Immigrants and the Spread of Tuberculosis in the United States: A Hidden Cost of Immigration Michael J.

Greenwood & Watson R.Warriner

Population Research and Policy Review in cooperation with the Southern Demographic Association (SDA) ISSN 0167-5923 Volume 30 Number 6 Popul Res Policy Rev (2011) 30:839-859 DOI 10.1007/s11113-011-9213-6

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Popul Res Policy Rev (2011) 30:839859 DOI 10.1007/s11113-011-9213-6

Immigrants and the Spread of Tuberculosis in the United States: A Hidden Cost of Immigration
Michael J. Greenwood Watson R. Warriner

Received: 8 February 2011 / Accepted: 16 August 2011 / Published online: 30 August 2011 Springer Science+Business Media B.V. 2011

Abstract This panel-data study concerns the incidence of newly diagnosed tuberculosis (TB) in specic U.S. metropolitan areas among immigrants and, in turn, the possible transmission of the disease to the native-born population of these same metropolitan areas. The study includes 50 U.S. Metropolitan Statistical Areas as annual observations, 19932007. We nd that a 10% increase in the number of high-incidence immigrants results in a 2.87% increase in TB among the foreignborn population, and that a 10% increase in the number of foreign-born TB cases increases the number of new TB cases among the native-born by 1.11%. The study concludes with a benet/cost analysis of the societal cost of TB and suggests that testing all immigrants for TB would be a cost-effective method to limit the amount of TB that enters U.S. from abroad, thus limiting the transmission to both the foreign- and native-born populations. Keywords Tuberculosis Immigrants United States Cost of disease

Introduction Tuberculosis (TB) has long been one of the worlds deadliest diseases. Moreover, according to a recent article in The Lancet, human migration has had a major effect on the spread of tuberculosis throughout the course of human history (Blumberg et al. 2010, p. 2127). In our paper, using unique data, we focus on the United States and uncover a link between the settlement in specic metropolitan areas of U.S. immigrants and the incidence1 of TB among both the foreign and the native born in
1

Incidence rates refer to the number of newly reported cases per 100,000 persons and not to the overall prevalence of the disease.

M. J. Greenwood (&) W. R. Warriner Department of Economics, University of Colorado, Campus Box 256, Boulder, CO 80309, USA e-mail: michael.greenwood@colorado.edu

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these same metropolitan areas. We go on to provide rough estimates of the societal costs of treating active TB cases in the U.S. and compare these costs to the costs of testing potential legal immigrants for the disease before their entry. The World Health Organization (WHO) estimates that 9.3 million new TB cases occurred in 2007, compared to 9.2 million in 2006 and 8.3 million in 2000 (WHO 2009a). In 2007 alone, nearly two million deaths occurred from tuberculosis, making it the second deadliest infectious disease in the world behind HIV/AIDS. However, the history of TB in developed countries, specically the United States, is quite different. Incidence and mortality rates have been rapidly declining in the developed world since the beginning of the 20th century. Most people born in the U.S. today do not receive a vaccination for tuberculosis; in contrast, South Africa vaccinates 75% of children at birth (WHO 2009a). The upsurge of multidrug-resistant (MDR) TB, of extensively drug-resistant (XDR) TB, and very recently of certain strains of TB that are resistant to all antituberculosis drugs is of great concern (Gandhi et al. 2010). Infectious drugresistant TB is contagious, and some believe that MDR TB will become the dominant form the disease (Gandhi et al. 2010). The evidence does not suggest that the drug-resistant strains are any more contagious than less virulent strains, but they are clearly more difcult to cure, which could make their carriers contagious for longer periods of time. Thus, the United States, whose population has generally not been inoculated against TB (CDC 2009b), may be especially vulnerable to the spread of this disease. In fact, in 2010, the medical journal The Lancet devoted a series of articles to tuberculosis, its spread, and the difculty of controlling the disease. The sustained global prevalence of TB may be affecting persons living in the U.S. (Chin et al. 1998), and the native-born population of the U.S. may be contracting TB through transmission from the foreign-born population. The goal of this study is to uncover any correlation that may exist between TB of foreign origin and TB among the native born. Do immigrants from countries with high TB incidence increase tuberculosis cases among the U.S. foreign-born population, and in turn, is the incidence of TB increased among the native-born population in the United States? Evidence of such transmission from immigrants to the native-born population should be cause of great concern. A serious outbreak of TB would not only threaten the health of U.S. citizens (Blumberg et al. 2010), but also could have potentially strong negative impacts on the U.S. economy (Miller et al. 2010). Given the contagious nature of TB coupled with a mainly inoculationfree U.S. population, uncovering any relationship between TB among the nativeand foreign-born populations is important.

Background: Tuberculosis History, Transmission, Treatment, and Policy Tuberculosis has been one of the greatest causes of human death throughout recorded history. Mycobacterium Tuberculosis infections can be dated to at least 1000 B.C. when people began congregating in urban environments (Collins 1997). Although TB continued to increase in prevalence over the next 3,000 years, it never experienced the rapid expansion of other infectious diseases (the plague, cholera,

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etc.) due to its inability to spread quickly in rural areas. In fact, it was not until the Industrial Revolution of the 18th and 19th centuries, and the subsequent rapid urbanization, that western civilization became aware of the devastating impacts of TB. In the 1700s, for example, annual TB mortality rates in the U.K. reached about one percent of the population (Collins 1997). TB is a contagious disease; the bacteria are transferred via tiny water droplets from either a cough or sneeze of an infected person, and once in contact, a person can take months or years to develop symptoms (NHS 2010). Three possible scenarios may occur once the bacteria are in contact with the host. For the majority of cases, the body kills the infection and no further symptoms are experienced. If the immune system cannot kill the bacteria, it may instead isolate the infection, resulting in no further symptoms unless the disease is activated. This case is referred to as a latent infection of TB; it cannot be transmitted in this form, but can be reactivated if the immune system is compromised. Lastly, the immune system may fail to kill and contain the infection, resulting in the movement of TB to the lungs. This result is the active form of TB (NHS 2010). If the TB infection becomes active, the patient should receive immediate and precise care. If left untreated, TB results in a two-thirds mortality rate within the rst 5 years of infection (Laxminarayan et al. 2007). TB is usually treatable through chemotherapy, which involves the administration of 34 drugs on a daily basis. Although the average course of treatment is 6 months when the regimen is daily, some treatments take longer to ensure that no reactivation occurs (CDC 2003). Failure to complete the course of treatment may cause the strain to become drugresistant; it is estimated that nearly 5% of all new global TB cases in 2008 were multi-drug resistant, compared to only 1.2% in the U.S. for 2007 (WHO 2008) (CDC, OTIS 2010b). The lower MDR rates in the U.S. are likely a result of the great emphasis placed on direct observed therapy2 to ensure all treatments are completed. One of the reasons TB chemotherapy is costly and time consuming is the fear of an increase in the MDR TB rate. Complacency in TB treatment increases the likelihood that the TB strain will become resistant, leading to stronger and costlier forms of the disease (CDC 2010a). Prevention of tuberculosis was rst somewhat attainable with the invention of the rin (BCG) vaccine in the early 20th century. The BCG Bacillus Calmette-Gue vaccine is typically administered only to children and remains effective for approximately 15 years. Although rarely used in the U.S., billions of people have been administered BCG; vaccination coverage exceeds 90% in countries such as India, Vietnam, Mexico, China, and the Philippines (Weibrod 2010). The BCG vaccine is popular mainly because of its documented protective effect against Meningitis and Disseminated TB3; however, BCG does not protect against primary TB infections or the reactivation of latent infections (WHO 2010a). Since the
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Direct Observed Therapy (D.O.T.) is the goal of all TB elimination programs to ensure all treatment courses are successfully completed. D.O.T. consists of direct monitoring from a government or WHO accredited doctor. Disseminated (or Miliary) TB is a rare occurrence (13% of all TB cases) in which the primary infection of TB (lungs) moves to other parts of the body, including the bones and joints, organ linings, bronchus, and skin.

