One in Four Refugees Sent to Tennessee Carry Tuberculosis

Nashville, Tennessee—Twenty-seven percent of the refugees who arrived in Tennessee between 2011 and 2015 tested positive for latent tuberculosis infection (LTBI), according to data provided to Breitbart News by the Tennessee Office for Refugees (TOR).

TOR is the subsidiary of Catholic Charities of Tennessee that was hired as the federal contractor to run the refugee resettlement program in the Volunteer State after former Gov. Phil Bredesen withdrew the state from the federal program in 2008.

TOR, however, has not been able to provide evidence that it has “assure[d]…… that refugees, known to the agency as having been identified . . . as having medical conditions affecting the public health and requiring treatment [such as active and latent TB], report to the appropriate county or other health agency,” or subsequently monitored their health status, both requirements of the Refugee Act of 1980.

Nor has either TOR or the Tennessee Department of Health been able to provide Breitbart News with information concerning the number of these refugees, if any, who were diagnosed with active TB on their arrival, as several other states (Colorado, Florida, Indiana), and one county (in Kentucky) have been able to do.

The refugee health data provided to Breitbart News by TOR makes Tennessee the state with the second highest rate of LTBI among recently resettled refugees in the nine states that have either publicly reported the information, or provided it upon request to Breitbart News.

The eight other states, in order of the percentage of resettled refugees who test positive for LTBI are: Vermont (35 percent), Indiana (26 percent), Minnesota (22 percent), Florida (20 percent for TST test, 6 percent for blood test), Arizona (18 percent), Utah (18 percent), Texas (15 percent), and California (12 percent).

Tennessee is one of fourteen states that have withdrawn from the federal refugee resettlement program. In those states, the federal government has hired voluntary agencies (VOLAGs) to manage the resettlement of refugees under the statutorily questionable Wilson Fish alternative program.

In April, the Tennessee General Assembly passed a joint resolution that authorizes the state of Tennessee to sue the federal government over the operation of the refugee resettlement program in the Volunteer State on Tenth Amendment grounds on Tenth Amendment grounds.

According to TOR, 1,898 of the 6,899 refugees who completed domestic medical screening shortly after their arrival in Tennessee during the five years between 2011 and 2015 tested positive for LTBI. During that same period of time, 8,000 refugees were resettled in Tennessee.

Siloam Health, the medical provider selected by TOR to conduct the initial medical screenings of arriving refugees tells Breitbart News it conducted 8,199 such screenings during this time, and that all refugees screened were tested for LTBI.

It is unclear why the results provided to Breitbart News by TOR were 1,300 fewer than the number of LTBI tests TOR’s vendor says it conducted.

The test results varied by year, and by type of LTBI test given.

In 2011, for example, when only the Tuberculin Skin Test (TST) was used, 40 percent of recently arrived refugees, or 437 out of 1,068, tested positive.

By 2015, when both the TST and IGRA blood tests were used, positive testing declined to 22 percent of recently arrived refugees, or 302 out of 1,348.

The 2015 data on LTBI positive tests provided by TOR to Breitbart News is based on is 194 fewer than TOR Refugee Health Coordinator (RHC) Michael Evans says were conducted that year.

“Tennessee’s medical screening program does, in fact, provide tuberculosis testing regardless of overseas results. For refugees under the age of 5, they receive a TST; for refugees 5 and older, they receive an IGRA. Positive and indeterminate results are referred to county health departments for further evaluation and treatment,” Evans tells Breitbart News.

“And to speak even more directly to the point, in FY2015, the medical screening program screened 1,542 refugees across Tennessee; of those, TOR does not have TB screening results for 7 individuals. This doesn’t mean those 7 were not screened for TB, only that this office doesn’t have the results,” Evans adds.

TOR CEO Holly Johnson tells Breitbart News her organization is under no legal requirement to report LTBI results to county health departments.

