Tuberculosis: Mass Migration Drives its Prevalence in the United States
A FAIR Research Report| October 2024
Download the PDF version here.
Executive Summary
Tuberculosis (TB) is a severe bacterial infection that is highly contagious, difficult to cure, and potentially deadly. If left untreated, the death rate from TB is approximately 50 percent.[1] According to the U.S. Centers for Disease Control and Prevention (CDC), “[t]hroughout the 1600-1800s in Europe, TB caused 25% of all deaths” and “[s]imilar numbers occurred in the United States.”[2] It was not until after the Second World War that TB in the U.S. and the wider Western world was largely eliminated due to a combination of antibiotics, vaccines, and improvements in sanitation.[3]
Unfortunately, after decades of decline, TB is beginning to resurface in the United States. In fact, cases of TB have grown significantly in recent years. The number of TB cases in the U.S. has increased 34 percent between 2020 and 2023. The number of TB cases is now higher than pre-pandemic levels (2019).
One key factor of the resurgence of TB in the U.S. is open borders and mass immigration. The massive, unregulated influx of migrants from countries with higher TB rates than the United States has helped spread the disease. Even legal immigrants and refugees—who are required to undergo medical screenings before arriving in the United States—may have latent TB which then progresses to active TB and becomes transmissible once inside the United States.
Key Findings
- Nationally, 76 percent of TB cases in 2023 occurred in foreign-born patients.[4]
- Counties, states and metropolitan areas with high foreign-born populations have higher TB rates than those with lower foreign-born populations.[5]
- Some countries of origin for both legal and illegal aliens have TB rates as high as 60 times the U.S. rate.[6]
- The government’s health screening for TB in potential immigrants is deficient; some categories of aliens do not undergo health screening at all.[7]
- Latent TB is not grounds for inadmissibility, even though the progression of latent TB accounts for over 80 percent of active TB cases in the U.S.[8]
- Some U.S. border counties have TB rates exceeding rates in high-risk countries such as Afghanistan, Iraq, and Lebanon.[9]
- The cost of treating each case of TB is over $20,000, and can reach over $500,000 if the case is extensively drug-resistant.[10]
What is Tuberculosis (TB)?
TB is a severe and hard-to-cure bacterial infection which is potentially fatal. It usually attacks the lungs but can also affect the brain, kidneys, spine or other parts of the body.[11] TB is contagious and is spread by germs in the air.[12] Its symptoms include severe, long-lasting coughing that can produce blood, weakness, fatigue, chills and fever. Individuals may also have latent or inactive TB, which is not contagious, but can develop into active TB if not treated.[13] TB prevalence in a population is measured by the number of cases per 100,000 people. This is also called the TB rate.
National Overview
After 29 years of declining cases in the United States, the number of TB cases began to grow in 2021 and has now surpassed pre-pandemic levels. In 2023, 9,615 TB cases were reported in the United States.[14] This represents a 16 percent increase over 2022 (8,320), a 22 percent increase over 2021 (7,874), and a 34 percent increase over 2020 (7,170).[15] This number also marks an 8 percent increase compared to 2019 (8,895), the year before the COVID-19 pandemic began.[16]
Figure 1: TB Cases and Rates, United States 1992-2022 (CDC Data). |
The incidence (or rate) of tuberculosis in the U.S. is measured by the number of TB cases per 100,000 persons.[17] In 2020, the rate of TB in the United States was 2.2. It has since grown to 2.4 in 2021, 2.5 in 2022, and 2.9 in 2023—surpassing the 2019 rate of 2.7.[18]
Data clearly indicate that the prevalence of tuberculosis is, in part, a function of immigration. Medical experts have long acknowledged this connection.[19] In 1990, for example, the CDC wrote, “Many tuberculosis cases in the United States occur among foreign-born persons who had asymptomatic infection but did not have current disease when they entered the United States. A large proportion of these persons are from countries where, according to available data, one-half or more of the adult population is infected and at risk of developing tuberculosis.”[20] More recently, research published by the National Institutes of Health (NIH) explained that for countries with low TB rates, “immigration is an important factor in TB epidemiology, where migrants may originate from countries with substantially higher TB burden.”[21]
In 2023, approximately 76 percent of nationwide TB cases in the U.S. occurred in foreign-born persons, with the total number of foreign-born cases increasing by 18 percent from 2022. The rate of TB was 15 per 100,000 foreign-born individuals, but just 0.8 per 100,000 U.S.-born individuals.[22] Additionally, the proportion of foreign-born individuals receiving a TB diagnosis after less than one year in the U.S. increased from 9.8 percent in 2021 to 16.5 percent in 2022.[23],[24]
The tendency of foreign-born residents to have higher TB rates than the native-born is also reflected in individual state rates. According to CDC data, the states with the highest foreign-born proportion of their population have TB rates over 3 times higher than the states with the smallest foreign-born populations (see Table 1).[25]
TB in the U.S. is Driven by Migration from Countries with High TB Rates
Increasing rates of TB in the U.S. are directly related to mass immigration, both legal and illegal. In both instances, the lion’s share of immigration into the U.S. is from developing countries with high rates of TB relative to the U.S. rate.