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efcacy of BCG begins diminishing 15 years after administration, older populations are still unprotected. BCG vaccine is not sufciently effective to be used as a method for TB elimination, but to date remains the best way to protect children. TB elimination efforts within the U.S. have been highly successful, mainly due to adequate resources and diligence in TB treatment monitoring (American Thoracic Society 2005). U.S. TB incidence rates were as low as 4.2 cases per 100,000 persons in 2008, having decreased nearly 50% since 1992, and almost 90% since the 1950s (CDC 2009a). Today the incidence of TB within the U.S. is falling increasingly on the foreign-born (CDC 2010b). This changed incidence is due both to the continual rise in global TB prevalence and to the fact that the U.S. accepts almost 20% of its immigrants from high-incidence countries.4 The U.S. government recognizes the threat that immigrants pose for spreading TB to the native-born population. Prior to 2007, a prospective U.S. immigrant needed only a chest x-ray before being allowed to enter the country (Weibrod 2010). The shortcoming of the chest X-ray is that it identies only active TB infections; a person with a latent infection would pass through security and face possible reactivation of the disease once within U.S. However, since 2007, all prospective immigrants aged 214, from countries with TB incidence rates of 20 or more per 100,000 population, have been required to take a tuberculosis skin test (TST),5 which identies both the active and latent forms of TB (Weibrod 2010). The problem with the current security measures involving the TST is that they apply only to children under the age of 15 (who most likely have been vaccinated) and not older persons who no longer have immunity to TB. Given the high incidence of TB in many of the countries of origin for U.S. immigrants, the latent form of TB will most likely continue entering the U.S. until further procedures are implemented to stop it. This is cause for concern in that many active cases of TB among the foreign-born are reactivations of the latent form of the disease (Dasgupta and Menzies 2005), and according to some, all such cases are reactivations (Cohen and Murray 2005). Reactivations of TB usually occur when the bodys immune system becomes compromised, which can often happen during times of increased stress from inter-country migration (Cohen and Murray 2005). Therefore, these unscreened latent infections are, we believe, a major source of TB among the U.S. foreign-born population.

Related Research A number of papers have been published on TB transmission patterns within developed countries. This research may be divided into two categories: (1) smallscale case studies of individual cohorts and (2) large-scale epidemiological studies of entire populations.
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This 20% gure is based on the mean from 1993 to 2007 for the 50 MSAs included in our sample, which is discussed in more detail below. The Tuberculosis Skin Test involves injecting a small portion of Tuberculin into the arm. If a person has some form of the TB infection, he/she will develop a red, bumpy rash in response to the shot within 4872 h.

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Small-scale case studies are the most common type conducted on TB transmission. The main purpose of such studies is to understand the effect that different groups have on TB transmission by closely examining TB trends within each group. The most direct form of this research involves analyzing different cluster DNA patterns of TB for different populations. Some DNA patterns of TB are specic to certain countries; therefore, individuals from specic countries will tend to transmit only a certain strain of TB. Thus, if at the end of the study period, the DNA patterns are found in both cohorts, transmission can be assumed between cohorts. One of the most prominent studies of this nature compares DNA cluster patterns between native-born and foreign-born TB patients in New York City (Tornieporth et al. 1997). These investigators compare 158 foreign-born and 231 native-born TB patients. They nd that 84% of the cases among the foreign born were reactivations of TB contracted abroad, but for this group new cases reect recent exogenous transmission from the native born to the foreign born with risk factors such as homelessness being similar for each group. Although the Tornieporth study does not specically show TB transmission from the foreign born to the native born, a later study by Chin et al. (1998) demonstrates some such transmission. The Chin study is a molecular epidemiologic investigation that focuses on 367 patients (252 of whom were foreign born) with TB strains recently introduced into San Francisco, California. Although the rate of transmission was quite low (with just two native-born persons who were denitely infected by a foreign-born person), what is noteworthy about this study is that some transmission was found. Other small-scale studies examine incidence-rate differences between groups. Although not as direct as Tornieporth et al. (1997), these studies focus on local areas, where certain socioeconomic and natural factors are presumed to be similar. Such studies add controls to the model in efforts to isolate transmission, but have mixed ndings. For example, Mangtani et al. (1995) examine incidence rates by county in London, and nd positive correlations between the TB rates and four socio-economic conditions (overcrowding, unemployment, social class, and migrant population); however, none is statistically signicant over time. Overall, small-scale studies have offered little conclusive evidence that immigration and TB incidence rates are correlated, and little or no evidence of immigrants transmitting TB to the native-born. The second tier of research is conducted over larger geographies. A study of this nature, conducted in California, denes the observation as a census tract, which is assumed to be sufciently local to have constant socio-economic characteristics (Myers et al. 2006). By regressing TB incidence rates over time on numerous ecological variables for each census tract, the Myers study concludes that race/ ethnicity (minorities), location of birth (foreign-born), and income (poverty) are strong determinants of the number of TB cases observed per census tract. However, the study offers no discussion of how the observed socio-economic variables affect solely native-born TB cases. Another epidemiological study (Baker et al. 2008) uses similar methods to those utilized by Myers et al. (2006), but focuses on the entire nation of New Zealand.

