H-1Bs with TB
H-1Bs with TB
Date: Sunday, April 20, 2008 7:23 PM
<<<<< JOB DESTRUCTION NEWSLETTER No. 1856 -- 4/20/2008 >>>>>
Alameda County TB control officer Dr. Robert Benjamin warned that tuberculosis
among H-1B visa holders has dramatically increased.
"During the dot-com boom, we in Alameda County and I know other
Bay Area counties saw a dramatic increase in tuberculosis among
the (H-1B) visa immigrants," said Benjamin, the Alameda County
TB control officer.
Dr. Benjamin laments the fact that H-1Bs aren't screened for TB.
"I don't know how or why, but at some point a decision was made by
the State Department that if a U.S. company sponsors a highly
educated, highly skilled worker, that they don't need screening
. . . . I think that just because they are highly educated and
have a job doesn't mean they can't have TB."
Dr. Benjamin is correct that H-1Bs aren't required to be screened for TB, but
he is wrong that the State Dept. changed their policy -- H-1B nonimmigrants
have never been required to be screened for infectious diseases, although some
employers may ask that their H-1Bs be tested.
Believe it or not, there is a rationale to justify the avoidance of screening
H-1Bs for TB. To understand the reasoning, however flawed it may be, it has to
be understood that nonimmigrants, on temporary visas, and immigrants, who seek
permanent residency, are considered very differently.
H-1B visas are nonimmigrant, which in theory means that they come to this
country temporarily and therefore are considered a lower risk of being a
disease vector than a permanent immigrant.
H-1Bs are unlikely to ever get tested for TB unless they apply for a change of
status to a green card. Once they apply for a green card they must get a TB
test. Even if they test positive for TB they won't necessarily be rejected
because they can apply for a waiver by filing "I-601, Application for Waiver
of Grounds of Inadmissibility".
All of this means that H-1B visas holders can be here for six years without
ever being tested for tuberculosis. So, if in the period of six years the H-1B
coughs, sneezes, or shouts the germs will spray into the air. Anyone who
breathes their aerosol can be infected with the disease.
Image of TB infected H-1B coughing
\\\\\\//
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jgs / _\':.
/ _\'..:. :.
/ ': : : : :.
: ' :: : :. <---- phlegm aerosol
. : ' .
You may be wondering what kind of idiot politician would allow this to happen.
I gotta surprise for you -- it's not politicians, it's the AMA!
Many of their politically correct physicians decided that the risk of
tuberculosis is outweighed by the advantages of open border politics.
http://www.ncbi.nlm.nih.gov/pubmed/11176758
Overseas TB screening of nonimmigrant visitors, who are unlikely to
have active TB and even less likely to transmit it, will be of
extremely low yield, would significantly deviate from the US
"open-door" policy for nonimmigrants, and would have great
logistical and political implications.
Of course medical researchers and doctors wouldn't rely on crass politics to
fully justify this non testing policy. They did a cost vs. benefit analysis to
figure out that testing nonimmigrants is just too dang expensive.
Screening and monitoring the nonimmigrant foreign-born population
would divert valuable resources from now established, successful
TB control programs for foreign-born immigrants.
NOTE: Google doesn't allow access to the entire medical study, so I wasn't
able to see which group of shameless corporations paid for the study.
+++++++++++++++++++++++++++++++++++++++++++++++++++
http://www.mercurynews.com/ci_8975501?source=most_emailed
New TB threat: Global ties bring an ancient disease to Silicon Valley
By Mike Swift
Mercury News
Article Launched: 04/18/2008 04:11:10 PM PDT
New TB threat: Doctors worry about powerful strains resistant to drugsNew TB
threat: Health worker fights disease, patient by patientIn a beautiful home
filled with mementos of world travel, a 44-year-old Silicon Valley executive
reluctantly picks up the telephone to tell several business contacts that he
might have infected them with tuberculosis.
In a one-bedroom apartment in Oakland, a new mother feels her life slipping
away. She is losing her hearing, her feet are going numb and her face carries
a rash from the toxic drugs being used to fight the drug-resistant bacteria in
her lungs. Her body has dwindled to 87 pounds and she wonders:
Would my husband and infant son be better off if I was dead?
In Helena, Mont., the state's tuberculosis official takes an urgent call from
the laboratory and feels her stomach knot. She has a patient with a
potentially infectious, dangerous TB strain - a case her state lacks the money
and the medical resources to treat.
Those three small snapshots are all part of a global tuberculosis epidemic
that threatens the Bay Area - with its web of international connections - like
few places in the nation.
Call it one price of globalism.
Last year, tuberculosis increased in four of the Bay Area's five largest
counties, and the San Jose area in 2006 had the highest TB rate of any large
American metro area, according to data from the U.S. Centers for Disease
Control and Prevention and the California Department of Public Health. San
Francisco, after an outbreak of TB among Latino day workers in the Mission
district, has the highest TB rate of any county in California - quadruple the
U.S. rate.
