Resistance to First-Line Antituberculosis Drugs in Washington State by Region of Birth and Implications for Latent Tuberculosis Treatment Among Foreign-Born Individuals.

The United States has a low burden of drug resistance among tuberculosis (TB) cases compared with other world regions. TB is increasingly concentrated among foreign-born individuals who have higher rates of drug resistance than U.S.-born individuals. While universal drug susceptibility testing is the standard for detecting active tuberculosis, there are limited guidelines for latent tuberculosis infection (LTBI) treatment based on risk factors for drug resistance. To quantify the variable risk of drug resistance among foreign-born individuals, all TB cases in Washington State between 1994 and 2014 with drug resistance data for isoniazid, rifampin, pyrazinamide, and ethambutol were divided into eight regions of birth. Logistic regression was used to characterize regional differences in resistance patterns. Genotypic cluster and lineage data were compared against drug resistance in a subanalysis. Among 4,298 cases, isoniazid resistance was more common in foreign-born individuals (12.6% versus 4.8%; P < 0.001), with the highest burden among individuals from the Asia-Pacific (14.8%) region. Rifampin resistance was slightly higher among foreign-born individuals (1.9% versus 1.1%; P = 0.063). Multivariate logistic regression demonstrated that older age was associated with a lower risk of resistance to isoniazid and rifampin (odds ratio [OR] = 0.86, P = 0.006 and OR = 0.64, P = 0.003 for each 20-year interval, respectively). These data suggest drug resistance in LTBI will remain a challenge and that rifampin-based regimens for treatment of LTBI in non-human immunodeficiency virus-infected adults may be preferable for individuals born in regions with high levels of isoniazid resistance. However, further research is needed to demonstrate whether LTBI treatment based on region of birth further decreases TB reactivation.

Seroprevalence of Hepatitis B Infection Among Immigrants in a Primary Care Clinic: A Case for Granular Ethnicity and Language Data Collection.

Chronic hepatitis B virus (HBV) infection is highly prevalent worldwide and is most often diagnosed through screening efforts. In order to identify the specific ethnic groups at greatest risk, it is necessary to go beyond traditional categories. We conducted a retrospective case series in a primary care clinic serving non-English speaking immigrants to determine the prevalence of HBV among patients of various primary spoken languages (used as a proxy for ethnicity). Among the 1378 patients, the overall prevalence of current infection was 8%. HBV infection was markedly higher among Somali, Oromo and Khmer speakerscompared to other groups. This study illustrates the use of granular language data in describing the serologic profiles of HBV infection among non-English speaking patients in primary care setting. The variations in prevalence by language have implications for public health HBV screening efforts, in addition to suggesting potential risk factors for transmission.

Care of Adult Refugees with Chronic Conditions.

Refugees share a common experience of displacement from their country of origin, migration, and resettlement in an unfamiliar country. More than 17 million people have fled their home countries due to war, generalized violence, and persecution. US primary care physicians must care for their immediate and long-term medical needs. Challenges include (1) language and cultural barriers, (2) high rates of mental health disorders, (3) higher prevalence of latent infections, and (4) different explanatory models for chronic diseases. This article discusses management strategies for common challenges that arise in the primary care of refugees.