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After including many socio-economic variables as controls, this study nds that crowding has a positive effect on TB incidence; but more importantly, it nds little evidence of transmission from the migrant to native populations. Large-scale studies such as Myers et al. (2006) and Baker et al. (2008) use observations that are geographic areas rather than actual individuals; thus, the variables are linked through area-wide characteristics rather than on a person-to-person basis. In our research on the United States, we also focus on geographic areas, but we are able to identify new active TB cases and also identify whether the individual is native born or foreign born. Such information provides a signicant advance over earlier work concerning the U.S. From prior research, we can conclude that socioeconomic conditions such as poverty, population density, and number of migrants are generally positively correlated with TB rates within a given area. However, the question of whether native-born populations are affected by immigrants is relatively unexplored; evidence is available that immigration affects TB rates, but this is the rst study to estimate the effect of immigration on TB among the native-born.

The Model In this study an observation is an individual Metropolitan Statistical Area (MSA) in a given year (19932007). Because most immigrants reside in metropolitan areas and because these areas are most densely populated, if any transmission exists from the foreign born- to the native-born population, we hypothesize that it most likely would be found in an MSA rather than a rural area. We employ a recursive model to explain the relationship between immigration and TB incidence among the native-born. A recursive model is one in which X causes Y, and in turn Y causes Z. X represents the number of U.S. immigrants from the top 50 high-TB incidence countries that specify an MSA of intended residence in a given year, whereas Y is the number of new TB cases among the foreign-born population in a given MSA and year. Z refers to the number of new native-born TB cases in a given MSA and year. Thus, the model explains how immigrants from high-TB incidence countries affect TB among the foreign-born who locate in the same MSAs, and in turn, how the number foreign-born TB cases affects the number of TB cases in the native-born population within specic MSAs. Due to the much higher incidence of TB among the foreign-born population (26.0 per 100,000) in our sample MSAs compared to the native-born population (5.0 per 100,000), we assume the transmission to be unidirectional from the foreign to the native-born population. Other studies (e.g., Cohen and Murray 2005) report such a nding, and we provide further evidence of such a relationship below. (Even when we treat the transmission as two way in a simultaneous context, the link for foreignborn transmission to the native-born remains statistically signicant.) Of course, the foreign-born also may infect other foreign-born persons; such transmission is partially accounted for in the rst stage of the model. The following is an outline of the recursive model, in which the rst line represents X to Y, and the second portrays Y to Z:

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1. 2.

FBTBit f HMIGit ; LMIGit ; DEMit ; SOCECONit ; and NBTBit gFBTBit ; DEMit ; SOCECONit ;

where FBTBit = newly reported foreign-born TB cases in MSA i, year t; HMIGit = ow of new immigrants from the top 50 high TB incidence countries in MSA i, years t and t - 1 summed; LMIGit = ow of new immigrants from all other countries in MSA i, years t and t - 1 summed; NBTBit = newly reported native-born TB cases in MSA i, year t; DEMit = a vector of demographic control variables in MSA i, year t; and SOCECONit = a vector of socio-economic control variables hypothesized to have causal relationships with TB, for MSA i, year t. The rst equation of the model concerns the relationship between the number of immigrants from both high-TB incidence and lower-TB incidence countries and the number of TB cases among the foreign-born. We expect a positive relationship between the settlement of immigrants from high-incidence countries and the number of new TB cases among the foreign-born population in specic MSAs. We anticipate a weaker relationship between the settlement of immigrants from lowerincidence countries and the number of new TB cases among the foreign-born. Given previous research regarding the relationship between certain socio-economic conditions and TB, we expect positive relationships between poverty and population density and the number of new TB cases among the foreign-born. The second branch of the recursive model concerns the relationship between TB among the foreign-born and TB among the native-born. We expect this relationship to be positive as well, due to the assumption that a less healthy foreign-born population may somehow affect the native-born persons living in that area.6 Specically, we hypothesize transmission of TB from the foreign born to the native born. Given the ndings of previous research, we expect positive relationships between the socio-economic variables poverty and population density and the number of new TB cases among the native-born.

Data This study incorporates the following ve types of data: (1) tuberculosis data, (2) demographic and socio-economic data, (3) country-specic TB incidence data, (4) MSA immigration data, and (5) HIV incidence data. The TB data set consists of basic tuberculosis statistics for each MSA provided by the Centers for Disease Control and Prevention (CDC), and can be found in their archived reports, or in the WONDER OTIS Database (CDC 2010b).7 In this
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Given the concentration of the foreign born in service occupations, at least some transmission could occur through the work place. The following respective percentages show foreign-born versus native-born employment in selected service occupations in 2009: health support, 2.6 versus 2.3; food preparation and serving, 8.0 versus 5.1; building and grounds cleaning and maintenance, 8.5 versus 3.0; and personal care and service, 4.5 versus 3.4 (Bureau of Labor Statistics, 2010).Transmission also could occur through the use of public transportation and in numerous other ways. The WONDER OTIS Database (Wide-ranging Online Data for Epidemiological Research) is an online tool provided by the CDC to offer researchers easy access to downloadable information. The OTIS (Online Tuberculosis Information System) portion of the database is specic to TB data.

