LETTERS MISSED OPPORTUNITY TO PREVENT TUBERCULOSIS We applaud Davidow et al. for their recent article highlighting missed opportunities for tuberculosis (TB) prevention among foreignborn persons in the United States.1 Their study found that a significant proportion of TB cases were among permanent residents who could have benefitted from treatment to prevent active TB.1 We concur with the authors that screening without further medical evaluation and treatment does little to protect an individual or reduce future transmission in the community.1 We would like to draw attention to an important opportunity for intervention that was briefly mentioned in the article: evaluation of permanent residency applicants who already live in the United States. Nearly 600 000 permanent residency applicants receive mandatory medical examinations by licensed “civil surgeons” in the United States annually, which includes TB screening with a tuberculin skin test (TST) or an interferon c release assay (IGRA).2---4 Despite the mandatory TB screening performed in this population, few civil surgeons offer treatment to eligible applicants.4

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We recently reached out to civil surgeons in Los Angeles County, California, to discuss incorporating newer diagnostic tests and therapeutic regimens for TB screening and treatment of permanent residency applicants. Bacillus Calmette-Guérin vaccination is widely used in high TB burden countries and is known to increase false positive TST results.5 Therefore, screening with IGRAs instead of TSTs could reduce the number of chest x-rays needed to rule out active TB, minimize unnecessary treatment of uninfected individuals, and possibly increase treatment acceptance. Despite this, very few civil surgeons use IGRAs to screen applicants.4 Furthermore, the standard regimen of nine months of daily isoniazid has been shown to have low rates of acceptance and completion.6 Administration of shorter drug regimens such as four months of daily rifampin or three months of weekly isoniazid and rifapentine (3HP) could improve treatment initiation and completion in this population.7 We found that many civil surgeons are eager to contribute to TB prevention efforts. However, innovative solutions will be needed to overcome a number of financial and logistical obstacles. For example, IGRAs and 3HP are more expensive than standard alternatives, and any increase in an applicant’s out-of-pocket costs may lead to poor acceptance of the intervention, particularly among low-income applicants. Despite such challenges, permanent residency applicants are already routinely screened for TB and represent a “low hanging fruit” for TB prevention programs. This group should be prioritized in the overall effort to eliminate TB in the United States. j Sanghyuk S. Shin, PhD Tiffany Hsu Edgar Chavez, MD Alicia H. Chang, MD, MS Peter R. Kerndt, MD, MPH

the Universal Community Health Center, Los Angeles. Alicia H. Chang is with the Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, and the Tuberculosis Control Program, Los Angeles County Department of Public Health, Los Angeles. Peter R. Kerndt is with the Tuberculosis Control Program, Los Angeles County Department of Public Health. Correspondence should be sent to Sanghyuk Shin, Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024 (e-mail: sanghyukshin@ mednet.ucla.edu). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This letter was accepted August 28, 2015. doi:10.2105/AJPH.2015.302895

Contributors S. S. Shin developed the original concept and wrote the first draft of the article. T. Hsu, E. Chavez, A. H. Chang, and P. R. Kerndt critically reviewed and revised the article.

References 1. Davidow AL, Katz D, Ghosh S, et al. Preventing infectious pulmonary tuberculosis among foreign-born residents of the United States. Am J Public Health. 2015;105(9):e81---e88. 2. United States Citizenship and Immigration Services. Data Set: Form I-485 Application for Adjustment of Status. USCIS. Available at: http://www.uscis.gov/tools/ reports-studies/immigration-forms-data/data-set-form-i485-application-adjustment-status. Accessed August 15, 2015. 3. Saraiya M, Cookson ST, Tribble P, et al. Tuberculosis screening among foreign-born persons applying for permanent US residence. Am J Public Health. 2002;92 (5):826---829. 4. Bemis K, Thornton A, Rodriguez-Lainz A, et al. Civil surgeon tuberculosis evaluations for foreign-born persons seeking permanent US residence. J Immigr Minor Health. 2015;Epub ahead of print. 5. Pai M, Zwerling A, Menzies D. Systematic review: T-cell---based assays for the diagnosis of latent tuberculosis infection: an update. Ann Intern Med. 2008;149 (3):177---184. 6. Horsburgh CR, Goldberg S, Bethel J, et al. Latent TB infection treatment acceptance and completion in the United States and Canada. Chest. 2010;137(2):401---409. 7. Sterling TR, Villarino ME, Borisov AS, et al. Three months of Rifapentine and Isoniazid for latent tuberculosis infection. N Engl J Med. 2011;365(23):2155---2166.

DAVIDOW RESPONDS About the Authors Sanghyuk S. Shin and Tiffany Hsu are with the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles. Edgar Chavez is with

December 2015, Vol 105, No. 12 | American Journal of Public Health

Shin et al. are correct in identifying the civil surgeon examination as an important opportunity for employing interferon c release

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Missed Opportunity to Prevent Tuberculosis.

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