Screening migrants for tuberculosis - a missed opportunity for improving knowledge and attitudes in high-risk groups: A cross-sectional study of Swedish-language students in Umeå, Sweden

Social participation and exposure to tuberculosis education: a cross-sectional study of older (≥ 60 years) domestic migrants in China

BACKGROUND

Older domestic migrants have a higher risk of infection of tuberculosis or reactivation of latent tuberculosis than other populations in China. This study aimed to assess the exposure level of older domestic migrants to tuberculosis education and its association with social participation.

METHODS

Data were extracted from the 2017 China Migrants Dynamic Survey (CMDS). A total of 5,787 study participants over 60 years of age were eligible for this study. Multilevel logistic regression models were established to determine the association between social participation and exposure to tuberculosis education after adjustment for variations in sociodemographic characteristics of the participants and health resources available in their migration destinations. Propensity score matching (PSM) was conducted to precisely estimate the average treatment effect on the treated (ATT) of social participation on exposure to tuberculosis education.

RESULTS

Only 28.5% of study participants reported exposure to tuberculosis education in various forms over the past year in their migration destination. Participation in social activities, both membership-based (aOR:1.68, 95% CI:1.46-1.94,) and non-membership-based (aOR:1.66, 95% CI:1.44-1.91) were associated with higher exposure to tuberculosis education after adjustment for variations in covariates. Those who resided in a province with higher prevalence of tuberculosis and higher health expenditure, established a local personal health record, were aware of the essential public health services, had a job, obtained higher levels of education, and self-rated good health were more likely to be exposed to tuberculosis education. The ATT of social participation reached 0.10, indicating an increase of 10% exposure to tuberculosis education in those with active social participation.

CONCLUSIONS

Low levels of exposure to tuberculosis education in older migrants are evident in China. Social participation is associated with higher exposure to tuberculosis education.

Knowledge, attitude and practice towards tuberculosis among healthcare and non-healthcare students at a public university in Saudi Arabia

Background

Tuberculosis (TB) is a bacterial infection. It mostly affects the lungs (pulmonary TB), but it can also affect other organs. This cross-sectional study evaluated knowledge, attitudes, and practices (KAP) related to TB among King Khalid University (KKU) students between October and November 2023.

Objective

The objective of this study was to investigate current TB knowledge, attitudes, and practices of students at King Khalid University in Abha, Saudi Arabia.

Methods

A self-administered, cross-sectional, descriptive, web-based questionnaire was conducted from October to December 2023 among the students of King Khalid University. We used a 29-item questionnaire with five sections. Section 1 contained five questions about sociodemographic factors, there were 13 knowledge questions in Section 2, Section 3 contained 7 attitude questions, Section 4 contained 3 practice questions, and Section 5 contained 1 source of information question. A chi-squared test was used to assess differences in participants' knowledge, attitude, and practices in relation to their demographic variables (p < 0.05).

Results

A total of 518 students completed the questionnaire. 53.66% were healthcare students and 46.33% non-healthcare students. The mean scores for healthcare and non-healthcare students, respectively, were as follows: knowledge 11.80 ± 4.81, 7.35 ± 4.96; attitude 6.94 ± 1.33, 5.05 ± 2.09; and practice 2.26 ± 0.85, 1.14 ± 0.87. The results of this study showed good knowledge (24.82 and 5.83% for healthcare and non-healthcare students, respectively) good attitude (67.62 and 46.25%) and good practice (45.32 and 9.58%). A total of 24.32% healthcare students and 28.18% non-healthcare students reported that most effective sources for obtaining information about TB were social networks, the internet and the radio.

Conclusion

The current study concludes that the knowledge, attitude, and practice about TB among healthcare faculty students is better than their non-healthcare counterparts. However, there are still areas of poor knowledge, attitude and practice toward some aspects of TB among the two categories, which shows the necessity of educational intervention that aims at improving student understanding about the disease and its impact on public health.

