摘要：Objectives. We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis. Methods. A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011. Results. Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI. Conclusions. Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings. Foreign-born populations are at greatest risk for having both latent tuberculosis infection (LTBI) and developing tuberculosis (TB) disease within high-income countries and, in 2012, accounted for 63.0% of the 9951 TB cases in the United States. 1 Newly diagnosed and reactivated TB infection among foreign-born individuals in the United States is currently 12 times greater (15.8 vs 1.4 cases per 100 000 population) than among US-born persons. 1 Among foreign-born individuals, LTBI often reactivates within 5 to 10 years after arrival to the United States. 2,3 Undocumented migrants and visitors from high-TB-prevalence countries, however, do not undergo routine LTBI screening and thus remain outside traditional health care screening and treatment programs in primary or specialty care settings except when they are acutely ill. 3,4 Thus, identifying and treating LTBI cases among these high-risk populations before transforming to TB disease and resultant transmission to others is crucial to ending the cycle of ongoing TB infection within the United States. Workplace screening, 4,5 mandatory criminal justice system screening, 6–8 screening for entry into medication-assisted therapy and drug treatment programs, 9 and refugee and naturalization programs 10,11 have been successful for reaching legal and domestic populations, but innovative options are needed to target foreign-born populations that are not yet integrated into mainstream care. Culturally and geographically isolated foreign-born groups may be overlooked especially if there is low self-perception of tuberculosis risk. 12 Tuberculin skin testing (TST), though imperfect, is internationally recognized and has been shown to be a reasonably accurate assessment of LTBI status in immunocompetent adults, despite receiving previous Bacillus Calmette-Guérin vaccine. 13 Whereas other studies have focused on traditional clinics or statewide programs, 14 we present an innovative mobile medical clinic (MMC) as a model to target “hidden” foreign-born populations for LTBI screening. New Haven, Connecticut, the country’s fourth poorest city for its size, with a census of 130 000, is a medium-sized urban setting in New England that has experienced extraordinary social and medical disparities including a high prevalence of poverty, drug addiction, HIV/AIDS, and unemployment and is disproportionately comprised of people of color, including 35.4% and 27.4% being Black or Hispanic, respectively. 15 As New Haven is an industrial city with low-paying jobs, there has been an influx of foreign-born people, now officially comprising 11.6% of the population, with many having an undocumented residency status. Health care access for this group is absent unless individuals pay directly for fee-for-service, and concern for deportation and arrest further hinders willingness to seek care. 16 The Community Health Care Van (CHCV) is an MMC that provides free health care 5 days per week in 4 impoverished neighborhoods in New Haven. Though at inception the program was linked to the needle and syringe exchange program, 17 it has since expanded over 20 years to become a vital bridge to a diverse array of health and addiction treatment services that includes services for medically underserved populations, including directly administered antiretroviral therapy to treat HIV, 18–21 buprenorphine maintenance therapy, 22–25 community transitional programs from the criminal justice system, 26–33 hepatitis B vaccination, 34 rapid hepatitis C screening, 35 and other ongoing primary health care programs such as screening and monitoring of sexually transmitted infections, 36 diabetes, and hypertension. In addition, the CHCV provides outreach and intensive case management services. 37 Screening for LTBI and TB disease began in 2003 to target high-risk undocumented and foreign-born clients, as well as clients entering drug treatment programs or homeless shelters, who were concerned about TB infection yet were reluctant to seek care in traditional health care settings for fear of deportation, prohibitive cost, or language barriers. The LTBI screening program shortly thereafter became successfully incorporated into the country’s first mobile buprenorphine maintenance therapy program. 9