Figure 2: Top 7 Nationalities Encountered by CBP in Fiscal Year 2023 |
According to the World Health Organization (WHO), the rate of TB in the top countries of origin for illegal aliens is between 2 and 60 times higher than the rate in the U.S.[26] The top seven nationalities of illegal aliens encountered by CBP in FY 2023 were Mexicans, Venezuelans, Guatemalans, Hondurans, Cubans, Colombians and Haitians.[27] These countries all have significantly higher TB rates than the U.S. rate (see Figure 3.) Haiti, which was ranked seventh in terms of encounters, has the highest TB rate in the Western Hemisphere, with a rate nearly 60 times higher than the U.S., as well as one of the highest TB death rates in the entire Western Hemisphere.[28]
Figure 3: TB Rate in Origin Countries of Top 7 Nationalities Encountered by CBP in Fiscal Year 2023 |
In terms of legal immigration, the top countries of origin for lawful permanent resident (LPR) admissions in FY 2023 (Mexico, India, Cuba, the Dominican Republic, and China), all have TB rates significantly exceeding the 2023 U.S. rate of 2.9.[29] The TB rates for the top five countries of origin for LPRs were 28 for Mexico, 199 for India, 7 for Cuba, 43 for the Dominican Republic, and 52 for China.[30]
There are also high rates in the most common countries of origin for refugees. During FY 2023, the top five countries of origin for refugees arriving in the U.S. were the Democratic Republic of Congo, Syria, Afghanistan, Burma, and Guatemala. [31] The TB rates for those countries were: 317 for the Democratic Republic of Congo; 17 for Syria; 185 for Afghanistan; 475 for Burma; and 26 for Guatemala.
In short, TB in the U.S. is aggravated significantly by large-scale migration, legal and illegal, from countries with much higher rates of TB than the U.S.
TB Screening Deficiencies Compound an Immigration-Driven Problem
The United States’ screening procedures for aliens entering the country do not adequately guard against the spread of TB in the U.S., especially from latent TB. Medical screening has long been part of the legal immigration process to protect Americans from the importation of infectious diseases like TB. Indeed, federal law declares that aliens with communicable diseases “of public significance” are inadmissible.[32] However, the vast majority of aliens granted visas or who otherwise enter the U.S. are never medically screened. Even for those who are medically screened, the standard for admission is lax, as it only excludes active TB and allows individuals with latent TB to enter the country, resulting in the importation of latent TB into the U.S.[33]
A medical examination, which includes TB screening, is mandatory for green card applicants (whether inside or outside the U.S.), aliens seeking admission as refugees, and asylees seeking lawful permanent resident status (green cards).[34] In addition, a new 2024 regulation requires all individuals 2 years and older to take a TB blood test, called an IGRA test.[35] Previously, only aliens aged 2-14 were required to take the IGRA test.[36]
Several outcomes are possible. If no TB is detected, then the applicant is cleared with no further testing needed. If the IGRA test detects TB, or if the applicant has symptoms of TB and/or is HIV positive, then a chest x-ray is ordered. If the chest x-ray suggests infectious TB, the applicant’s sputum (mucus from coughing) must be tested. This can detect the presence of TB germs responsible for active TB, and can also determine if TB medication is working.[37] If the x-ray shows the presence of active TB, or sputum samples show active TB, this renders an applicant inadmissible. If the x-ray and sputum tests show latent TB, the applicant is still medically admissible, but must be reported to the health department of the destination jurisdiction.[38]
A physician screening an alien for TB will typically classify applicants based on results of the TB screening as either No TB, Class A TB, or Class B TB.[39] Only an A classification (active TB) renders an applicant inadmissible. If the alien receives a B classification, of which there are four different types, they are still admissible even though that classification indicates they are infected with TB.[40],[41]
The problem with this screening process is that while it detects both the active and latent forms of the illness, only active TB is grounds for declaring an alien inadmissible for entry.[42] The alien’s local health department in the U.S. will be alerted to screening results, but there is no requirement that the aliens undergo or complete treatment before entering.[43]