Assessment of Knowledge, Attitude, and Practice towards Tuberculosis among Taif University Students

Tuberculosis (TB) remains a significant public health concern worldwide. Given the dense living and interactive nature of university environments, students may be at higher risk. This cross-sectional study assessed tuberculosis-related knowledge, attitudes, and practices (KAP) among students at Taif University (TU) from November 2022 to May 2023. Using a self-administered online questionnaire with 40 items, 1155 students participated. Key demographics: 68.2% females, 96.9% Saudi citizens, 94.5% unmarried, and 87.5% non-smokers. Of the respondents, 26.5% had no knowledge of TB. The TB-related KAP scores among the aware students were 64.9%, 74.8%, and 81%, respectively. Medical college students exhibited significantly higher TB-related knowledge and attitudes than their non-medical peers (p < 0.001). The findings indicate a commendable level of TB-awareness among TU students, but there remains a substantial uninformed segment. Campaigns to enhance TB knowledge among TU students are suggested.

Knowledge, attitudes and practices on tuberculosis among screened immigrants in Norway. A cross-sectional study

Aims

Most tuberculosis (TB) cases in Norway occur among immigrants from high-incidence countries. Although there is an extensive screening program for vulnerable groups, many do not appear for their screening appointment and do not understand why they require screening. This study aimed to further understand these vulnerable groups’ knowledge, attitudes and practices (KAP) regarding TB to inform the screening program and health care personnel dealing with TB.

Methods

A KAP questionnaire developed by the World Health Organization (WHO) and adjusted to Norwegian conditions was used. The study has a cross-sectional design. One study group was immigrant students receiving primary screening in the municipality (MVIC) who completed an English questionnaire; the other was immigrants who were referred to hospital (POPD) for follow-up of screening results. They were interviewed with a translator when necessary. Statistical analyses to describe and compare groups of participants were done.

Results

Altogether, 275 persons were eligible, and 219 (85%) participated. In the MVIC group 184 persons (86%) participated and in the POPD group 35 persons (80%). The mean knowledge score was 5.53 (maximum score: 11) with no significant differences between study groups or associations with demographics or length of education. There were serious knowledge gaps related to TB symptoms and transmission. Approximately half would have reacted with fear or surprise if they had TB, and 60% were afraid of being infected. Only 14% would avoid a person with TB.

Conclusion

The mean knowledge score was reasonably good but with some serious knowledge gaps. We detected fear of being infected or having TB disease but no serious stigma. More information and teaching about TB catered towards different immigrant groups are necessary.

Perceptions of Tuberculosis Among Individuals Born in a High-Endemic Setting, Now Living in a Low-Endemic Setting

Of all individuals diagnosed with tuberculosis (TB) in Sweden 2015 were 90% born in other countries. Early diagnosis and treatment is essential to avoid TB transmission. Lack of knowledge about TB and anticipated negative social consequences have proved to be significant contributing factors to delay in seeking health care. This study aimed to understand the perception of TB among people originating from a high-endemic region, currently living in a low-endemic region. A qualitative study design, with male and female participants from a high-endemic region divided into focus groups. A semi-structured interview guide was used to elicit their perceptions of TB. A qualitative content analysis was performed on the recorded material from the interviews. The informants noted that their attitude towards individuals with TB had changed, previously they had felt prejudiced towards them whereas now they felt supportive. It seems possible to diminish TB stigma by ensuring suitable health care is available in combination with correct information about transmission, infectiousness and treatment.

The role of tuberculosis control institutes in delivering tuberculosis information to domestic migrants in China: A multi-level analysis of a nationwide cross-sectional survey

OBJECTIVES

The aim of this study was to understand how tuberculosis (TB) control institutes raise awareness of TB among domestic migrants in China, specifically whether migrants have received TB information and how they received it.

METHODS

This multi-level analysis included both county-level data and individual-level data covering 31 provinces in mainland China. Multi-level logistic models were used to explore the factors associated with receiving TB information.

RESULTS

This analysis included 205 990 migrants from 31 provinces and municipalities. Only 77 460 (37.60%) migrants reportedly received any TB information in mainland China. The center for disease control and prevention (CDC), the center for tuberculosis control (CTC), and the center for prevention and treatment of chronic diseases (CPTCD) were the most likely to provide TB information for migrants in comparison to other types of TB control institutes, such as general hospitals, specialized hospitals, and community healthcare centers. The odds ratios were calculated as: 1.563 (95% confidence interval (CI) 1.246-1.959) for CDCs, 1.385 (95% CI 1.063-1.804) for CTCs, and 1.723 (95% CI 1.424-2.085) for CPTCDs.