“It’s worth noting that—while a positive test result is one that our contracted clinics take seriously—reporting those results to county health departments is not required by the Refugee Act of 1980, our state plan, nor by the Tennessee Department of Health,” Johnson tells Breitbart News.

“This is because LTBI is not a communicable disease,” she adds.

“However, our contracted clinics do indeed report positive and indeterminate test results to county health departments, and refer positive and indeterminate clients for further screening and evaluation. This is in the best interest of both the refugee and John Q. Public,” Johnson concludes.

Johnson’s claim that TOR is not required to report LTBI to county health departments because it is “not a communicable disease,” however, appears to be incorrect.

The standard in the statute is “having medical conditions affecting the public health and requiring treatment,” not communicable.

Numerous scientific studies conclude that high rates of latent TB among resettled refugees “affects public health” and “requires treatment” are numerous.

Active TB cases in the United State increased in 2015, the first time in 23 years. Foreign born cases as a percentage of total TB cases have increased from 22 percent in 1986 to 66 percent in 2015.

TOR also appears to have an obligation to report and track LTBI results from refugee domestic medical screenings to county officials under the state’s Tuberculin Skin Testing Policy, which the Tennessee Department of Health announced in 2004 as part of its Tuberculosis Elimination Program.

“Based on the . . . current CDC recommendations, the Tennessee Department of Health has instituted a policy that targeted tuberculin testing of high-risk persons be performed statewide,” the policy states.

“Under this policy, tuberculin testing should . . . be performed for the following persons at higher risk for exposure to or infection with TB, . . . [including] Foreign-born persons from areas where TB is common [excepting those from] . . . Canada, Western Europe, Japan, Australia, and New Zealand,” the policy adds.

Under the Refugee Act of 1980, TOR is required to “assure that refugees, known to the agency as having been identified . . . as having medical conditions affecting the public health and requiring treatment [such as active and latent TB], report to the appropriate county or other health agency upon their resettlement in an area.” (8 US Code 1522 (4) (B) (D) and (7) (C))

“We refer all refugees with an indeterminate or positive TB test to the local health departments,” TOR CEO Johnson tells Breitbart News.

But the public health departments at Davidson County and Shelby County, where more than 80 percent of all the refugees who enter Tennessee are resettled, say they have received no such reports from TOR.

Brian Todd, Public Information Officer for Davidson County’s Metro Public Health Department tells Breitbart News that Davidson County has not received referrals from TOR of “all refugees with an indeterminate or positive TB test.”

“I am aware of three voluntary agency affiliates that operate in Nashville. .. I am told they are the agencies that you could contact to answer your questions [about the number of refugees who are medically screened and test positive for latent tuberculosis infection—LTBI] and [the number of refugees who are medically screened that test positive for LTBI who successfully complete medical treatment],” Todd says.

Shelby County Department of Health Public Information Officer Ellen Hart tells Breitbart News “We in Shelby County do not have the information you requested [concerning the number of refugees who are medically screened and test positive for LTBI.”

Johnson offers this unusual explanation.

“TOR doesn’t send a report – or an individual – to the health department, so the county health departments are correct in that they have not received anything from TOR,” she tells Breitbart News.

Johnson then offers a peculiar definition of what the statutory requirement refugees with latent TB “report to the appropriate county health agency” means.

“The screening clinics [hired by TOR] refer refugees to the health department and the resettlement agencies [TOR and those agencies selected by TOR in Tennessee] make sure they get there,” Johnson tells Breitbart News.

One attorney familiar with the refugee resettlement program isn’t buying it.

“As written, the language of the Refugee Act of 1980 is clear as to the responsibilities of the agencies that resettle refugees with regard to issues affecting the public health. In Tennessee, TOR is the administrative agency with oversight responsibilities regarding the law’s mandates,” the attorney tells Breitbart News, adding:

Among other duties, that is what they get paid for. The intent of this provision in the Refugee Act is further expressed in the regulations; duties that TOR assumed when it accepted the Office of Refugee Resettlement’s offer to become the state replacement designee.