Allowing aliens with latent TB to enter the United States increases the risk of spreading TB among the U.S. population. While latent TB is not in itself infectious, it can develop and become active/infectious TB at any time without treatment.[44] In fact, data show that over 80 percent of TB cases in the U.S. arise in patients whose latent TB becomes active.[45] According to the CDC, there are 13 million people in the U.S. with latent TB, and without treatment, 5 to 10 percent of them will develop active TB in their lifetimes.[46]
However, most aliens who enter the U.S. are not required to undergo any medical screening at all.[47] Tourists and business visitors, who make up the vast majority of entries to the U.S., are not screened for communicable diseases before receiving a visa or being admitted to the country. U.S. government guidance states that “nonimmigrant visa applicants, nonimmigrants seeking change or extension of status, and Temporary Protected Status (TPS) applicants are only medically examined if the consular officer or immigration officer [at the port of entry] has concerns as to the applicant’s inadmissibility on health-related grounds.”[48] This means that what medical screening takes place relative to the vast majority of aliens entering the U.S. is, at best, discretionary, sporadic, and not designed to prevent the spread of communicable diseases. Thus, tourists or business travelers with TB are extremely unlikely to be detected and the risk they pose to public health increases.
Even when a medical screening is ordered by a CBP officer, and latent TB is detected, aliens are typically held by CBP no longer than 72 hours.[49] This is a fraction of the time the CDC recommends for latent TB treatment.[50] Depending on the exact treatment method, the full course can take between 3 and 9 months, and requires patients to carefully and consistently take medication during this period.[51] Thus, treatment cannot be completed before the alien is released and the alien assumes responsibility for completing this lengthy, complex, and expensive treatment.
A similar scenario is unfolding with respect to unaccompanied alien children (UAC). Upon apprehension at the southern border, UACs are quickly transferred to the Department of Health and Human Services (HHS), where they are medically screened. If an unaccompanied alien child is found to have active TB, HHS policy states that the minor “may” be placed in a space suitable for quarantine or isolation and “must” be admitted to a hospital if clinically indicated.[52]
However, even if HHS determines that the minors have latent TB, they are not given treatment while in custody, as the average length of stay in HHS custody is typically shorter than the time required to complete treatment.[53] A report by the U.S. Department of Health and Human Services (HHS) documented that more than 2,450 unaccompanied alien children with latent TB were released into 44 states between June 2022 and May 2023—without treatment.[54] Instead, health officials assumed the children would complete the treatment course at a later date. As the Washington Times bluntly reported, “HHS releases infected children to sponsors and notifies local health authorities in the hope that they can arrange for treatment before the latent infection becomes active. Those hopes are often dashed.”[55] As HHS admits, it is releasing minors with latent TB into local communities, thereby increasing the public health risk for American children, teachers, and all those associated with their school systems.
Regarding aliens who are already in the U.S. and apply for lawful permanent residence (green cards), the Biden-Harris administration recently made it easier for them to satisfy the required medical examination. Pursuant to a new policy, the results of civil surgeon examinations performed after November 1, 2023, will remain valid indefinitely.[56] USCIS officers have discretion to request a new exam or more evidence if they feel the applicant’s medical situation has changed or if they feel the form does not accurately reflect the applicant’s medical condition.[57]
Regional Overview
Foreign birth remains the most prominent risk factor for TB in the United States.[58] TB rates in the United States vary by region, but the prevalence of TB is closely connected to higher immigration levels, both legal and illegal. There are multiple factors that explain some of the regional differences in TB rates, such as population density or poor health infrastructure. The largest correlating factor is, by far, the size of the foreign-born population. Even if the foreign-born population is low, within that small foreign-born population, the prevalence of TB is still much higher than in the U.S. population.