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database, the CDC believes that it reports 100% of all cases because if left untreated, TB proves fatal in a relatively short period of time. The sample for this study includes the top 50 MSAs by total cases of TB (19932007) because the number of TB cases become too few and are suppressed for smaller MSAs.8 The 50 MSAs included in the study account for 69.5% (or 185,234 of 266,556) of all newly reported TB cases in the U.S., 19932007. CDC data also provide TB cases broken down by the native- and foreign-born populations. Nativity was not recorded for 1,176 cases in our sample (0.6% of the total observations) and these were allocated based on known native- and foreign-born TB incidence rates. That is, the fractions of the known native-born and foreign-born TB cases, by MSA, were applied to the cases in which nativity was unknown, by MSA, and then included with the known MSA cases. The 50 MSAs account for 60.1% (89,979 of 149,698) of the total U.S. native-born TB and 81.5% of the total U.S. foreign-born TB (94,255 of 116,858) over the study period. Due to condentiality restrictions, the WONDER database releases MSA TB statistics only in minimum 5-year increments. Therefore, TB data were downloaded in 15- and 14-year blocks, and were subtracted to obtain TB statistics by MSA per year. For example 19932006 data were subtracted from the 19932007 block to obtain 2007 TB statistics for each MSA. Finally, TB data are made available in the OTIS Database by geographic MSA denitions that are constant over time.9 The second data set includes demographic and socio-economic statistics broken down by MSA. These data are available from the U.S. Census Bureau through the American Community Survey in 2007 and the for 1990 and 2000 (U.S. Bureau of
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The 50 sample MSAs and their respective annual average (19932007) native and foreign-born TB rates per 100,000, grouped by Census region/division, are as follows: Northeast: New EnglandBostonCambridge-Quincy (1.7, 26.7), Providence-New Bedford-Fall River (1.8, 21.2); Middle AtlanticNew York-Nothern New Jersey-Long Island (8.3, 26.8), Philadelphia-Camden-Wilmington (3.8, 28.5), Pittsburgh (2.1, 16.0); Midwest: East North CentralChicago-Naperville-Joliet (6.4, 17.2), ClevelandElyria-Mentor (3.3, 18.5), Columbus (1.9, 38.1), Detroit-Warren-Livonia (4.4, 13.6); West North CentralKansas City (2.3, 26.4), Minneapolis-St. Paul-Bloomington (1.3, 38.1), St. Louis (2.7, 25.3); South: South AtlanticAtlanta-Sandy Springs-Marietta (6.6, 23.7), Baltimore-Towson (4.1, 27.1), Charlotte-Gastonia-Concord (5.9, 22.9), Jacksonville (8.5, 22.6), Miami-Fort Lauderdale-Miami Beach (7.1, 16.3), Orlando-Kissimee (7.7, 17.6), Raleigh-Cary (5.0, 26.4), Tampa-St. Petersburg-Clearwater (5.3, 13.9), Virginia Beach-Arlington-Alexandria (2.6, 31.5); East South CentralBirmingham-Hoover (7.0, 26.1), Louisville-Jefferson County (4.0, 26.7), Memphis (8.6, 31.7), Nashville-DavidsonMurfreeboro (6.6, 35.8); West South CentralAustin-Round Rock (4.9, 23.0), Dallas-Fort Worth-Arlington (5.7, 22.2), El Paso (5.3, 25.8), Houston-Sugar Land-Baytown (10.3, 22.9), McAllenEdinburg- Mission (9.3, 29.4), New Orleans-Matairie-Kenner (9.6, 21.8), Oklahoma City (4.7, 26.6), San Antonio (4.9, 19.5); West: MountainDenver-Aurora (1.5, 19.2), Las Vegas-Paradise (3.5, 19.4), Phoenix-Mesa-Scottsdale (3.0, 19.6); PacicBakerseld (5.0, 30.4), Fresno (5.1, 32.6), Honolulu (4.5, 61.2), Los Angeles-Long Beach-Santa Ana (5.1, 28.0), Oxnard-Thousand Oaks-Ventura (2.9, 29.2), Portland-Vancouver-Beaverton (2.0, 29.8), Riverside-San Bernardino-Ontario (3.0, 16.4), SacramentoArden-Arcade-Roseville (3.1, 35.5), San Diego-Carlsbad-San Marcos (4.9, 41.0), San Francisco-OaklandFremont (6.2, 36.7), San Jose-Sunnyvale-Santa Clara (2.4, 39.4), Seattle-Tacoma-Bellevue (2.3, 32.9), Stockton (5.4, 40.0). MSA geographic denitions, which are based on counties except in New England, change on an annual basis; however, the OTIS system provides TB statistics for constant geographies, with respect to the 2007 MSA denitions provided by the Executive Ofce of the President (2007).

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the Census 2010).10 Data were linearly interpolated for years 1991 to 1999 and 2001 to 2006, using 1990, 2000, and 2007 as endpoints. These data provide MSA population controls, including total population broken down by the foreign born and native born, as well as race/ethnicity controls. All race/ethnicity variables are recorded for the entire population, and are therefore not distinguishable by foreign or native-born. The Census Bureau data also provide socio-economic controls that have been previously shown to have causal relationships with TB, including population density (persons per square mile) and poverty. The poverty variable was created to measure the annual number of families earning less than $25,000 per year based on 2007 dollar equivalents. According to the Bureau of Labor Statistics CPI Ination Calculator, $25,000 in 2007 had the same purchasing power as about $15,000 in 1990. The number of families earning under $15,000 in 1990 and the number of families earning under $25,000 in 2007 were deemed to be under the same realincome poverty threshold, and the number of impoverished families between these years was linearly interpolated. The third data set is from annual reports of the World Health Organization and provides annual incidence rates for all WHO countries during the study period. The top 50 high-TB incidence countries were dened using the average incidence rate from 1990 to 2007 (WHO 2010b).11 The fourth data set is from the Department of Homeland Security (DHS) (and before the formation of this Department, the Department of Justice.) The DHS data contain the intended MSA of residence of all legal U.S. immigrants, by country of the immigrants birth (DHS 2008).12 We compiled the data for the top 50 highincidence countries of birth and assigned these immigrants to their intended MSA of residence. Due to the availability of TB data, immigration statistics need to correspond to constant geographies with respect to the 2007 MSA denitions. Since the DHS immigration data available for download corresponded to inconsistent
10 To remain consistent in geographic denitions with the CDC, data collected from the Census Bureau are on a county-wide level. 2007 MSA denitions were used and the county level data were combined by this distinction for both 1990 and 2000. 11 The list of 50 countries and the corresponding average incident rate per 100,000, 19902007 is as follows: AfricaDjibouti (691.4), Swaziland (679.6), Zimbabwe (608.2), Namibia (596.2), Botswana (568.8), South Africa (556.3), Zambia (535.9), Lesotho (451.9), Malawi (375.4), Togo (365.3), Sierra Leone (361.4), Mozambique (335.4), Uganda (322.6), Congo (313.6), Rwanda (308.8), Cote dIvoire (306.9), Democratic Republic of the Congo (304.6), Kenya (303.4), Mali (296.4), Ethiopia (294.0), United Republic of Tanzania (290.5), Burundi (285.3), Mauritania (270.3), Central African Republic (268.3), Somalia (249.0), Angola (243.9), Nigeria (241.7), Liberia (235.8), Chad (232.3), Senegal (231.1), Gabon (230.3), Gambia (219.8), Ghana (212.7), Madagascar (212.1), Sudan (207.0); Asia and West PacicCambodia (538.9), Kiribati (435.1), Bhutan (375.1), Democratic Peoples Republic of Korea (344.0), Philippines (339.3), Indonesia (281.8), Papua New Guinea (250.0), Bangladesh (242.7), Tuvalu (225.6), Solomon Islands (207.3), Nepal (206.1), Mongolia (205.0); Caribbean and South AmericaHaiti (306.0), Peru (207.9), Bolivia (200.6). By contrast, the United States had a 2005 rate of 4.8. 12 The immigration data include only legal permanent residents. Temporary residents (called nonimmigrants) and illegal migrants may also spread TB. Illegal immigrants residing in the U.S. have been estimated to number as high as 12 million in recent years. Although the illegal migrants themselves are not included in the migration numbers used here, they (along with non-immigrants) could be included in the TB data for which the only distinction is foreign born.

