Am. J. Respir. Crit. Care Med., Volume 158, Number 6, December 1998, 1797-1803

Differences in Contributing Factors to Tuberculosis Incidence in U.S.-born and Foreign-born Persons

DANIEL P. CHIN, KATHRYN DERIEMER, PETER M. SMALL, ALFREDO PONCE de LEON, RACHEL STEINHART, GISELA F. SCHECTER, CHARLES L. DALEY, ANDREW R. MOSS, E. ANTONIO PAZ, ROBERT M. JASMER, CRISTINA B. AGASINO, and PHILIP C. HOPEWELL

Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital Medical Center, Department of Epidemiology and Biostatistics, San Francisco General Hospital, and the Department of Medicine, University of California, San Francisco; Tuberculosis Control Branch, California Department of Health Services; Division of Public Health Biology and Epidemiology, School of Public Health, University of California, Berkeley; Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California

To determine the factors contributing to tuberculosis incidence in the U.S.-born and foreign-born populations in San Francisco, California, and to assess the effectiveness of tuberculosis control efforts in these populations, we performed a population-based molecular epidemiologic study using 367 patients with strains of Mycobacterium tuberculosis recently introduced into the city. IS6110-based and PGRS-based restriction fragment length polymorphism (RFLP) analyses were performed on M. tuberculosis isolates. Patients whose isolates had identical RFLP patterns were considered a cluster. Review of public health and medical records, plus patient interviews, were used to determine the likelihood of transmission between clustered patients. None of the 252 foreign-born cases was recently infected (within 2 yr) in the city. Nineteen (17%) of 115 U.S.-born cases occurred after recent infection in the city; only two were infected by a foreign-born patient. Disease from recent infection in the city involved either a source or a secondary case with human immunodeficiency virus (HIV) infection, homelessness, or drug abuse. Failure to identify contacts accounted for the majority of secondary cases. In San Francisco, disease from recent transmission of M. tuberculosis has been virtually eliminated from the foreign-born but not from the U.S.-born population. An intensification of contact tracing and screening activities among HIV-infected, homeless, and drug-abusing persons is needed to further control tuberculosis in the U.S.-born population. Elimination of tuberculosis in both the foreign-born and the U.S.-born populations will require widespread use of preventive therapy.

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