Indeed, the relationship between size of the foreign-born population and the rate of TB in the states is statistically much stronger than any other variable. Data show that states with a relatively low foreign-born population typically have lower TB rates than those with higher foreign-born populations.[59] In the state with the lowest foreign-born population (West Virginia), the rate of TB is just one-fifteenth the rate in the state with the highest foreign-born population (California).
Table 1: TB Rate in 10 States with Lowest Percentage of Foreign-Born Population versus the 10 States with Highest Percentage of Foreign-Born Population | ||||||
10 States with Lowest Percentage of Foreign-Born Population | % Foreign-born | TB Rate | 10 States with Highest Percentage of Foreign-Born Population | % Foreign-born | TB Rate | |
Louisiana | 4.2% | 1.9 | California | 26.7% | 4.5 | |
Missouri | 4.1% | 1.3 | New Jersey | 23.5% | 3.2 | |
Maine | 4.1% | 1.0 | New York | 22.7% | 6.2 | |
Kentucky | 4.0% | 1.3 | Florida | 21.7% | 2.3 | |
Alabama | 3.8% | 1.8 | Nevada | 18.9% | 1.9 | |
S. Dakota | 3.5% | 1.3 | Massachusetts | 18% | 2.2 | |
Wyoming | 3.1% | 0.5 | Texas | 17.2% | 3.4 | |
Montana | 2.3% | 0.3 | Hawaii | 17.1% | 7.4 | |
Mississippi | 2.2% | 1.6 | Maryland | 16.7% | 3.2 | |
W. Virginia | 1.8% | 0.3 | Connecticut | 15.7% | 1.5 | |
Average | 3.3% | 1.1 | Average | 19.8% | 3.6 | |
Data Sources: U.S. Census, CDC, 2022[60] |
As shown in Table 1, the average TB rate in the ten states with the highest percentage of foreign-born residents was over three times as high as the average TB rate in the ten states with the lowest percentage of foreign-born persons. Maine and Hawaii’s total populations are roughly the same size, but Maine has a foreign-born population approximately one-fifth the size of Hawaii’s.[61] Yet, Hawaii’s rate of TB is nearly 7 times higher than that of Maine’s.[62]
Furthermore, place of birth is a more significant risk factor in the U.S. than population density.[63] TB is a communicable disease that spreads more easily in densely populated locales.[64] However, analysis of the TB rates in the most and least densely populated states shows that the differential between TB rates in different states cannot be attributed to population density. New Jersey is the most densely populated state in the U.S. with 1,263 people per square mile and has a lower TB rate than much less densely populated Texas (112 people per square mile), but both states have high rates of TB and both share large foreign-born populations. Therefore, it is the presence of a large foreign-born population, not population density that is the main determinative factor for TB rates.
Other data confirm this conclusion. The average TB rate in the 10 most densely populated states is 75 percent higher than the average rate of the 10 least densely populated states (2.1 versus 1.3 respectively.) However, the average TB rate in the ten states with the highest percentages of foreign-born residents is more than 200 percent higher than the average rate in the ten states with the lowest percentages of foreign-born residents (3.6 versus 1.1 per, respectively.)
Table 2: Most and Least Densely Populated States and TB Rates, 2022 CDC Data | ||||||
10 Least Densely Populated States | Population Density (People per Square Mile) | TB Rate | 10 Most Densely Populated States | Population Density (People per Square Mile) | TB Rate | |
Oregon | 44 | 1.7 | New Jersey | 1,263 | 3.1 | |
Utah | 40 | 1.0 | Rhode Island | 1,061 | 1.6 | |
Kansas | 36 | 1.8 | Massachusetts | 901 | 2.2 | |
Nevada | 28 | 2.0 | Connecticut | 745 | 1.8 | |
Nebraska | 26 | 1.5 | Maryland | 636 | 2.5 | |
Idaho | 22 | 0.6 | Delaware | 508 | 1.3 | |
New Mexico | 18 | 1.4 | New York | 429 | 3.6 | |
South Dakota | 12 | 1.1 | Florida | 401 | 2.4 | |
North Dakota | 11 | 1.3 | Pennsylvania | 291 | 1.3 | |
Montana | 7 | 0.5 | Ohio | 289 | 1.2 | |
Average | 24 | 1.3 | Average | 652 | 2.1 | |
Data Sources: U.S. Census, CDC, 2022 |
Even in states with relatively low foreign-born populations, those small foreign-born populations still have much higher TB rates than the U.S.-born population in that state. For example, states in the Midwest and South have fewer foreign-born individuals than the national average, but foreign-born populations in those states still have significantly higher rates of TB than their U.S.-born counterparts. [65] A good illustration is five states in the geographic center of the U.S. (North Dakota, South Dakota, Nebraska, Kansas and Oklahoma), where the overall TB rate is low, but among those states’ modest foreign-born populations the TB prevalence is far higher than the statewide rate.