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848 Table 1 Descriptive statistics Variable Mean Standard deviation 219 240 27,159 4,874 3,086,156 2,278,708 891,794 1,629,987 538,430 299,398 11,274 70,131 893,002 551 106,687 9 M. J. Greenwood, W. R. Warriner

Number of native TB cases Number of foreign-born TB cases Total immigrants Immigrants from top 50 high TB countries Total population Native-born population Foreign-born population Non-hispanic whites Non-hispanic blacks Asians American Indians Other races Hispanics Population density (people per square mile) Families earning under $25,000 per year HIV Incidence (per 100,000) for 20032007

120 126 14279 2604 2905694 2417600 488094 1740128 409482 169176 10499 57931 518479 644 103040 15

geographic boundaries, John Simanski, from the Ofce of Immigration Statistics of the DHS, provided us with immigration statistics that are adjusted to correspond to 2007 MSA denitions. Immigration data are based on scal years (October through September), whereas all other data are based on calendar years. Therefore, the immigration data reect a three-month lead over all other data in the model. The nal data set is comprised solely of HIV incidence data, and was obtained from the CDC Division of HIV/AIDS Preventions archived reports (CDC 2005). The data provide HIV incidence rates per 100,000 persons in every MSA, but are limited in availability. Prior to 2003, the HIV incidence rates were not recorded by 2007 MSA denitions, and thus could not be used for the entire 19932007 period. The HIV incidence control is used for 20032007 only. Table 1 provides descriptive statistics, including means and standard deviations.

Econometric Approach This study utilizes an ordinary least squares (OLS) double-log regression, which allows the coefcients to be interpreted as estimated elasticities. The estimated model is of the following form: 1. 2. FBTBit a1 HMIGit1 LMIGit2 DEMit3 SOCECONit4 e1it c c c NBTBit a2 FBTBit1 DEMit2 SOCECONit3 e2it :
b b b b

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Taking logarithms of the terms on each side of the model yields estimated relationships that are linear in logarithms. The robust feature13 is added to all regressions in case of any heteroskedasticity (variance in the error term) or large outliers in the data set. The data for all MSAs and years are pooled into a single panel data set with 750 observations (15 years and 50 MSAs per year), with an MSA in a given year as an individual observation. In order to control for time and location, the model employs temporal (annual) and cross-sectional (MSA) xed effects. The basic idea that underlies the use of xed effects is that the measurable variables of the model do not capture all of the variance in the dependent variable. Certain unobservables also inuence this variable. However, differences across various groups (e.g., MSAs or years) are reected in differences in the constant term. Thus, to control for unobserved variance, we introduce dummy variables (or 0 and 1 variables) for years and for different regions and, alternatively, groups of regions. One example of an unobservable is illegal immigration, which tends to be region specic and could affect exposure to TB. The immigration variables are dened to include years t and t - 1. Thus, a single observation of the high-incidence immigration variable includes all immigrants from the top 50 high-incidence countries for MSA i in years t and t - 1. TB is unlikely to spread immediately from the foreign-born population; some sort of lagged transmission is more likely to occur. Cohen and Murray (2005) nd that the highest TB incidence rates among immigrants occur within the rst year of arrival, and that the incidence rates decrease dramatically in subsequent years. For example, an immigrant arriving in December has the greatest chance of reactivating any latent TB before the following December, and therefore should be counted in the following calendar year as well. Summing the immigration variable to include the present and prior year should account for lagged transmission. The race/ethnicity variables are omitted from the rst model (in which foreignborn TB is the dependent variable), due to the fact that these statistics do not reect the foreign-born population that is at high risk to contract TB.

Empirical Results In Table 2, we report double-logarithmic estimates and t-ratios for ve regressions for the rst equation of the recursive model: the rst of the ve with no xed effects; the second with only temporal xed effects (with 1993 as the base year); the third with temporal and cross-sectional (all MSAs) xed effects (with Atlanta-Sandy Springs-Marietta as the base MSA); the fourth with temporal and regional (four geographic subgroups) xed effects (with West as the base region); the fth with temporal and divisional (nine geographic subgroups) xed effects (with Pacic as

13 The robust feature in STATA (the data analysis and statistical software used in this research) is a method of econometrics that allows for the research to circumvent certain OLS limitations regarding variance in the error term and large outliers in the data set.

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Table 2 Number of TB cases among the foreign-born population in U.S. metropolitan areas, 19932007: double logarithmic estimates (b) and t-ratios (t) Variables (1) ln(FBTB) (2) ln(FBTB) (3) ln(FBTB) (4) ln(FBTB) (5) ln(FBTB)

ln(Immigrants from top 50 Inc. countries) b: t: ln(Immigrants from all other countries) ln(Foreign-born population) ln(Native population) ln(Population density) ln(Families in poverty) Temporal xed effects Cross-sectional xed effects Regional xed effects Divisional xed effects Observations R2 0.173 (5.769) 0.139 (2.936) 0.819 (16.39) -0.121 (-1.885) 0.0391 (1.700) -0.23 (-3.700) N N N N 750 0.914 0.258 (7.744) 0.178 (3.338) 0.734 (12.66) -0.267 (-3.799) 0.0270 (1.299) -0.117 (-1.757) Y N N N 750 0.924 0.241 (3.414) 0.0544 (0.779) 1.500 (6.764) 3.313 (2.950) -4.815 (-3.540) 0.449 (0.955) Y Y N N 750 0.960 0.269 (7.851) 0.143 (2.601) 0.741 (12.36) -0.323 (-4.632) 0.0277 (1.123) -0.0472 (-0.761) Y N Y N 750 0.925 0.285 (7.926) 0.0313 (0.579) 0.845 (12.76) -0.233 (-3.593) 0.0803 (3.254) -0.141 (-2.189) Y N N Y 750 0.940