CONCLUSIONS

China has not achieved universal coverage of TB awareness. TB awareness levels are higher in regions with CDC, CTC, and CPTCD institutes. Domestic migrants who have moved to western areas are more likely to have received TB information.

Preventing Tuberculosis in a Low Incidence Setting: Evaluation of a Multi-lingual, Online, Educational Video on Latent Tuberculosis

Treating latent tuberculosis infection (LTBI) in those at risk is an important yet challenging cornerstone of TB elimination. We evaluated a culturally-tailored, multi-lingual, 4.5-min, health promotional video on LTBI. Mixed methods study assessed use of the video with web-analytics, acceptability of content through interviews and survey questions, and compared knowledge scores in viewers and non-viewers using a survey. The video was viewed 6999 times in six languages over 1 year. Of 1598 survey respondents, 193 viewers had a mean knowledge score of 59%, compared to 38% in non-viewers. Eighty-four percent of viewers rated the video as helpful. When controlling for other factors, viewing the video was associated with a 1.04 (95% CI 0.85-1.26) or a 21% increase in a knowledge score. Qualitative data suggested the video was acceptable and may facilitate behavior change. This online, educational video shows promise as a tool to supplement clinical care.

'Valuable but incomplete!' A qualitative study about migrants' perspective on health examinations in Stockholm

Background

A voluntary health examination is offered to asylum seekers in Sweden with the purpose of detecting infectious diseases and identifying other health needs. This study aimed to explore the organization, content and perceived value of the health examination from the perspective of asylum seekers.

Methods

Semi-structured interviews were conducted with 18 migrants recruited from different settings in Stockholm. Data were transcribed verbatim and analysed using thematic analysis in relation to the availability, accessibility, acceptability and quality framework.

Results

Participants reported positive aspects of the health examination while raising important concerns, categorized into the following themes: availability-despite being available, the service was considered to be delayed with perceived implication for infection control; accessibility-migrants experienced no physical or economic barrier to access the health examination, especially when it was performed through a mobile clinic, however, they had limited access to information; acceptability and quality-migrants trusted the health staff, however, the examination lacked important aspects related to mental health and dental care needs, among other health needs.

Conclusion

Health examinations are valued by participants but failed to identify and address many perceived health needs. Mobile clinics seem a practical strategy to improve accessibility.

Enhanced surveillance for tuberculosis among foreign-born persons, Finland, 2014-2016

BACKGROUND

Tuberculosis (TB) in foreign-born residents is increasing in many European countries including Finland. We conducted enhanced TB surveillance to collect supplementary information on TB cases among recent immigrants and their children to provide data for revising TB control policies in Finland to take into account the decrease in native cases and increase in foreign-born cases.

METHODS

TB cases were identified from the National Infectious Diseases Register. Data on foreign-born (if not available, most recent nationality other than Finnish) TB cases notified during 2014-2016 (country of birth, date of arrival to Finland, participation in TB screening, date of first symptoms, and details of possible contact tracing) were requested from physicians responsible for regional communicable disease control through a web-based questionnaire.

RESULTS

Questionnaires were returned for 203 (65%) of 314 foreign-born TB cases; 36 (18%) were paediatric cases TB was detected in arrival screening in 42 (21%) and during contact tracing of another TB case in 18 (9%); 143 (70%) cases sought care for symptoms or were identified by chance (e.g. chest x-ray because of an accident). Of cases with data available, 48 (24%) cases were diagnosed within 3 months of arrival to Finland, 55 (27%) cases between 3 months and 2 years from arrival, and 84 (42%) cases after 2 years from arrival. Of all the foreign-born cases, 17% had been in a reception centre in Finland and 15% had been in a refugee camp abroad.

CONCLUSIONS

In addition to asylum seekers and refugees, TB screening should be considered for immigrants arriving from high TB incidence countries, since the majority of TB cases were detected among persons who immigrated to Finland due to other reasons, presumably work or study. Further evaluation of the target group and timing of TB screening is warranted to update national screening guidance.

Acceptability of latent tuberculosis testing of migrants in a college environment in England

OBJECTIVES

The majority of tuberculosis (TB) cases in England occur from reactivation of latent tuberculosis infection (LTBI) in the settled migrant population. The National Institute for Health and Clinical Excellence recommends that new entrants from high-incidence countries are screened to detect LTBI. This article seeks to describe an outreach programme and testing for LTBI in an innovative setting-ESOL (English for Speakers of Other Languages) classes at a community college (CC) with evaluation of acceptability.