Table 3: Comparison of TB Prevalence by nativity | |||
State | Foreign-Born Population | TB Rate, All Residents[66] | TB Rate, Foreign-Born Residents[67] |
North Dakota | 4.6% | 1.3 | 12 |
South Dakota | 3.8% | 1.1 | 8 |
Nebraska | 7.5% | 1.5 | 21 |
Kansas | 7.1% | 1.8 | 29 |
Oklahoma | 6.1% | 2.0 | 36 |
Data Sources: U.S. Census, CDC, 2022 |
Government data show almost all states have TB cases, and in those states, foreign-born patients were disproportionally represented. In 2021, the last year that the CDC did a foreign-versus native-born breakdown by state, forty-eight states reported foreign-born TB cases, and in every single one of these states, foreign-born individuals were overrepresented in TB cases relative to their share of the population.[68] Foreign-born TB patients were a majority of all cases in 40 states in 2021.[69] In 2023, an even larger percentage – 76 percent compared to 71 percent in 2021 – of TB cases nationally occurred in the foreign-born population, which likely only reinforced the trend at the state level.
State and City Overview
New York City
New York City has long been a major destination for immigrants, both legal and illegal, and its role as a destination city has only grown during the current border crisis. Over 200,000 illegal aliens have arrived in the city since early 2022, many encouraged by sanctuary policies.[70] New York City is also the most popular destination for legal immigrants, a distinction it has held for decades.[71],[72]
Figure 4 shows that the TB rate in New York City is much higher than the national average.
The presence of TB in New York City has grown over the past few years. Between 2022 and 2023, the number of cases of TB in New York City increased from 536 cases to 684 cases;[73],[74],[75] and the TB rate from 6.1 to 7.8.[76]
The TB rate in New York City is much higher for foreign-born residents than U.S.-born residents. The 2022 rates for U.S.-born and foreign-born residents were 1.1 and 14.7 respectively.[77]In 2023, the rate for U.S.-born residents increased to 1.4, and the rate for foreign-born residents grew significantly to 18.9.[78]
Between 2019 and 2023, the rate of TB in New York City increased 29 percent among foreign-born residents.[79] In centers of recent immigration, the prevalence of TB among the foreign-born is even more pronounced. In Sunset Park, Brooklyn (with a foreign-born population of 54 percent), 94 percent of TB cases in 2022 were in foreign-born patients.[80],[81] In Flushing, Queens, where more than half of the population is foreign-born, 95 percent of TB cases in 2022 were among the foreign-born.[82],[83]
In comparison, the rate of TB among U.S.-born New Yorkers declined by 22 percent between 2019 and 2023. Indeed, in 2023 only 11 percent of TB cases in the city were in U.S.-born residents.[84]
In both 2022 and 2023, the New York City Department of Health and Mental Hygiene acknowledged in its annual TB report that mass immigration accounted for nearly 9 out of 10 TB cases in the city. The 2022 report states that “[the] past year also brought a large increase in the number of people arriving in NYC from Ukraine, and an influx of asylum-seekers from the U.S. southern border.”[85] In 2023, the Department of Health and Mental Hygiene also noted that high immigration was a factor in its growing TB rate: “Since Spring 2022, NYC has experienced a sustained influx of individuals arriving from other parts of the world, including individuals migrating through the U.S. southern border, individuals arriving in conjunction with humanitarian parole programs and individuals arriving with an overseas TB classification.”[86]
California
California is home to the largest foreign-born population in the U.S., both in terms of absolute numbers and as a percentage of the total state population.[87],[88] California also has the largest percentage of illegal aliens living in the United States, due in part to its sanctuary policies and the benefits it provides those here illegally.
