The following press releases and news article provide background on the current
situation in Thailand. A Question & Answer document from the State Department
and CDC is copied in below; it is not yet on either website. Thanks to Savitri
Tsering, Wisconsin Refugee Health Coordinator, for sharing these items.
From U.S Department of State, Bureau of Population, Refugees and Migration
(PRM), Office of Multilateral Coordination and External Relations ( PRM/MCE):
Robert Hilton, 202-663-1979 and Centers for Disease Control.
- Question: Are refugees tested for infectious diseases,
such as TB, prior to coming to the U.S.?
Answer: Yes. Under contract to the U.S. government, the International
Organization for Migration performs the required medical examinations for
many overseas refugee populations. The Centers for Disease Control and Prevention
(CDC) is responsible for providing technical guidance to the physicians
who perform the overseas medical screening examination.
- Question: When did the U.S. government become concerned about
tuberculosis among Hmong refugees from Laos who are at the Wat Tham Krabok
complex in Thailand?
Answer: CDC routinely recommends enhanced screening for TB, such
as TB cultures and other rapid testing, for migrants who have lived in or
are migrating from areas of the world with high TB prevalence, including
parts of Asia and Africa. The Hmong refugee group at Wat Tham Krabok met
this profile and so enhanced screening procedures were established.
In June 2004, the CDC noted a prevalence of tuberculosis among Hmong Lao,
as detected by chest x-rays. This led the CDC to implement additional pre-departure
tuberculosis screening procedures for this group that are standard for populations
with high TB rates. Following implementation of these new procedures, CDC
learned of cases of multiple drug resistant tuberculosis among this group.
- Question: When did you become aware of a cluster of TB in the
Hmong refugees from Laos?
Answer: In January 2005 CDC received reports of several Hmong refugees
in the United States with active tuberculosis, including two cases of multiple
drug resistant tuberculosis. These cases had not been identified during
overseas medical examinations. Refugees receive additional TB screening
upon arrival to the United States. CDC is working with state and local health
officials and the Hmong refugee community in the U.S. to ensure individuals
gets appropriate screening and treatment, if needed. The exact number of
cases in the U.S. is still being determined.
- Question: Why were these cases missed in the overseas exams?
Answer: CDC is investigating these cases. There are numerous reasons
why some persons with tuberculosis might not be identified, despite enhanced
screening and treatment protocols. First, although TB cultures identify
the majority of persons with pulmonary TB disease, a small percentage of
infected persons will have negative tests. This can be due to the nature
of TB disease. In addition, some persons who have been exposed to TB will
be later be infected with TB, but have not yet developed the symptoms of
TB disease until after screening and migration to the U.S.
- Question: How long will the moratorium on Hmong refugee movements
from Thailand continue? What is the impact of the suspension on overall U.S.
refugee admission efforts?
Answer: We can't say yet. CDC teams are now re-screening the remaining
population in Thailand, approximately 6,000 individuals. Travel to the U.S.
will not resume until CDC and the State Department believe it is safe to
do so. The suspension does not affect our commitment to meeting the goals
of the President's refugee determination for fiscal year 2005. We do not
anticipate that the suspension will affect the overall admission figures
for fiscal year 2005.
- Question: Is there a chance that some Hmong refugees at Wat Tham
Krabok may not be able to resettle in the U.S.?
Answer: The Department of State is committed to bringing all of
the Hmong refugees approved for U.S. resettlement to the United States.
Travel to the U.S. for approved refugees in this group will resume once
these health issues are addressed. All refugees who pass the new medical
screening will be moved to the United States as quickly as possible. Refugees
who do not pass the screening initially will be provided with treatment
in Thailand and will travel to the U.S. when they have completed treatment
and are medically cleared.
Question: Will any of the sick refugees who have been admitted
be sent back to Thailand?
Answer: No. No one will be removed from the U.S. CDC will work with
state and local health officials and the Hmong community to ensure that
affected individuals get the treatment they need. This heath problem does
not change the underlying humanitarian reasons for which the Hmong refugees
from Laos were granted refugee status and allowed to emigrate to the U.S.