From the bodies of Peruvian mummies to 21st-century tech workers, tuberculosis
has been mankind's dark partner for centuries - a highly infectious disease
that never followed the path to eradication of smallpox and polio. One in
three people worldwide are infected, and 1.7 million died last year, mostly in
poor countries where people lack the access to detection and treatment
available in the United States.
No case of TB is easy. The waxy-sheathed, rod-shaped, slow-growing bacteria,
if untreated, colonizes the lungs, creating such dense cavities of disease
that pieces must sometimes be excised. TB spreads through the air; untreated,
one person infects 10 to 15 people a year, according to the World Health
Organization.
But among public health officials, nothing is more worrisome than the relative
handful of drug-resistant TB cases. WHO and U.S. experts are warily watching
the record level of such cases - found from former Soviet prisons to remote
provinces in China - as hints of something even scarier on the horizon.
"It worries me that we're going to have increased cases of multi-drug
resistance because we have no control over the rest of the world," said Dr.
Marty Fenstersheib, the public health officer for Santa Clara County, which
has had a 21 percent jump in TB cases since 2005. "The person on the street,
when you go up to them and say, 'Do you know what one of our major problems
is?' and they guess everything else and you go, 'Tuberculosis,'
and they go, 'No. We still have TB? We have that?' "
Treating one drug-resistant case can easily cost several hundred thousand
dollars or more - the bill often ends up with the county health department if
a patient lacks insurance. And in a growing number of extremely resistant
cases - including a few in the Bay Area - there are no drugs that can cure the
disease, raising the specter of an infectious, incurable, potentially fatal
infection.
With California in a budget crisis - and the state's total number of TB cases
declining - a disaster which hasn't happened yet is not a high priority for
politicians. But that is precisely what worries Bay Area TB officials. They
say emerging drug resistance, global travel connections, and Gov. Arnold
Schwarzenegger's plans to cut TB spending will all handicap California's
ability to protect residents from dangerous drug-resistant TB.
"It drops our pants around our ankles," Alameda County TB control officer Dr.
Robert Benjamin said of the budget cuts. "And we can't run like that."
Demographics
Valley's strong links to other countries If affluent, modern Silicon Valley
seems an unlikely hunting ground for a disease often presumed a medieval
scourge, nothing could be more wrong. This region has intimate ties to
countries with the world's highest TB burdens, countries where the lack of
access to antibiotics and basic health care has allowed the disease to
flourish in the 21st century.
Ninety percent of Santa Clara County's 241 TB cases in 2007 were in students,
immigrants, temporary workers, tourists and others born in other countries. At
the same time, the number of multi-drug-resistant cases in the county -
bacteria resistant to isoniazid and rifampin, the first-line TB antibiotics -
jumped from two to seven.
The top five countries of origin for foreign-born people with TB are Mexico,
the Philippines, Vietnam, India and China, according to the CDC.
Those nationalities are also Santa Clara County's largest five foreign-born
populations. At 430,000 people, they are one-quarter of the county's total
population.
"Our TB reflects the countries of origin that our patients come from, and it's
the Philippines and Vietnam and India where there is a lot of drug
resistance," said Dr. Sundari Mase, Santa Clara County's former TB control
officer, now with the CDC.
Many are not recent immigrants - two-thirds of Santa Clara County's foreign-
born cases have been in the United States for at least five years.
In that sense, TB is a public health issue, not an immigration issue, heath
officials say.
State health officials estimate there are 2 million foreign-born residents of
California infected with latent TB. The great majority will never get sick,
but if their immune systems weaken - by way of HIV infection, diabetes, aging
or immune-suppressing drugs - their TB could multiply, and they could transmit
the disease.
In 2005, soon after she gave birth to a son, a young immigrant wife was
hospitalized with TB. In her native Mongolia, she had nursed an older sister,
who ultimately died of TB, just before she immigrated to the United States and
got married.
Soon something was ominously clear - Battsengel, who asked that her last name
not be used because of her embarrassment at having TB - had a drug-resistant
case. It forced doctors to use second-line drugs that can cost 100 times more
than standard antibiotics. And they can produce terrible side effects.
Drug-induced nausea chopped her weight from 110 to 87 pounds. She had ringing
in her ears and her feet became numb because of nerve myopathy - a common side
effect of second-line TB drugs. And the beautiful skin on the young mother's
face was covered by a rash.
"I was very depressed. There was no happiness, no smile," she said.
"Because of my depression, sometimes I would get so angry - sometimes I would
try to jump out of home, not try, but I say if I die, it will be better."
Loopholes
Screening isn't always effective The United States screens legal immigrants
and refugees for TB before they are allowed to enter the country, by checking
medical histories and requiring a chest X-ray for those at risk.
But Bay Area health officials say there are loopholes in the nation's
defenses, and that budget cuts will only make the gaps bigger.
Denise Ingman, who heads Montana's TB program, learned about one of those
loopholes firsthand in summer 2006. Ingman used a new genetic test developed
by the California Department of Public Health to confirm a 20-year-old at the
University of Montana had potentially infectious drug-resistant TB.