As of 2023, California’s TB rate is the third highest in the United States (behind only Hawaii and Alaska) and TB cases are increasing in number.[89],[90] In 2023, the number of TB cases statewide was 2,113, a 15 percent increase compared to 2022 (1,842) and a 21 percent increase compared to 2021 (1,752).
Like other parts of the U.S., TB cases in California are dominated by foreign-born individuals. In 2023, 82 percent of TB patients in California were foreign-born, compared to 76 percent of TB patients nationwide who were foreign-born.[91] The highest rates of TB were among residents born in the Philippines and Vietnam, followed by India, China, and Mexico.[92]
The vast majority of TB cases in California in 2023 (85 percent) were due to latent tuberculosis infection (LTBI) progressing to active TB.[93] More than 2 million Californians (5 percent of the state’s population) have LTBI, 1.8 million of whom (90 percent) were born outside the U.S.[94] Of this figure, just 23 percent were aware of their LBTI status and only 13 percent had received treatment.[95] Nearly half of all TB cases in foreign-born patients occurred more than 20 years after they arrived in the U.S., suggesting that current immigration levels create a significant long-term health risk to local communities, particularly since medical screenings for immigrants are inadequate to stop the spread.[96]
TB has had a significant impact on California, both in terms of the toll it takes on patients and in terms of the cost of medical treatment. TB kills over 200 Californians per year, and in 2021, 12 percent of patients with active TB died, a significant increase from the 8.4 percent rate a decade earlier. Statistics show that 28 percent of them died before ever receiving treatment. The medical and societal cost of TB in California reaches $265 million per year.[97]
Texas
Texas has a large foreign-born population, constituting 17 percent of the state’s total population. Its 2022 TB rate was 3.4, nearly 31 percent higher than the 2022 U.S. rate of 2.5. Between 2022 and 2023, TB cases in Texas increased 12 percent, from 1,100 cases to 1,235 cases.[98]
Texas’ high foreign-born population is due to the fact that it is a major focal point for legal and illegal immigration. Texas shares 1,250 miles of border with Mexico, which has served as the crossing point for millions of illegal aliens. Between FY 2021 and July of FY 2024, 41.6 percent of all illegal alien encounters with CBP occurred along the Texas-Mexico border.[99]
As a border state, Texas is especially exposed to TB from aliens who have never been screened. The Texas-Mexico border is particularly rife with TB. In 2019, the average TB rate in Texas border counties was double the average rate of Texas counties as a whole, and triple the TB rate nationwide.[100] In 2022, Texas’ border counties represented 21.2 percent of TB cases in the state, despite border counties being home to just 9.5 percent of the state’s population.[101] Healthcare professionals in Texas fear even these alarming numbers may be an undercount, as COVID-19-related pressure meant that hospitals in Texas conducted fewer TB tests during the pandemic.[102]
The TB rates in some Texas counties are so high, they are comparable to low-income countries in Africa and Asia. In Frio County, which lies between San Antonio and Laredo, the TB rate is 264. This rate is higher than the TB rate in countries such as Pakistan, Somalia, Kenya, India and Afghanistan. Indeed, if Frio County were a country, its TB rate would rank among the top 30 countries in the world.[103] Other counties in Texas are similarly suffering. Maverick County, which lies directly on the border, has a TB rate higher than Iraq, and Webb County has a TB rate higher than Lebanon.[104] Even compared to the TB rate in the U.S. as a whole, the rate of TB in most Texas border counties is much higher.
Fig 6: TB Rate in Texas Border Counties (2022) Compared to U.S. Rate. |
It is not just Texas’ border counties that are at greater risk of TB. As is the case elsewhere, a high foreign-born population in the county is a strong predictor of a high TB rate. FAIR compared the TB rate in the ten Texas counties with the highest proportion of foreign-born individuals with the TB rate in the ten Texas counties with the lowest proportion of foreign-born individuals. The results are in Tables 4 and 5 respectively.
Counties in Texas with high foreign-born populations have high TB rates. This is true even when the population is relatively small. For example, Dallam County has a population of only around 7,000 people, yet over 22 percent of its population is foreign-born.[105] The rate of TB in Dallam County is 27.6, much higher than the Texas-wide rate of 3.6. Another example is Bailey County, which only has a population of 6,600 people, 28 percent of whom are foreign-born. Bailey County has a TB rate of 14.8, much higher than the statewide rate.
