. What is the difference
between tuberculosis disease and latent tuberculosis infection?
There are two common forms of tuberculosis—latent tuberculosis
infection and tuberculosis disease. People with latent
tuberculosis infection have tuberculosis germs in their bodies,
but they are not sick because the germs are not active. These persons
do not have symptoms of tuberculosis disease, and they cannot spread
the germs to others. However, they may develop tuberculosis disease
in the future. They are often prescribed treatment to prevent the
disease from developing.
People with tuberculosis disease are sick from tuberculosis
germs that are active, meaning that they are multiplying and damaging
organs or other areas of their body. These persons usually have
symptoms of tuberculosis disease. People with tuberculosis disease
of the lungs or throat are capable of spreading germs to others.
Drugs are prescribed to cure tuberculosis disease in these persons.
6. What is the U.S.
policy regarding tuberculosis testing for people who are coming
to the United States?
All refugees who are 15 years of age and older are required to
have a chest radiograph (also known as chest x-ray). Persons with
a chest radiograph that is suggestive of active tuberculosis disease
are required to submit three sputum specimens on separate days to
have acid-fast bacilli (AFB) smear evaluation. Refugees with infectious
pulmonary tuberculosis disease (as defined by the presence of acid-fast
bacilli on sputum smear) receive treatment before resettlement;
theyare not allowed to travel until treated and no longer infectious.
In addition to the required standard overseas screening, CDC has
in the past recommended enhanced screening for tuberculosis (and
other diseases) for migrants who have lived in or are migrating
from areas of the world with high tuberculosis prevalence, including
parts of Asia, Africa, and the Central Asian republics.
In June, 2004, CDC recommended that U.S.-bound Hmong refugees in
Thailand undergo enhanced overseas screening and treatment for tuberculosis.
To improve clinical diagnosis and management of tuberculosis, tuberculosis
culture and drug-resistance testing was recommended for refugees
whose screening examination suggested the presence of active pulmonary
7. Should anyone who
comes in contact with refugees be tested for tuberculosis?
A person with latent tuberculosis infection cannot spread germs
to other people. You do not need to be tested if you have spent
time with someone with latent tuberculosis infection. However, if
you have spent time with someone with tuberculosis disease or someone
with symptoms of tuberculosis, you should be tested.
People with tuberculosis disease are most likely to spread the
germs to people they spend time with every day, such as family members
or coworkers. If you have been around someone who has tuberculosis
disease, you should go to your doctor or your local health department
The general symptoms of tuberculosis disease include feelings of
sickness or weakness, weight loss, fever, and night sweats. The
symptoms of tuberculosis disease of the lungs also include coughing,
chest pain, and coughing up blood. Symptoms of tuberculosis disease
in other parts of the body depend on the area affected.
8. Should people who
have been living in substandard housing for several years be tested
or retested for tuberculosis?
You should get tested for tuberculosis if:
- you have spent time with a person who is known or suspected
to have tuberculosis disease
- you have HIV infection or another condition that puts you at
high risk for tuberculosis disease
- you think you might have tuberculosis disease
- you are from a country where tuberculosis disease is very common
(most countries in Latin America and the Caribbean, Africa, Asia,
Eastern Europe, and Russia)
- you inject drugs
- you live somewhere in the U.S. under conditions where tuberculosis
disease is more common (homeless shelters, migrant farm camps,
prisons and jails, and some nursing homes)
9. A few years ago,
CDC established a National Action Plan to Combat Multidrug-Resistant
Tuberculosis. Is this program still active? Are there funds available
to treat refugees who are no longer eligible for medical assistance?
Are there efforts to educate the Hmong community or to enlist their
support in assisting their relatives in following drug treatment
The National Action Plan to Combat Multidrug-Resistant Tuberculosis
was a critical component to our nation’s response to a resurgence
of tuberculosis that peaked in 1992. Concerted Federal and local
efforts and substantial increase in resources resulted in improved
tuberculosis control. The original plan has been revised into subsequent
strategic plans and linked to many guidelines. Although CDC reported
11 years of decline in the number of tuberculosis cases since 1992,
the decline is slowing and the fraction of cases among those born
in countries outside the United States is increasing. There are
efforts in collaboration with immigrant and refugees groups to educate
the Hmong community about the sign and symptoms of tuberculosis,
its prevention, diagnosis, and treatment. Local public health departments
provide free diagnosis and treatment of tuberculosis.
The National Action Plan to Combat Multidrug-Resistant Tuberculosis
has been revised and incorporated into a number of guidelines, including
Treatment of Tuberculosis: www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm
Other guidelines and recommendations can be accessed via the CDC
Division of Tuberculosis Elimination website: www.cdc.gov/nchstp/tb/
A number of TB educational materials are available in the Hmong
language. These materials, along with other TB educational materials,
can be accessed at the TB Education & Training Resources Website:
10. How has the Federal
Government organized itself to respond to the problem of tuberculosis
in the Hmong refugees?
The Department of State and the Department of Health and Human
Services (including the Centers for Disease Control and Prevention)
have organized a task force to organize and coordinate the United
States Government’s response, which pulls together efforts in Thailand
and by U.S. State and local health departments. A critical component
is community outreach through the refugee health networks.
11. Please describe
the current CDC tuberculosis prevention program available through
the United States.
State and local health departments have the primary responsibility
for preventing and controlling tuberculosis. However, other health
care providers who provide tuberculosis services in settings such
as private clinics, managed care organizations, HIV clinics, correctional
facilities, and hospitals also have responsibility for preventing
and controlling tuberculosis in communities.
Prevention and control efforts should be conducted through the
coordination of health care providers in a variety of settings to
ensure the provision of direct services for tuberculosis patients.
Prevention and control efforts should include three priority strategies:
- Identifying and treating all persons who have tuberculosis disease.
This means finding persons with tuberculosis and ensuring that
these patients complete appropriate therapy;
- Finding and evaluating persons who have been in contact with
tuberculosis patients to determine whether they have tuberculosis
infection or disease, and treating them appropriately; and
- Testing high-risk groups for tuberculosis infection to identify
candidates for treatment of latent infection and to ensure the
completion of treatment.
Although tuberculosis care and treatment are often provided by
other medical care providers, the health department has the ultimate
responsibility for ensuring that tuberculosis patients do not transmit
M. tuberculosis to others. Health departments must ensure
that medical services are available, accessible, and acceptable
for tuberculosis patients, suspects, contacts, and others at high
risk, without regard to the patients’ ability to pay for such services.
DTBE - TB Questions and Answers for Hmong Community Leaders
and Service Providers - March 2005