But the student, who was from Mongolia, probably never would have been able to
enter the United States if the country, like Canada, had a system to screen
students, temporary workers on H-1B visas or other visitors who may live here
for years on non-immigrant visas.
Once she had the confirmation, Ingman contacted county health authorities who
were tracking the student.
"They said, 'Oh. We just gave her permission to go on a little trip,' "
Ingman recalled.
For three tense days, Montana officials searched for the student, who was on a
driving tour of the Pacific Northwest. Her family had their cell phones off.
Ingman contacted the Seattle airport, issuing a "do not board"
order, because she was worried the student was trying to return home.
Ingman and the TB control officers in Santa Clara, San Mateo, San Francisco
and Alameda counties, as well as the executive director of the National
Tuberculosis Controllers Association, agree the United States should screen
all long-term visitors.
Canada prevents an estimated 600 TB cases a year by screening everyone who
plans to stay in the country permanently, for longer than six months if they
are coming from a country with a high incidence of TB, or for any length of
time if they will be working in health care, education, child care or domestic
work, said Dr. Edward Ellis, manager of TB control for the Public Health
Agency of Canada.
"During the dot-com boom, we in Alameda County and I know other Bay Area
counties saw a dramatic increase in tuberculosis among the (H-1B) visa
immigrants," said Benjamin, the Alameda County TB control officer. "I don't
know how or why, but at some point a decision was made by the State Department
that if a U.S. company sponsors a highly educated, highly skilled worker, that
they don't need screening. . . . I think that just because they are highly
educated and have a job doesn't mean they can't have TB."
The cost of every TB case to local taxpayers is significant.
Santa Clara County spent an average of $18,000 a case in 2007 - about $4.3
million total - for drugs, testing and for the labor-intensive contact
investigation required for families, co-workers or schoolmates who have
contact with an infectious person.
With state and local funding in doubt, Fenstersheib, the county health
officer, went to Washington in March to lobby Silicon Valley's congressional
representatives to have Santa Clara County join the dozen U.S. cities and
counties that get direct federal TB funding.
"I think we deserve it," Fenstersheib said. "We have more cases than half the
cities that have direct funding."
Emotional toll
S.F. executive's unexpected fight Scott Halstead is an optimistic, athletic
person - the kind of guy who would bike several hundred miles a week - a
Silicon Valley executive and venture investor.
In January, five months before his wife was due to deliver their first child,
Halstead, the former chief executive of WageWorks in San Mateo, learned he had
TB. He didn't have a drug-resistant case, but for 3 1/2 weeks, he was required
to stay in his Noe Valley home, going outside only in a surgical mask.
Instead of business meetings and dinners with his wife, his schedule was tied
to the daily arrival of a San Francisco health worker, who would deliver his
medicine and watch him take it - a public health requirement to make sure he
took all his doses to prevent the survival of drug-resistant bacterial in his
body. The drugs fogged his mind to the point he couldn't work.
And he had to call several business contacts and the relatives he shared
Thanksgiving with, and tell them that they all needed to get tested for TB.
"It's hard to even connect to what it was like to be well," he said.
Halstead probably was infected on his honeymoon in Africa last year, and
immune-suppressing arthritis drugs allowed his TB to multiply. He expects to
be in good health by the time his wife delivers later this spring.
For patients with a multi-drug-resistant case, however, the medical odyssey
can be much, much longer.
Battsengel survived hers. After two years, two months and 15 days of
medication, she is healthy, her TB cured after two years of treatment.
"I feel great," said Battsengel, who is studying to become a nurse. "I have a
smile on my face. I have a future."
One TB patient who spent most of the past three months in Stanford University
Hospital - a 30-year-old Sunnyvale woman who flew from New Delhi to San
Francisco International Airport with a contagious case of multi-drug-resistant
TB in December - faces a similar trial. The case triggered a national hunt by
the CDC for 44 other passengers sitting nearby.
At least one person on the flight might have been infected, although it's
impossible to definitively confirm that the infection came from the airline
exposure at this point, the CDC reported Wednesday. The Sunnyvale woman, who
declined an interview request and whose identity is being withheld by public
health officials, is enduring what Fenstersheib said could be a two-year
regimen of drugs with potential side effects including hearing and liver
damage.
TB experts say she won't be the last person to bring a dangerous strain of
drug-resistant disease to the Bay Area.
International hubs are at "very, very serious risk," said Dr. Marcos Espinal,
who heads the Stop-TB Partnership, an international health partnership housed
at the WHO in Geneva.
"TB is endemic in many countries that have a strong relationship with the
U.S., in trade, exchanges in the arts, in sports," Espinal said. "Many people
from those countries meet in the U.S. It's very serious in my view."
Contact Mike Swift at mswift@mercurynews.com or (408) 271-3648. Mercury News
Staff Writer Saqib Rahim contributed to this report.
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