As African-born cases rise, programs adjust
As African-born cases rise, programs adjust
Earlier age, quicker onset among this group’s trends
In Seattle, this year’s TB case totals will reflect a shift in demographics that has left public health experts here slightly amazed. For the first time, foreign-born TB cases from Eastern Africa will outnumber those from Southeast Asia.
"That’s something I never thought I’d live to see," says Charles Nolan, MD, chief medical advisor to the TB control program in King County, which includes Seattle.
Most of the African cases are turning up among refugees fleeing war, famine, and unrest in Somalia, Eritrea, and Ethiopia in the Horn of Africa.
To a lesser extent, the increase in African-born cases is reflected in what’s going on at the national level. Nationally, this year’s ceiling for African refugees is 18,000, up from last year’s ceiling of 13,000, according to U.S. State Department figures. As in Seattle, the majority of the 85,000 African refugees who’ve been admitted to the U.S. since 1980 are from Ethiopia (which has supplied over 30,000 refugees) and Somalia (around 25,000), with smaller numbers of Sudanese, Liberians, Zairians, Rwandans, Ugandans, and Angolans rounding out the pie. The pool of African refugees is also growing increasingly diverse, with citizens from 43 African nations admitted to the U.S. last year.
In Seattle, the shift in demographics has dictated a shift in TB control program strategies, because the East African cases differ in several ways from other foreign-born groups the area had grown accustomed to seeing, Nolan says. "First, we’re finding that active disease onsets earlier after arrival and in a younger age group. We’re also seeing more extrapulmonary disease, including a good bit of Potts Disease [TB of the spine]," says Nolan.
Cases among the young and in extrapulmonary sites present in a variety of ways and thus can be tougher to spot, he adds. "We’re trying to alert the medical community to this fact and get them to think about it more."
As for earlier onset, experts in Seattle have determined that about 30% of the active cases among east Africans occur within the first year after arrival in the United States, and 80% of cases occur within the first five years. By comparison, about half of the cases among other foreign-born groups occur within the first five years. "That means outreach to these groups is really important," Nolan says. "We’ve got to get them as soon as we can, screen them, and, assuming they’re infected but free of active disease, get them on treatment for latent TB infection. That’s another message we’re trying hard to get out to primary health care providers."
What’s new in Seattle sounds like a rerun to TB controllers in Minnesota. There, the biggest group of caseloads tipped from Asians to East Africans in 1996, says Deb Sodt, RN, head of the state TB program. Somalis make up the biggest group of all TB cases, followed by American-born patients and then by Ethiopians, Sodt says. Asians don’t make the list until the number-four spot, which is occupied by Vietnamese people.
Many of the same trends Seattle TB experts are spotting also hold true in Minnesota, says Sodt. The Minneapolis area, especially, is a favored site for secondary migration, as refugees relocate there from other parts of the country hoping to land a job in the booming economic climate. "We’re definitely seeing early onset of disease, with our biggest group in their 20’s, followed by [patients in their] early teens," she says. As in Seattle, clinicians here are also seeing more extrapulmonary cases, particularly lymphatic TB, Sodt says. "Usually it’s present in just one or two nodes," she says. "It also tends to go with earlier presentation."
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