STUDY DESIGN

Partnership working with mixed methods used for evaluation of acceptability.

METHODS

A pre-existing network from the local TB partnership designed an outreach intervention and screening for LTBI among students from an ESOL programme at a CC. Screening for LTBI with interferon gamma release assay was the culmination of a programme of health improvement activities across the college. Any student on the ESOL programme younger than the age of 35 years and resident in the UK for less than 5 years was eligible for testing. LTBI testing was carried out on-site, and the experience was evaluated by questionnaires to staff, students and partners. A facilitated debrief among the partners gave further data.

RESULTS

A total of 440 eligible students were tested. One hundred and seventy-two student feedback questionnaires were completed, and 36 partner questionnaires were received with 18 CC staff responding. Students, tutors and healthcare professionals found the setting acceptable with some concerns about insufficient resource for timely follow-up.

CONCLUSIONS

Students, tutors, community organisations and health professionals found the exercise worthwhile and the method and setting acceptable. There were resource issues for the clinical team in follow-up of students with positive results for such a large screening event. Unexpected barriers were found by the CC as this kind of activity was not recognised for external quality review purposes. There were concerns about reputational loss and stigma of being involved in a TB project. As current initiatives aim to divert workload from stretched general practice surgeries, this may be an important addition to primary care screening.

Development and validation of college students' tuberculosis knowledge, attitudes and practices questionnaire (CS-TBKAPQ)

BACKGROUND

China faces many challenges in controlling tuberculosis (TB). One significant challenge is the control of college students' TB. In particular, cross-sectional studies of college students' knowledge, attitudes and practices (KAP) in regard to TB have attracted substantial attention. However, few measurement tools have been developed to aid processes related to expert consultation, pre-testing, reliability and validity testing. Our study developed the College Students' TB Knowledge Attitudes and Practices Questionnaire (CS-TBKAPQ) following the scale development steps.

METHODS

The construction of the CS-TBKAPQ was based on the Theory of Knowledge, Attitude, Belief, and Practice (KABP or KAP). The item pool was compiled from literature reviews and individual interviews. The reliability validation was assessed by calculating Cronbach's α coefficient, the split-half reliability coefficient, and the test-retest reliability coefficient. Construct validity was assessed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The diagnostic accuracy was evaluated using the World Health Organization Advocacy, Communication and Social Mobilization KAP Survey Questionnaire (WHO-TBKAPQ) as the reference standard.

RESULTS

A total of 31 questionnaire items were proposed. Cronbach's α coefficient, the split-half reliability coefficient and the test-retest reliability coefficient were 0.86, 0.78 and 0.91. Four factors that explained 62.52% of the total variance were also identified in EFA and confirmed in CFA. The CFA model fit indices were x ² /df = 1.82 (p < 0.001), GFI = 0.925, AGFI = 0.900, RMR = 0.068, and RMSEA = 0.049. The CS-TBKAPQ was significantly correlated with the WHO-TBKAPQ and the Chinese Public TB KAP Questionnaire (CDC-TBKAPQ) developed by the Chinese Center for Disease Control and Prevention (r = 0.59, 0.60, p < 0.001). The receiver operating characteristics curve (ROC) analysis suggested a cut-off point of 47.5, with which the CS-TBKAPQ showed a sensitivity of 73.63% and a specificity of 80.51% in identifying students with low-level KAP. The positive and negative predictive values were 83.23% and 69.91%.

CONCLUSIONS

The findings of this study demonstrate that the CS-TBKAPQ is a reliable and valid tool for measuring the KAP towards TB in college students.

Increased adolescent knowledge and behavior following a one-time educational intervention about tuberculosis

OBJECTIVE

To evaluate the impact of a tuberculosis (TB) educational intervention (EI) on change in adolescent student knowledge and participation in a TB prevention program.

METHODS

From 2/2013-5/2015, students from 2 high schools in Houston, TX participated. The 25-min EI discussed TB bacteriology, epidemiology, symptoms, and indications for TB testing/treatment. Students completed pre- and post-quizzes. Immediately after the EI, students were invited to participate in voluntary TB risk-factor screening, testing and treatment. At 6 months, focus groups were conducted.

