UC Irvine

Latent Tuberculosis Screening by Civil Surgeons: A Population-Based Assessment of Current Practiceby Valerie Anne Pham Doctor of Philosophy in Nursing Science University of California, Irvine, 2022 Associate Professor Sanghyuk Shin, Chair

Background: An estimated 13 million people in the US have latent tuberculosis (TB) infection (LTBI) and act as reservoirs from which deadly active TB disease can develop. Of the total number of TB cases reported nationally in 2020, non-US-born persons accounted for approximately of 71%; however, the disproportion is even greater in Orange County, California, where non-US-born persons accounted for approximately 87%. A recent study of TB among non-US-born residents found 58.6% of TB cases were from permanent residents, indicating a significant missed opportunity for LTBI intervention in the immigration process. A population that can be screened and treated to reduce the incidence of LTBI is “green” card applicants (GCAs) seeking a change in status from temporary to permanent US residency. Green card applicants are already procedurally screened for LTBI through medical examination made mandatory by U.S. Citizenship and Immigration Services. In 2018, the Centers for Disease Control and Prevention (CDC) released new guidelines that may provide favorable opportunities to ensure LTBI-positive GCAs are provided with evidence-based treatment. This study sought to increase the current knowledge base about the reach, effectiveness, and implementation fidelity of the new guidelines through the following two aims: 1) To determine civil surgeon adherence to CDC Tuberculosis Technical Instructions, specifically the percentage of civil surgeons who a) screen using an IGRA blood test, b) report LTBI to the health department, c) notify GCAs of LTBI diagnosis, d) inform GCAs that LTBI is reported to the health department, and e) provide LTBI counseling, measured as patient teaching and treatment recommendation/referral. 2) To determine the effect of CDC guidelines on LTBI treatment initiation. Methods: Using the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework, a two-phase cross-sectional survey evaluated the dissemination of CDC Technical Instructions for civil surgeons. Phase 1 civil surgeon data included sociodemographic factors, their knowledge of changes to CDC Technical Instructions, civil surgeon activity (screening, reporting, teaching, and treatment), and whether the COVID-19 pandemic affected their practice. Phase 2 GCA data included sociodemographic factors and GCA perception of civil surgeon services. Civil surgeon and GCA data were triangulated to depict a more accurate reflection of the impact of CDC guidelines on green card applicants. Results: Triangulation provided evidence for compliance and non-compliance on different aspects of the Technical Instructions. Of the six components measured, two were in compliance. Blood test screening achieved 100% compliance. As for notification of LTBI results, 94% of civil surgeons report they often/very often notify GCAs of their LTBI diagnosis, confirmed by 74% of GCAs reporting they were notified. The rest of the guideline components demonstrated contradicting results. While more than 80% of civil surgeons reported they often/very often inform GCAs that LTBI would be reported to the health department, that they provide LTBI patient education, and recommend treatment, GCA responses did not align well. The majority (83%) of GCAs responded that the civil surgeon did not inform GCAs that LTBI would be reported to the health department; 55% reported that the civil surgeon did not explain about LTBI; and 80% reported that the civil surgeon did not mention treatment. Civil surgeon perception of services rendered did not align with GCA perception of services received. As a result, 94% GCAs did not start treatment. Conclusion: Current Technical Instructions places unprecedented emphasis on the public health importance of treating LTBI that could dramatically improve the quality of LTBI care among green card applicants and accelerate progress towards TB elimination in the US. However, our assessment of current civil surgeon practice revealed that new guidelines did not lead to increased LTBI treatment initiation. Barriers to guideline compliance must be fully explored to not miss the small window of opportunity to address LTBI care during the status adjustment medical evaluation.