title: Estimating the impact of newly arrived foreign-born persons on tuberculosis in the United States.
abstract: BACKGROUND
  Among approximately 163.5 million foreign-born persons admitted to the United States annually, only 500,000 immigrants and refugees are required to undergo overseas tuberculosis (TB) screening. It is unclear what extent of the unscreened nonimmigrant visitors contributes to the burden of foreign-born TB in the United States.
  
  
  RESULTS
  We defined foreign-born persons within 1 year after arrival in the United States as "newly arrived", and utilized data from U.S. Department of Homeland Security, U.S. Centers for Disease Control and Prevention, and World Health Organization to estimate the incidence of TB among newly arrived foreign-born persons in the United States. During 2001 through 2008, 11,500 TB incident cases, including 291 multidrug-resistant TB incident cases, were estimated to occur among 20,989,738 person-years for the 1,479,542,654 newly arrived foreign-born persons in the United States. Of the 11,500 estimated TB incident cases, 41.6% (4,783) occurred among immigrants and refugees, 36.6% (4,211) among students/exchange visitors and temporary workers, 13.8% (1,589) among tourists and business travelers, and 7.3% (834) among Canadian and Mexican nonimmigrant visitors without an I-94 form (e.g., arrival-departure record). The top 3 newly arrived foreign-born populations with the largest estimated TB incident cases per 100,000 admissions were immigrants and refugees from high-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of ≥100 cases/100,000 population/year; 235.8 cases/100,000 admissions, 95% confidence interval [CI], 228.3 to 243.3), students/exchange visitors and temporary workers from high-incidence countries (60.9 cases/100,000 admissions, 95% CI, 58.5 to 63.3), and immigrants and refugees from medium-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of 15-99 cases/100,000 population/year; 55.2 cases/100,000 admissions, 95% CI, 51.6 to 58.8).
  
  
  CONCLUSIONS
  Newly arrived nonimmigrant visitors contribute substantially to the burden of foreign-born TB in the United States. To achieve the goals of TB elimination, direct investment in global TB control and strategies to target nonimmigrant visitors should be considered.
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. yliu@cdc.gov
authors.forename: Yecai
authors.initials: Y
authors.lastname: Liu
authors.forename: John A
authors.initials: JA
authors.lastname: Painter
authors.forename: Drew L
authors.initials: DL
authors.lastname: Posey
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Cain
authors.forename: Michelle S
authors.initials: MS
authors.lastname: Weinberg
authors.forename: Susan A
authors.initials: SA
authors.lastname: Maloney
authors.forename: Luis S
authors.initials: LS
authors.lastname: Ortega
authors.forename: Martin S
authors.initials: MS
authors.lastname: Cetron
mesh_terms: D003140:Communicable Disease Control; D054242:Emigrants and Immigrants; D004641:Emigration and Immigration; D006801:Humans; D015994:Incidence; D008403:Mass Screening; D013997:Time Factors; D014376:Tuberculosis / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission; D018088:Tuberculosis, Multidrug-Resistant / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission; D014481:United States; D014944:World Health Organization