Additionally, TOR’s guidance per the Wilson-Fish guidelines says specifically that the State Refugee Coordinator (which in Tennessee is TOR’s director), has a ‘fiduciary duty to serve the best interests of all of the state’s refugees.’ In the context of the Refugee Act of 1980, this would include ‘assur[ing]’ that refugees with active, latent or even suspected TB are properly identified and treated.

A policy letter sent out earlier this month by the Office of Refugee Resettlement’s Administration for Children & Families on the role of Refugee Health Coordinators working for resettlement agencies like TOR confirms this obligation:

“ORR encourages RHCs (Regional Health Coordinators to be involved in each core area. . .[including] initial medical screening and surveillance.” :

Initial medical screening and surveillance is the core responsibility of RHCs and a priority for refugee health. .. Specific activities under this area may include:

• Managing the medical screening program;

• Providing technical assistance to ensure comprehensive and quality medical screening direct services;

• Monitoring medical screening activities to ensure appropriate use of funds and services; . . .

• Providing surveillance, data collection, and reporting of medical screening outcomes. (emphasis added)

But TOR’s RHC Michael Evans does not appear to be tracking, monitoring, or reporting medical screening outcomes for refugees who test positive for LTBI, either in terms of the number who successfully receive treatment for LTBI, or the number who are subsequently diagnosed and treated for active TB.

“Data related to LTBI treatment should be sought from either the Tennessee Department of Health or individual county health departments,” Evans tells Breitbart News.

When asked about active TB among newly arrived refugees, Evans offered this response: “The Tennessee Refugee Screening Program does not diagnose refugees with either latent or active TB. Our program provides a preliminary TB screening, and makes appropriate referrals to county health departments for further testing, diagnosis, and treatment- as needed.”

Breitbart News asked Gov. Haslam if he would order the Tennessee Department of Health to comply with the Refugee Act of 1980 and provide information on the number of refugees resettled in Tennessee who tested positive for LTBI in their initial domestic medical screening and subsequently were diagnosed with active TB.

A spokesperson for the Governor did not address these questions, but responded that “The Tennessee Department of Health has not failed to comply with the Refugee Act of 1980. Woody McMillin from the department will be in touch with more information.”

McMillin offered this:

The Tennessee Department of Health has not failed to comply with the Refugee Act of 1980…

In Tennessee, Catholic Charities is the recipient of the federal funds for this purpose [overseeing refugee health screenings] and has under its supervision the Tennessee Office of Refugees. TOR contracts with providers to perform screenings; when these providers identify TB, they provide direction to the individuals on how they may receive medical care. Those with adequate financial resources may seek this through their physician’s office or a similar healthcare setting; those lacking the financial ability to pay for care may go to a county health department.

Most individuals upon learning they have a form of TB, even if inactive, do seek treatment. Not having proof of being TB-free can impact a person’s ability to be employed in some workplaces and from enrollment in certain schools. . .

Because LTBI is not a reportable condition in Tennessee, the Tennessee Department of Health does not know how many individuals complete LTBI treatment in healthcare settings outside of county health departments.

Neither the Tennessee Office for Refugees (TOR), the resettlement agency hired by the federal government to manage the refugee resettlement program in the Volunteer State, nor the Tennessee Department of Health appear to be monitoring the treatment of refugees who test positive for LTBI.

Neither organization can say whether any of these refugees have subsequently developed active TB.

“Tennessee maintains an aggressive program to address tuberculosis and is continuing to experience a downward turn in the number of TB diseases cases confirmed; in 2015 that number was the lowest ever since TB data has been recorded in our state – 131 cases. Of these, 72 were U.S.-born and 59 were foreign-born,” Tennessee Department of Health spokesperson McMillin tells Breitbart News.

But foreign-born cases of TB as a percentage of total cases in Tennessee have increased from 36 percent in 2011 to 45 percent in 2015.

Residents of Tennessee have a right to know how much of this increase is attributable to the estimated 8,000 refugees who have been resettled in the state over that five year period.


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