Table 4: Texas Counties with Highest Proportion of Foreign-Born Residents and Corresponding TB Rate (2022) | ||
County | Foreign-Born Population (%) | TB Rate |
Hudspeth | 36.9 | 0 |
Presidio | 35.9 | 0 |
Ochiltree | 31.1 | 0 |
Fort Bend | 30 | 2.3 |
Maverick | 29.8 | 25.9 |
Kennedy | 29.3 | 0 |
Bailey | 28.3 | 14.8 |
Moore | 26.8 | 9.5 |
Starr | 26.3 | 10.7 |
Harris | 26.2 | 5.6 |
Data sources: Texas Department of Health and Human Services, CDC |
In 6 of the 10 Texas counties with the higher proportion of foreign-born residents, the TB rate exceeds the 2022 U.S.-wide rate of 2.5, in some cases by a significant margin. By contrast, the TB rate in Texas counties with the lowest proportions of foreign-born residents is 0, compared to the national rate of 2.5 (see Table 5).
Table 5: Texas Counties with Lowest Proportion of Foreign-Born Residents and Corresponding TB Rate (2022) | ||
County | Foreign-Born Population (%) | TB Rate |
Callahan | 1.3 | 0 |
Delta | 1.3 | 0 |
Shackelford | 1.3 | 0 |
Motley | 1.1 | 0 |
Kent | 1.1 | 0 |
Newton | 1 | 0 |
Foard | 0.9 | 0 |
Borden | 0.7 | 0 |
Cottle | 0 | 0 |
Roberts | 0 | 0 |
Data sources: Texas Department of Health and Human Services, CDC |
Notably, a significant percentage of TB cases in Texas were in correctional facilities, and 64 percent of these correctional facility cases were specifically in immigration detention facilities. In 2022, there was a total of nearly 122,000 inmates in prisons or jails in Texas.[106] The same year, over 11 percent of the TB cases statewide were in jails, prisons or other correctional facilities; 2.1 percent of cases (23 people) were in city or county jails, 1.3 percent (14 people) were in state prisons, and 7.7 percent (84 people) were in “other correctional facilities.”[107] Of these “other correctional facilities”, 6 of those were in federal prison, and 78 were in immigration detention/ICE facilities. This demonstrates that the vast majority of TB cases in the correctional system are coming out of immigration detention/ICE facilities specifically.
Minnesota
Minnesota has a relatively small foreign-born population. Nevertheless, it still has a significant TB rate, driven by foreign-born patients. The foreign-born patients come from a wide variety of geographic regions of the world, such as Africa, Southeast Asia and the Indian subcontinent. Thus, the risk posed by TB is not linked to just one particular nationality or diaspora.
Minnesota has a smaller foreign-born population than the U.S. as a whole, 8.7 percent compared to 13.9 percent nationally.[108] However, consistent with other states, it has high rates of TB within its foreign-born population.[109] There were 703 cases of TB in Minnesota between 2018 and 2022, and 83 percent (585 cases) were in foreign-born individuals.[110] Nationwide, 76 percent of TB patients are foreign-born.
In terms of birthplace, Minnesota residents born in Somalia accounted for 19 percent of the total TB cases in the state, and 23 percent of the total foreign-born cases. While Somalians are the largest share of foreign-born TB patients, they are not the only group of foreign-born individuals with significant representation in the state’s TB population. In fact, between 2018 and 2022, individuals from 6 countries (Somalia, Ethiopia, Laos, Vietnam, Kenya and India) accounted for 50 percent of all cases in the state, and nearly 60 percent of all the foreign-born cases in Minnesota.[111]
The Minnesota Department of Health Tuberculosis Medication Program offers “free” treatment for infected individuals, paid for with state tax dollars.[112] This may result in significant costs to state taxpayers. The cost of treating TB is over $20,000 per case, but this can be over $180,000 if the disease is drug-resistant, and over $500,000 if the TB is “extensively drug-resistant,” i.e., does not respond to multiple drugs typically used to treat the illness.[113]
Conclusion
TB is a highly infectious and potentially lethal illness. The rate of TB in the U.S. is driven by mass immigration. Thus, it is not surprising that cases of TB are rising at the same time that unprecedented numbers of aliens from TB-prone nations are arriving in our country. The crisis at our border has resulted in over 10 million illegal alien encounters at our borders. Many of these 10 million aliens come from countries with vastly higher TB rates than the United States. After nearly three decades of declining numbers of TB cases in the United States, TB cases are now on the rise again, and have surpassed pre-pandemic levels.