Robust t-statistics in parentheses. Y used in regression, N not used in regression

the base division). The regional and divisional distinctions are Census Bureau classications and are reected in footnote 8. All regressions have relatively high R2 s, with the R2 s in the rst relationship of the recursive model ranging from 0.914 when no xed effects are used to 0.960 when the temporal and all-MSA cross-sectional xed effects are employed, and in the second relationship ranging from 0.749 when no xed effects are used to 0.954 when temporal and all MSA cross-sectional xed effects are employed. Even though all estimations are similar in sign and signicance, our focus will be on the fth regression with the temporal and divisional xed effects. We focus on this regression because when the more detailed cross-sectional xed effects are included, most of the coefcients on the individual MSAs are not signicantly different from zero. In the rst branch of the recursive model, foreign-born TB is the dependent variable and both high-incidence and lower-incidence immigration are the independent variables. The key immigration variables in this regression are both consistent in their hypothesized relationships with foreign-born TB. The elasticity for immigrants from high-TB incidence countries is statistically signicant with a value of 0.285, meaning that an increase in high-incidence immigrants of 10% results in an increase in the number of new foreign-born TB cases by 2.85%, other

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factors held constant. Furthermore, the elasticity for immigrants of lower incidence countries is not statistically signicant. The stark contrast in the elasticities for both key variables shows the direct and unique connection between immigrants from high incidence countries and TB within the foreign-born population. Although this may seem obvious, it is important to realize that the foreign-born population is contracting TB through immigrants from the 50 high-TB incidence countries, and not the 156 remaining low-incidence countries. This nding provides further evidence of a unidirectional relationship that runs from the foreign born to the native born. If immigrants from countries other than the top 50 do not affect the foreign-born incidence, then the native U.S. population, with considerably lower rates than those of countries below the top 50, are unlikely to affect the incidence among the foreign born.14 As expected, most of the control variables also have the appropriate sign and are highly signicant. For example, increased population density results in increased TB cases among the foreign-born population, holding all else constant. Foreignborn TB is negatively associated with the poverty rate with an elasticity of -0.141. This nding suggests that the higher rates of TB among the foreign-born population are most likely not a result of conditions associated with lower income areas but rather the disease is carried by the immigrant population itself. Table 3 shows the regression results for the second segment of the recursive model with native-born TB cases as the dependent variable and foreign-born TB cases as the key independent variable. As predicted, the number of TB cases among the foreign-born positively affects the number of native-born TB cases with an elasticity of 0.111, which is also highly signicant. In other words, a 10% increase in the number of new foreign-born TB cases increases the number of TB cases among the native-born population by 1.11%. Also shown in Table 3 are the hypothesized key socio-economic control variables of race/ethnicity and poverty. Poverty has the most prominent relationship with native TB with a statistically signicant elasticity of 0.759. Population density also positively and signicantly inuences TB among the native-born, but with a lower elasticity of 0.077. Blacks, Asians, and Hispanics are the races/ethnicities most likely to have TB within the native-born population, a nding consistent with previous research. Tables 4 and 5 provide additional estimations of all regressions, but include an HIV/AIDS control, due to the large number of co-infections between HIV and Tuberculosis. In 2006, nearly 12% of the newly reported TB cases in the U.S. were also co-infections with HIV (CDC 2007); co-infection rates reach as high as 80% in sub-Saharan Africa, where a large portion of the high-incidence countries are located (Infectious Diseases Society of America 2007). Omitting this control will likely leave a positive omitted variable bias (an overestimation) on the foreign-born TB coefcient in the second branch of the recursive model. This is due to the likely
14 As noted above, we also estimated the model using 2 stage least squares to account for any possible simultaneity between native- and foreign-born TB. When the rst-stage regression contains all of the temporal and cross-sectional xed effects, the coefcient on the foreign-born TB variable is highly signicant in the regression for native-born TB, although the magnitude of the coefcient declines somewhat (to 0.531 with the t statistic of 2.326).

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Table 3 Number of TB cases among the native-born population in U.S. metropolitan areas, 19932007: double logarithmic estimates (c) and t-ratios (t) Variables (1) ln(NBTB) (2) ln(NBTB) (3) ln(NBTB) (4) ln(NBTB) (5) ln(NBTB)

ln(Foreign-born TB cases) c: t: ln(Native population) ln(Foreign-born population) ln(Non-Hispanic Whites) ln(Non-Hispanic Blacks) ln(Asians) ln(American Indians) ln(Other races, including mult-racial) ln(Hispanics) ln(Population density) ln(Families in poverty) Temporal xed effects Cross-sectional xed effects Regional xed effects Divisional xed effects Observations R2 0.279 (5.081) 0.188 (1.017) -0.407 (-4.407) -0.263 (-2.406) 0.369 (14.13) 0.271 (5.213) 0.149 (4.361) -0.549 (-10.91) 0.104 (2.277) 0.191 (4.312) 0.675 (7.155) N N N N 750 0.749 0.136 (3.292) 0.114 (0.819) -0.305 (-4.358) -0.368 (-4.727) 0.415 (20.30) 0.123 -3.043 -0.0344 (-1.155) -0.0835 (-1.829) 0.182 (5.142) 0.106 (2.964) 0.69 (8.529) Y N N N 750 0.853 0.198 (5.599) 1.812 (1.133) 0.652 (2.185) 0.366 (0.769) 0.545 (2.377) -0.919 (-4.187) 0.0160 (0.135) 0.131 (0.935) -0.491 (-2.356) -1.972 (-1.261) 0.747 (1.914) Y Y N N 750 0.954 0.129 (3.328) -0.301 (-1.992) -0.349 (-4.804) -0.0133 (-0.171) 0.232 (9.315) 0.300 (5.972) -0.154 (-5.300) -0.0107 (-0.246) 0.129 (3.582) 0.0537 (1.555) 1.018 (11.04) Y N Y N 750 0.879 0.111 (2.685) -0.0422 (-0.275) -0.241 (-2.577) -0.0997 (-1.210) 0.234 (7.173) 0.179 (3.040) -0.0579 (-1.795) -0.00405 (-0.0906) 0.133 (3.409) 0.0771 (2.089) 0.759 (7.246) Y N N Y 750 0.879

Robust t-statistics in parentheses. Y used in regression, N not used in regression

positive relationships between HIV/AIDS and native-born TB, and HIV/AIDS and immigrants, since most high-TB incidence countries are also in high-HIV/AIDS regions. Because the data are available only after 2003, the estimations including HIV incidence contain a panel with 250 observations. Both branches of the recursive model were run again, but only for the ve available years. The fth and sixth regressions in each table are with the temporal and divisional xed effects; however, the fth omits HIV incidence and the sixth includes the HIV incidence as a control. The estimations in all regressions are different given the smaller sample, but the