RESULTS

895 students attended the EI. 827 students (92%) completed the EI quizzes. Knowledge improved by 12% (pre: 70%; post: 82%, p<0.001); 78% shared their TB knowledge. Following the EI, 671/827 (81%) enrolled in a TB prevention program. Focus groups indicated that the EI stimulated student learning about TB and increased their willingness to participate.

CONCLUSION

A brief, one-time, TB EI is an effective method to encourage adolescents to learn about TB and motivate their uptake of TB risk-factor screening, testing and treatment. Similar EIs should accompany TB prevention programs targeting adolescents.

PRACTICE IMPLICATIONS

The study's procedures could be considered for incorporation into school-based TB prevention programs to improve the identification, testing and treatment of adolescents at risk for TB.

Health Assessment and the Right to Health in Sweden: Asylum Seekers' Perspectives

BACKGROUND

Swedish law entitles asylum seekers to a voluntary health assessment and to "health care that cannot be postponed". The last expression suggests, however, restrictions on the entitlement, and what it may or may not include remains ultimately a decision for health professionals in the specific case. Indeed, the health assessment constitutes the sole active effort from Swedish authorities to fulfill this right. This study was therefore aimed at assessing how the information, procedures and services related to the health assessment are accessible and acceptable to fulfill the right to health of asylum seekers, from their own perspective.

METHODS

The study has a cross-sectional design. A questionnaire was administrated in 16 language schools for immigrants, in four counties of Sweden. Three hundred eighty-six individuals fulfilled the inclusion criteria. The frequency of their answers was tabulated to estimate how the information, procedures and services related to the health assessment correspond to the criteria for accessibility and acceptability regarding the right to health.

FINDINGS

Forty-eight (12.4%) respondents did not undergo the health assessment. Thirty-one of them did not even receive the invitation letter. They said they lost the opportunity to know their health status, to obtain treatment for or advice about their health problems. Additionally, 55.2% of those who attended the health assessment indicated that their needs were overlooked, particularly when these were of a psychological nature. Two in three participants also considered the health assessment to be a communicable disease control, rather than an effort to take care of their health needs. Nevertheless, the respondents had a positive attitude towards the health assessment as such.

CONCLUSIONS

Although being an important contribution, the health assessment does not suffice to fulfill the right to health of asylum seekers because there are shortcomings regarding the accessibility and acceptability of the information, procedures and services that it includes.

Perspectives and experiences of new migrants on health screening in Sweden

BACKGROUND

In Sweden, migrants from countries considered to have a high burden of certain infectious diseases are offered health screening to prevent the spread of these diseases, but also identify their health needs. However, very little is known about their experiences and perceptions about the screening process. This study aimed at exploring these perceptions and experiences in order to inform policy and clinical practice.

METHOD

Using an interpretive description framework, 26 new migrants were interviewed between April and June 2013 in four Swedish counties. Thematic analysis was used to analyze data.

RESULTS

The three themes developed include: new country, new practices; new requirements in the new country; and unmet needs and expectations. Participants described what it meant for them to come to a new country with a foreign language, new ways of communicating with caregivers/authorities and being offered health screening without clarification. Participants perceived health screening as a requirement from the authorities to be fulfilled by all newcomers but conceded that it benefits equally the host society and themselves. However, they also expressed concern over the involvement of the Migration Board staff and feared possible collaboration with health service to their detriment. They further stated that the screening program fell short of their expectations as it mainly focused on identifying infectious diseases and overlooked their actual health needs. Finally, they expressed frustration over delay in screening, poor living conditions in reception centers and the restrictive entitlement to care.

CONCLUSIONS

Migrants are aware of their vulnerability and the need to undergo health screening though they view it as an official requirement. Thus, those who underwent the screening were more concerned about residency rather than the actual benefits of screening. The issues highlighted in this study may limit access to and uptake of the screening service, and compromise its effectiveness. To maximize the uptake: (1) linguistically and culturally adapted information is needed, (2) other screening approaches should be tried, (3) trained medical interpreters should be used, (4) a holistic and human right approach should be applied, (5) the involvement of migration staff should be reconsidered to avoid confusion and worries. Finally, to improve the effectiveness, (6) all migrants from targeted countries should be offered screening and efforts should be taken to improve the health literacy of migrants and the living conditions in reception centers.

Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement

In low-incidence countries in the European Union (EU), tuberculosis (TB) is concentrated in big cities, especially among certain urban high-risk groups including immigrants from TB high-incidence countries, homeless people, and those with a history of drug and alcohol misuse. Elimination of TB in European big cities requires control measures focused on multiple layers of the urban population. The particular complexities of major EU metropolises, for example high population density and social structure, create specific opportunities for transmission, but also enable targeted TB control interventions, not efficient in the general population, to be effective or cost effective. Lessons can be learnt from across the EU and this consensus statement on TB control in big cities and urban risk groups was prepared by a working group representing various EU big cities, brought together on the initiative of the European Centre for Disease Prevention and Control. The consensus statement describes general and specific social, educational, operational, organisational, legal and monitoring TB control interventions in EU big cities, as well as providing recommendations for big city TB control, based upon a conceptual TB transmission and control model.

"It is a challenge to do it the right way": an interpretive description of caregivers' experiences in caring for migrant patients in Northern Sweden

BACKGROUND

Experiences from nations with population diversity show extensive evidence on the need for cultural and linguistic competence in health care. In Sweden, despite the increasing diversity, only few studies have focused on challenges in cross-cultural care. The aim of this study was to explore the perspectives and experiences of caregivers in caring for migrant patients in Northern Sweden in order to understand the challenges they face and generate knowledge that could inform clinical practice.

METHODS

We used an interpretive description approach, combining semi-structured interviews with 10 caregivers purposively selected and participant observation of patient-provider interactions in caring encounters. The interviews were transcribed and analyzed using thematic analysis approach. Field notes were also used to orient data collection and confirm or challenge the analysis.

RESULTS

We found complex and intertwined challenges as indicated in the three themes we present including: the sociocultural diversity, the language barrier and the challenges migrants face in navigating through the Swedish health care system. The caregivers described migrants as a heterogeneous group coming from different geographical areas with varied social, cultural and religious affiliations, migration histories and statuses, all of which influenced the health care encounter, whether providing or receiving. Participants also described language as a major barrier to effective provision and use of health services. Meanwhile, they expressed concern over the use of interpreters in the triad communication and over the difficulties encountered by migrants in navigating through the Swedish health care system.

CONCLUSIONS

The study illuminates complex challenges facing health care providers caring for migrant populations and highlights the need for multifaceted approaches to improve the delivery and receipt of care. The policy implications of these challenges are discussed in relation to the need to (a) adapt care to the individual needs, (b) translate key documents and messages in formats and languages accessible and acceptable to migrants, (c) train interpreters and enhance caregivers' contextual understanding of migrant groups and their needs, (d) and improve migrants' health literacy through strategies such as community based educational outreach.

Epidemiology of tuberculosis in a low-incidence Italian region with high immigration rates: differences between not Italy-born and Italy-born TB cases

BACKGROUND

Emilia Romagna, a northern Italian region, has a population of 4.27 million, of which 9.7% are immigrants. The objective of this study was to investigate the epidemiology of tuberculosis (TB) during the period 1996-2006 in not Italy-born compared to Italy-born cases.

METHODS

Data was obtained from the Regional TB surveillance system, from where personal data, clinical features and risk factors of all notified TB cases were extracted.

RESULTS

5377 TB cases were reported. The proportion of immigrants with TB, over the total number of TB cases had progressively increased over the years, from 19.1% to 53.3%. In the not Italy-born population, TB incidence was higher than in Italians (in 2006: 100.7 cases per 100,000 registered not Italy-born subjects and 83.9/100,000 adding 20% of estimated irregular presences to the denominators. TB incidence among Italians was 6.5/100,000 Italians). A progressive rise in the not Italy-born incident cases was observed but associated with a decline in TB incidence. Not Italy-born cases were younger compared to the Italy-born cases, and more frequently classified as "new cases" (OR 2.0 95%CI 1.61-2.49 for age group 20-39); 60.7% had pulmonary TB, 31.6% extra pulmonary and 7.6% disseminated TB. Risk factors for TB in this population group were connected to lower income status (homeless: OR 149.9 95%CI 20.7-1083.3 for age group 40-59).

CONCLUSIONS

In low-incidence regions, prevention and control of TB among sub-groups at risk such as the foreign-born population is a matter of public health concern. In addition, increasing immigration rates may affect TB epidemiology. TB among immigrants is characterized by particular clinical features and risk factors, which should be analyzed in order to plan effective action.