This public health concern is only aggravated by serious weaknesses in the health screening procedures for green card applicants and those seeking to enter as refugees. Deficiencies in this screening regime, which often results in no screening, mean that infected individuals are being allowed into the U.S.
In addition to the tragic toll on TB patients themselves, the financial costs associated with treatment, especially in cases of drug-resistant strains of TB, can be extremely high. There are strains of TB in some countries which are “extensively drug-resistant,” i.e., do not respond to the most commonly used drugs to treat the illness. The cost of treating each case of TB is over $20,000 and can be over $500,000 if it is extensively drug-resistant.[114] This imposes a significant cost at a time when U.S. healthcare budgets are already stretched.
Footnotes and endnotes
[1] https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-disease-burden/2-2-tb-mortality
[3] Ibid.
[6]https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&iso2=%22US%22&lan=%22EN%22;
[9] https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2023/tb-disease-burden/1-1-tb-incidence
[11] https://www.lung.org/lung-health-diseases/lung-disease-lookup/tuberculosis/learn-about-tuberculosis
[13]https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&iso2=%22US%22&lan=%22EN%22; https://www.cdc.gov/tb/about/index.html
[19] See e.g., https://www.cdc.gov/mmwr/preview/mmwrhtml/00001958.htm; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353558/
[24] No corresponding data were reported for 2023
[26] Ibid.
[29] https://www.dhs.gov/immigration-statistics/special-reports/legal-immigration (Legal Immigration and Adjustment of Status Report Fiscal Year 2023, Quarter 4)
[32] https://uscode.house.gov/view.xhtml?edition=prelim&num=0&req=granuleid%3AUSC-prelim-title8-section1182
[33] CDC guidelines for civil surgeons allow individuals who test positive for TB to enter the country, with a report to destination health departments, if it has not progressed to infectious TB at time of screening. See https://www.cdc.gov/immigrant-refugee-health/hcp/civil-surgeons/tuberculosis.html
[38] Ibid.
[46] Ibid.
[48] Ibid.
[52] https://www.acf.hhs.gov/orr/policy-guidance/unaccompanied-children-program-policy-guide-section-3#3.4.6
[53] Flores v. Meese, 2:85-cv-04544, (C.D. Cal. July 3, 2023), ORR Juvenile Coordinator Annual Report 11, ECF No. 1344-3
[54] Ibid.
[55] https://www.washingtontimes.com/news/2023/jul/18/health-department-released-thousands-of-illegal-im/
[57] https://www.uscis.gov/newsroom/alerts/uscis-announces-new-guidance-on-form-i-693-validity-period
[69] Ibid,
[70] https://www.nyc.gov/office-of-the-mayor/news/482-24/adams-administration-releases-competitive-rfp-reduce-asylum-seeker-costs
[72] https://www.dhs.gov/ohss/topics/immigration/yearbook/2022 at LPR Supplemental Table 2
[73] https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2022-annual-report.pdf
[76] https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2023-annual-report.pdf
[77] https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2022-annual-report.pdf
[78] https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2023-annual-report.pdf
[79] See https://www.nyc.gov/assets/doh/downloads/pdf/tb/tb2019.pdf and https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2023-annual-report.pdf
[80] https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2022-annual-report.pdf
[83] Ibid., p. 23
[84] https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2023-annual-report.pdf
[85] https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2022-annual-report.pdf
[86] https://www.nyc.gov/assets/doh/downloads/pdf/tb/tuberculosis-in-new-york-city-2023-annual-report.pdf
[88] https://www.fairus.org/sites/default/files/2023-06/2023%20Illegal%20Alien%20Population%20Estimate_2.pdf
[92] Ibid.
[94] Ibid.
[95] Ibid.
[97] Ibid.
[99] https://www.cbp.gov/newsroom/stats/nationwide-encounters as of July 2024
[104] Ibid.
[111] Ibid.
[114] Ibid.