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Table 4 Number of TB cases among the foreign-born population in U.S. metropolitan areas (HIV incidence included), 20032007: double logarithmic estimates (b) and t-ratios (t) Variables (1) ln(FBTB) (2) ln(FBTB) (3) ln(FBTB) (4) ln(FBTB) (5) ln(FBTB) (6) ln(FBTB)

ln(Imms. of top-50 Inc. countries) b: t: ln(Imms. of all other countries) ln(Foreign-born population) ln(Native population) ln(Population density) ln(Families in poverty) ln(HIV incidence rate) Temporal xed effects Cross-sectional xed effects Regional xed effects Divisional xed effects Observations R2 0.227 (4.521) -0.130 (-1.642) 0.955 (11.74) -0.144 (-1.376) 0.0929 (2.497) -0.0732 (-0.741) -0.108 (-2.564) N N N N 250 0.927 0.312 (5.688) -0.0659 (-0.753) 0.84 (8.902) -0.303 (-2.620) 0.0836 (2.314) 0.0519 (0.492) -0.138 (-3.314) Y N N N 250 0.933 0.196 (1.067) 0.0698 (0.621) 2.35 (2.083) 0.511 (0.0912) -3.049 (-0.456) 0.742 (0.360) -0.0885 (-1.062) Y Y N N 250 0.975 0.316 (5.715) -0.0718 (-0.787) 0.872 (8.438) -0.317 (-2.681) 0.0729 (1.911) 0.0277 (0.259) -0.142 (-2.890) Y N Y N 250 0.933 Y N N Y 250 0.940 0.294 (4.913) -0.0854 (-0.886) 0.917 (8.045) -0.236 (-1.951) 0.109 (2.531) -0.115 (-1.022) 0.307 (5.120) -0.0918 (-0.951) 0.919 (7.990) -0.248 (-2.092) 0.109 (2.530) -0.0897 (-0.796) -0.0732 (-1.496) Y N N Y 250 0.941

Robust t-statistics in parentheses. Y used in regression, N not used in regression

importance of these tables lies in the difference between the fth and sixth regressions, which shows the change in coefcients with the inclusion of the HIV control. The sixth regression in Table 4 shows the regression results when foreign-born TB is the dependent variable and high- and lower-incidence immigrants are the key independent variables. The results show that the HIV incidence of an area does not have a signicant relationship with the number of foreign-born TB cases, given the associated small and negative elasticity and t-statistic of -1.496. This makes sense given that the coefcients for the other key variables do not change much once the HIV control is included (comparing the fth and sixth regressions). Therefore, it seems that most of the foreign-born persons who get TB are not getting it because of the HIV-incidence of an area, but are getting it either because of where they come from or who they associate with. The inclusion of the HIV-incidence variable portrays a much different picture in the second branch of the recursive model with native-born TB as the dependent variable. As shown in Table 5, an increase in HIV incidence positively and signicantly increases TB within the native population, with an elasticity of 0.323.

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Table 5 Number of TB cases among the native-born population in U.S. metropolitan areas (HIV incidence included), 20032007: double logarithmic estimates (c) and t-ratios (t) Variables (1) ln(NBTB) (2) ln(NBTB) (3) ln(NBTB) (4) ln(NBTB) (5) ln(NBTB) (6) ln(NBTB)

ln(Foreign-born TB cases) c: t: ln(Native population) ln(Foreign-born population) ln(Non-Hispanic Whites) ln(Non-Hispanic Blacks) ln(Asians) ln(American Indians) ln(Other races, including multi-racial) ln(Hispanics) ln(Population density) ln(Families in poverty) ln(HIV incidence rate) Temporal xed effects Cross-sectional xed effects Regional xed effects Divisional xed effects Observations R2 0.211 (3.123) 0.424 (1.949) -0.726 (-5.920) -0.391 (-3.220) 0.203 (4.285) 0.297 (4.088) 0.0902 (1.869) -0.193 (-2.380) 0.255 (3.914) 0.185 (3.190) 0.621 (4.812) 0.405 (6.057) N N N N 250 0.838 0.162 (2.591) 0.461 (2.136) -0.671 (-5.565) -0.411 (-3.372) 0.217 (4.653) 0.329 (4.702) 0.0796 (1.636) -0.232 (-2.755) 0.254 (4.026) 0.182 (3.184) 0.596 (4.852) 0.377 (5.623) Y N N N 250 0.850 0.124 (1.267) -5.669 (-0.768) 3.837 (2.125) 1.610 (0.620) 2.064 (1.774) 0.351 (0.267) -0.131 (-0.340) 0.445 (1.022) -4.234 (-2.776) -1.073 (-0.139) 4.046 (1.877) 0.0506 (0.451) Y Y N N 250 0.956 0.155 (2.505) -0.221 (-1.046) -0.687 (-6.247) -0.0124 (-0.113) 0.0594 (1.162) 0.533 (6.136) -0.0757 (-1.624) -0.110 (-1.410) 0.205 (-3.326) 0.0956 (1.734) 1.054 (7.752) 0.276 (3.562) Y N Y N 250 0.882 Y N N Y 250 0.871 0.172 (2.607) 0.0676 (0.306) -0.366 (-2.327) -0.142 (-1.171) 0.239 (4.305) 0.264 (2.569) -0.0182 (-0.336) -0.0942 (-1.211) 0.136 (1.932) 0.139 (2.304) 0.653 (4.168) 0.136 (2.111) 0.213 (1.003) -0.502 (-3.546) -0.151 (-1.304) 0.0835 (1.389) 0.367 (3.550) 0.0441 (0.802) -0.142 (-1.769) 0.168 (2.737) 0.137 (2.333) 0.662 (4.020) 0.323 (4.177) Y N N Y 250 0.883

Robust t-statistics in parentheses. Y used in regression, N not used in regression

Most importantly, the elasticity of foreign-born TB decreases when HIV is included, from 0.172 to 0.136, but still remains positive and statistically signicant. Given that this estimate decreases when HIV incidence is included, a positive omitted variable bias probably is associated with not including HIV incidence for the previous years. Therefore, the estimate in Table 3 for foreign-born TB is probably overestimated. Furthermore, the elasticity on Blacks changes from positive and

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signicant to insignicant upon the HIV inclusion. This result suggests that the Black population within the native-born is contributing importantly to the HIV/TB co-infections, and the omitted variable bias may be picked up by the Black population and not the foreign-born TB variable.