- Question: What is the situation in Thailand? Are Thai people at
Answer: CDC has initiated an overseas epidemiological investigation
in Thailand. A team of six CDC staff members, including an Epidemic Intelligence
Service Officer, is traveling to Thailand now. They will join the ongoing
Thailand Ministry of Public Health/CDC joint investigation into the prevalence
and epidemiology of tuberculosis among the remaining Hmong refugees at Wat
Tham Krabok. They will take all necessary steps to control potential disease
transmission within this population and to others.
We do not believe that the prevalence of TB within the Hmong population
at Wat Tham Krabok poses a threat to the Thai people. To become infected,
a person normally would have to spend a relatively long time in a closed
environment where a person with untreated TB who was coughing had contaminated
the air. Anyone -- in Thailand or the U.S. -- concerned about possible exposure
to TB, should see a doctor.
- Question: How will care be provided for Hmong refugees in the
U.S. who have TB?
Answer: Upon arrival in the U.S., refugees are provided a health assessment
and follow-up care in order to prevent the spread of health conditions that
could affect the public health and to identify and treat any health issues
that could impede resettlement. These services are supported with funds
from the Office of Refugee Resettlement's Preventive Health program.
Many refugees qualify for Medicaid which will cover their health care.
For refugees not eligible for Medicaid, Refugee Medical Assistance is available
for health care for the first eight months after arrival to the U.S.
- Question: How has the Federal Government organized itself to respond
to this important issue?
Answer: The Centers for Disease Control and Prevention is leading
the federal government's response to the health issues, working with the
Office of Refugee Resettlement, which is also part of the Department of
Health and Human Services, and the Department of State. In Thailand, CDC
and State Department officials are working with the government of Thailand,
the International Organization for Migration, the United Nations High Commissioner
for Refugees, and other organizations.
- Question: How common is TB, both in the US and worldwide?
Answer: Worldwide, 9 million new cases of tuberculosis are reported
to the WHO each year. Tuberculosis is a leading infectious cause of death
and about 2 million people die from this curable disease each year. In the
United States, in 2003, 14,874 new cases of tuberculosis were reported to
CDC, marking 11 years of decline since the resurgence in 1992. Fifty-three
percent of these cases are among foreign born. In 2003, 108 of these cases
were multi-drug resistant.
- Question: Is tuberculosis an infectious and contagious disease
that can be treated?
Answer: Tuberculosis is an infectious disease caused by germs that
are spread from person to person through the air. Tuberculosis usually affects
the lungs, but it can also affect other parts of the body, such as the brain,
the kidneys, or the spine. A person with tuberculosis can die if they do
not get treatment. Tuberculosis disease can be cured by taking several drugs
for 6 to 12 months. It is very important that people who have tuberculosis
disease finish the medicine, and take the drugs exactly as prescribed. If
they stop taking the drugs too soon, they can become sick again; if they
do not take the drugs correctly, the germs that are still alive may become
resistant to those drugs. Tuberculosis that is resistant to drugs is harder
and more expensive to treat. In some situations, staff of the local health
department meets regularly with patients who have tuberculosis to watch
them take their medications. This is called directly observed therapy (DOT).
DOT helps the patient complete treatment in the least amount of time.
- Question: What is drug resistant tuberculosis? Can people with
drug-resistant tuberculosis be treated?
Answer: Multidrug-resistant tuberculosis (MDR TB) (i.e., tuberculosis
resistant to at least isoniazid and rifampin-the two most important drugs
used to treat tuberculosis) presents difficult treatment problems. Treatment
must be individualized and based on the patient's medication history and
drug susceptibility studies. Unfortunately, adequate data are not available
on the effectiveness of various regimens and the necessary duration of treatment
for patients with organisms resistant to both isoniazid and rifampin. Moreover,
many of these patients also have resistance to other first-line drugs (e.g.,
ethambutol and streptomycin) when drug resistance is discovered. Because
of the poor outcome in such cases, it is preferable to give at least three,
but often as many as four to six, new drugs to which the organism is susceptible.
