immigration status has been demonst

immigration status has been demonstrated to be an effective tool for identifying persons with TB disease before they enter the United States (3). However, given the nature of TB, vigilance after arrival also is needed, because persons with latent TB infection can convert to an active state after arrival. During the period in which the 1991 TB TI was in use, 7% of immigrants and refugees who
had abnormal chest radiographs suggestive of TB, but negative sputum smears, were diagnosed with TB disease after their arrival in the United States (3). Under CDOT TB TI, early data suggest that percentage has declined to 1%–2% (4). Although formal economic analyses have not been completed, the gains in overseas diagnosis and the decrease in cases suggest that successful implementation of this screening program could result in crude savings in excess of $15 million yearly. A previous analysis determined that investments in TB control in countries where the disease is endemic can yield a greater return on investment than only improving preentry screening algorithms (5). For this reason, a key component of DGMQ’s implementation plan has been to link panel physicians with their country’s national TB programs. Such successful linkages have included panel physicians in the Dominican Republic, who entered into a public-private partnership with that country’s National Tuberculosis Program (6), and the International Organization for Migration, which manages refugee resettlements and serves as the panel physician for applicants in Nairobi, Kenya, providing laboratory testing and DOT for certain nonresettling or immigrating populations (International Organization for Migration, unpublished data, 2011). To maximize the opportunity for the laboratory and treatment infrastructure to benefit more than U.S.-bound populations, efforts should continue to seek ways in which the screening program can collaborate with in-country TB programs. Although the 1991 algorithm was shown to help prevent importation of TB (2), it did not incorporate newer, more sensitive technologies for diagnosing TB or include a treatment component. To help determine what changes could be made to the TI, DGMQ and CDC’s Division of Tuberculosis Elimination collaborated on research activities. A key outcome of that effort was the 2006 publication of a study demonstrating that, compared with the gold standard of mycobacterial cultures, the 1991 algorithm relying on sputum smears was only 34% sensitive in diagnosing TB (7). Implementation of CDOT TB TI is one part of a broader strategy to address TB among foreign-born persons in the United States. Resources should be devoted toward rigorous monitoring of the program to maintain what has been developed and increase linkages with in-country efforts. Moreover, additional strategies to further decrease TB among foreignborn persons might be explored, such as extending screening to long-term visitors (8), developing innovative strategies to address the reservoir of latent TB infection in the foreign-born population (9), and strengthening U.S. follow-up for arriving persons identified overseas as being at risk for TB (10). 1Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC (Corresponding author: Drew L. Posey, dposey@cdc.gov, 404-498-1600)