Tuberculosis in Philippine National World War II Veterans Immigrating to Hawaii, 1992-1993

The Immigration Act of 1990 * allows World War II veterans who are Philippine nationals to be naturalized as U.S. citizens and to enter the United States without any medical screening or restrictions. Following the diagnosis of tuberculosis (TB) in February 1992 in a Philippine national veteran who had recently arrived in Hawaii, the Hawaii Department of Health (HDOH) initiated efforts to assist veterans who had already arrived in Hawaii to receive TB testing and appropriate treatment and monitoring. This report describes the first case of TB identified in a veteran who entered Hawaii from the Philippines under this act and summarizes efforts by HDOH to detect and treat TB among Philippine national veterans.

In February 1992, because of a requirement for food-handling jobs, a 72-year-old man visited the TB health center in Honolulu to be evaluated and obtain a certificate stating he did not have active TB. ** At the time of this visit, he was asymptomatic but had a positive purified protein derivative (PPD) skin test, a chest radiograph with multiple cavitary lesions, and sputum smears with acid-fast bacilli (AFB). Sputum cultures were positive for Mycobacterium tuberculosis. The patient reported he had recently arrived in Hawaii as a World War II veteran from the Philippines.

Consultation with the Immigration and Naturalization Service indicated that as many as 60,000 Philippine national veterans could be eligible for naturalization as U.S. citizens under the Immigration Act of 1990. The overall occurrence of TB in the Philippines is substantial: during 1990, the most recent year for which reliable data are available, 180,683 TB cases were reported, for an incidence rate of 289 cases per 100,000 population (1).Therefore, in March 1992, HDOH initiated efforts to directly contact, for providing screening, diagnosis, and treatment or prophylaxis for TB, all Philippine national World War II veterans who had already arrived in Hawaii. In addition, HDOH worked with CDC staff at the Honolulu International Airport to provide an information brochure to arriving veterans encouraging them to visit HDOH facilities for a free TB evaluation.

Based on these efforts, 1659 (80.2%) of 2069 veterans (age range: 62-79 years) who had arrived in Hawaii from February 1992 through March 1993 were evaluated by HDOH. Chest radiographs and PPD skin tests were performed for 1580 (95.2%) veterans; 1425 veterans had their tests read (155 did not return for reading). Of those with skin-test readings, 996 (69.9%) showed a significant ( greater than or equal to 10 mm induration) reaction to a two-step Mantoux skin test.

Of the 996 persons who were skin-test positive, 450 (45.2%) had abnormal chest radiographs. Of these, 106 persons had clinical and/or radiographic evidence of active TB. Of sputum samples obtained from 69 patients, M. tuberculosis was isolated from 65; for 22 (33.8%) of these patients, sputum samples were smear positive for AFB. Each of the 106 veterans with evidence of active TB was placed on four-drug therapy consisting of isoniazid (INH), rifampin (RIF), pyrazinamide, and ethambutol. Sixteen veterans were hospitalized for treatment. Of the 65 isolates, 12 were resistant to some drugs: eight were resistant to INH, and four were resistant to at least INH and RIF.

Preventive therapy was initiated for 195 (43.3%) of the 450 veterans with abnormal chest radiographs because their chest radiographs were consistent with previous, healed TB, with or without additional medical conditions that warranted preventive therapy. Of these, 98 veterans completed preventive treatment, and 97 are still undergoing treatment. Twenty-one considered to have inactive TB did not receive medication.

Of the 546 veterans who were skin-test positive with a normal chest radiograph, preventive therapy was initiated for 39; 51 were referred to their private physician for follow-up and treatment as indicated. Reported by: AC Ignacio, MD, Tuberculosis/Hansen's Disease Control Br, RL Vogt, MD, State Epidemiologist, Hawaii Dept of Health. Immigration and Naturalization Svc, US Dept of Justice. Div of Quarantine, and Div of Tuberculosis Elimination, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The findings of this investigation indicate the need for a reliable approach for screening, diagnosing, and treating TB in Philippine national World War II veterans who apply for naturalization under provisions of the Immigration Act of 1990. The detection of drug-resistant TB in some of the veterans underscores this need.

This group of Philippine national veterans is an exception to the medical screening requirements of the Immigration Act: all other applicants for immigrant visas are required to receive medical screening -- which includes an examination for TB -- as part ofthe visa application process, and all other immigrants are required to reside in the United States for at least 5 years before they can be naturalized. In contrast, other groups of foreign nationals -- including parolees, asylees, students and their families, and several categories of workers --- are permitted to enter the United States for prolonged residence without medical screening. Many of these persons enter from areas with a high prevalence of TB; however, the impact of TB among these persons on the overall epidemiology of TB in the United States is unknown because none of these groups have been systematically screened after their entry into the United States. The Advisory Council for the Elimination of Tuberculosis recommends that special efforts be made to screen foreign-born persons from countries with a high prevalence of TB (2,3).

References

1. World Health Organization. Tuberculosis notification update, July 1992. Geneva: World Health Organization, Division of Communicable Diseases, Tuberculosis Program, 1992; publication no. WHO/TB/92.169.

2. CDC. Screening for tuberculosis and tuberculous infection in high-risk populations and the use of preventive therapy for tuberculous infection in the United States. MMWR 1990;39(no. RR-8).

3. CDC. Tuberculosis among foreign-born persons entering the United States. MMWR 1990;39(no. RR-18).

* Public Law 101-649.

** State law (section 11-164-7) in Hawaii requires that food handlers receive a health certificate indicating they do not have active TB before they can work in restaurants.

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