This regimen should be continued for a total of 18 to 24 months. MDR TB
drugs should be given using a daily regimen under directly observed therapy
(DOT). Intermittent administration of medications is generally not possible
in treatment of MDR TB.
- Question: Can people be vaccinated against tuberculosis?
Answer: BCG is a vaccine for tuberculosis disease. BCG is used in
many countries, but it is not generally recommended in the United States.
BCG vaccination does not completely prevent people from getting tuberculosis.
It may also cause a false positive tuberculin skin test. However, persons
who have been vaccinated with BCG can be given a tuberculin skin test.
- Question: What is the difference between tuberculosis disease
and latent tuberculosis infection?
Answer: People with latent tuberculosis infection have tuberculosis
germs in their bodies, but they are not sick because the germs are not active.
These people do not have symptoms of tuberculosis disease, and they cannot
spread the germs to others. However, they may develop tuberculosis disease
in the future. They are often prescribed treatment to prevent them from
developing tuberculosis disease. People with tuberculosis disease are sick
from tuberculosis germs that are active, meaning that they are multiplying
and destroying tissue in their body. They usually have symptoms of tuberculosis
disease. People with tuberculosis disease of the lungs or throat are capable
of spreading germs to others. They are prescribed drugs that can cure tuberculosis
- Question: Should anyone who comes in contact with refugees be
tested for TB?
Answer: To become infected, a person would have to spend a relatively
long time in a closed environment, where the air was contaminated by a person
with untreated TB who was coughing. A person with latent tuberculosis infection
cannot spread germs to other people. If you have spent time with someone
with tuberculosis disease or someone with symptoms of tuberculosis, you
should be tested. People with tuberculosis disease are most likely to spread
the germs to people they spend time with every day, such as family members
or coworkers. Anyone concerned about possible exposure to TB, should go
to your doctor or your local health department for a TB skin test.
- Question: A few years ago, CDC established a National Action Plan
to Combat Multidrug-Resistant TB, is this program still active?
Answer: The National Action Plan to Combat Multidrug-Resistant Tuberculosis
has been revised and incorporated into a number of guidelines, including
Treatment of Tuberculosis: www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm
Other guidelines and recommendations can be accessed via the CDC Division
of Tuberculosis Elimination website: www.cdc.gov/nchstp/tb/
There are a number of TB educational materials available in the Hmong language.
These materials, along with other TB educational materials, can be accessed
at the TB Education & Training Resources Website: www.findtbresources.org
- Question: Please describe the current CDC tuberculosis prevention
program available through the United States?
Answer: State and local health departments have the primary responsibility
for preventing and controlling tuberculosis. However, other health care
providers who provide tuberculosis services in settings such as private
clinics, managed care organizations, HIV clinics, correctional facilities,
and hospitals also have responsibility for preventing and controlling tuberculosis
Prevention and control efforts should be conducted through the coordination
of health care providers in a variety of settings to ensure the provision
of direct services for tuberculosis patients. Prevention and control efforts
should include three priority strategies:
- Identifying and treating all persons who have tuberculosis disease.
This means finding cases of tuberculosis and ensuring that patients complete
- Finding and evaluating persons who have been in contact with tuberculosis
patients to determine whether they have tuberculosis infection or disease,
and treating them appropriately;
- Testing high-risk groups for tuberculosis infection to identify candidates
for treatment of latent infection and to ensure the completion of treatment.
Although tuberculosis care and treatment are often provided by other medical
care providers, the health department has the ultimate responsibility for
ensuring that tuberculosis patients do not transmit M. tuberculosis to others.
Health departments must ensure that medical services are available, accessible,
and acceptable for tuberculosis patients, suspects, contacts, and others
at high risk, without regard to the patients' ability to pay for such services.