Societal Cost of TB Transmission The economy incurs many costs from TB. Such societal costs are considered in (Miller et al. 2010), who group the costs into the following four categories: (1) infrastructure costs which are dened as the hospitals opportunity costs15 of treating TB; (2) actual treatment expenditures, which range from diagnostic procedures, to pharmaceuticals used in treatment, to the labor costs of the hospital employees; (3) transmission costs, which represent all costs associated with further transmissions of a given case; and (4) patient costs, which include all lost wages due to treatment, possible pulmonary impairment, or even death. Miller et al. (2010) use Tarrant County, Texas (which is part of the Dallas/Fort Worth Metropolitan Area), in 2002, as their sample area because it reects the average U.S. county. Tarrant County contained just over 1.5 million people in 2002, had 108 conrmed TB cases (43.5% of which were foreign-born), a subsequent TB case rate of 7.2 per 100,000 persons, and had many of the risk factors associated with tuberculosis as deemed by the researchers. To determine the average cost per TB case, Miller et al. (2010) use reported government and local organization costs and QALYs to estimate the effect of all the various costs described above. QALY (or Quality Adjusted Life Year) is a measure used to determine if the loss of potential health a person incurs is affected by a certain aspect of a disease. In this case, QALYs were used to calculate the production that a worker could have contributed if not affected by tuberculosis (either by death or disability) over his expected lifespan. Using the QALYs method, the Miller study nds that the average societal cost of TB for Tarrant County, Texas, in 2002, was $346,756 per case. These costs include transmission costs of future TB which were estimated at $176,778 per case, but do not include TB testing costs which were estimated at an additional $29,498 per case. Furthermore, the research nds that if both impairment and death were avoided, and if the further transmission of TB were prevented, the estimated societal cost would be only $32,248. The cost of Tuberculosis testing was also estimated by the same study for Tarrant County in 2002. Miller et al. (2010) nd that the average cost of a TST (Tuberculosis Skin Test, used to detect latent TB infections), including the actual test and labor, was $18 per test, or $11,875 per actual TB case detected. This number is less than the total cost of TB testing noted above ($29,498/case) because the smaller cost excludes extra infrastructure, treatment, and correctional costs that would not be associated with solely applying a TST to a specic group. Although

15 Opportunity cost is the value of the next best choice. In this case, the opportunity costs consist of the resources a hospital could direct to other functions if they were not being used to treat TB patients.

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still rather expensive, this cost is signicantly less than that of cleaning up an active TB case. Based on the lower cost per case noted above, we extrapolate the costs measured for Tarrant County, Texas, for the entire U.S. to provide an estimate of what TB is costing the country as a whole. The national estimates do not include the transmission costs because these costs occur over the lifespan of a TB strain and thus cannot be estimated for a given year. Cost estimates are inated by 19.68% due to the CPI ination from 2002 to 2008. In 2008, there were 12,904 newly reported TB cases in the United States, of which 5,283 were native-born, 7,563 were foreignborn, and 58 were not reported by nativity (CDC 2009a). Again, the unreported cases were allocated to either foreign or native. We use the projected cost estimate per case if the person suffers no disability or death from the TB infection. In this case, the lowest bound for the total U.S. societal cost of TB for 2008 was $0.50 billion. If the additional costs of death and disability are included, our upper-bound estimate of the societal cost of TB in 2008 is $2.63 billion (or $203,428.42 per case) for the U.S. economy as a whole. Compared to the 2008 total GDP estimate for the U.S. economy of $14.61 trillion, the TB societal cost amounts to only 0.018% of total GDP (CIA 2010). The estimated cost of latent TB testing using TSTs can also be calculated for testing all persons obtaining legal permanent residence (LPR) in the U.S. in 2008. The average cost of a TST was $9 with an additional $9 for labor and surveillance costs in Tarrant County in 2002. In 2008, 1,107,126 people obtained legal permanent resident status (DHS 2008). If the cost statistics from Tarrant County are extrapolated to the entire U.S. population (accounting for ination), then testing every LPR immigrant for latent TB in 2008 would have cost the U.S. economy $23.8 million. The estimates provided in our study should be accepted only conditionally. Only one study has attempted to calculate entire societal costs of TB and then for only one county in Texas. In providing potential costs for the entire U.S., numerous assumptions are made including the supposition that Tarrant County provides an adequate representation of the rest of the U.S., as well as the assumption that no major changes have been made since 2002 regarding the framework behind the original studys calculated costs. However; the benet/cost analysis of this section does provide rough estimates and an overall idea of whether testing immigrants for latent-TB would be cost effective. If the above calculations are reasonable, testing all LPR immigrants for latent and active TB infections using the TST would cost anywhere between 0.91 and 4.79% of TBs societal cost in 2008. Requiring all LPR immigrants to take a TST would cost the U.S. very little compared to the cost it is incurring from current levels of TB, which makes a TST requirement for all immigrants extremely cost effective. Given our ndings of TB transmission from high-incidence immigrants to the foreign-born and then to the native-born populations, limiting the amount of latent TB that crosses U.S. borders would benet both groups in the U.S. and probably would signicantly reduce the number of latent TB infections that enter the U.S.

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Discussion Previous research on TB transmission in the U.S. has failed to discover a clear link between immigration and the native-born population. However, by dening the observation as a Metropolitan Statistical Area and using unique data provided by the CDC, as well as other unique data, we uncover evidence of TB transmission from U.S. immigrants to the foreign- and to the native-born populations. Our estimated elasticities show that the number of immigrants from countries of high-TB incidence positively affects the number of foreign-born TB cases, and that, in turn, an increase in TB among the foreign-born causes an increase in the number of new TB cases among the native-born population. Therefore, areas that experience relatively much immigrant settlement are likely to have relatively more TB cases within their native populations, a direct result of TB transmission from the foreign to the native-born populations. Specically, at the means in our data, a 10% increase the settlement of immigrants from high-incidence countries (260.4 more immigrants, on average) results in an average of 3.6 more new TB cases among the foreign born in an MSA. In turn, a 10% increase in the number of TB cases among the foreign born of an MSA (12.6 more cases, on average) results in an average of 1.3 more new cases among the native born. Our study also solidies previous knowledge by nding signicant relationships between TB and certain socio-economic conditions. In the U.S., areas that have higher population densities, increased numbers of Blacks, Asians, and Hispanics, increased poverty, and higher HIV-incidence rates also have more TB cases among the native-born populations. Because immigrants are contributing to increased TB among both the foreign and native populations, a case can be made for enacting policies targeting immigrant tuberculosis. As previously mentioned, the U.S. currently tests only for latent TB infections in children, aged 214, from countries with TB incidence rates of greater than 20 per 100,000 persons. We recommend that this policy be extended to immigrants of all ages. The importance of implementing TB immigration policy has become even more pressing. In 2009, President Barack Obama announced the lifting of the nations 22 year-old ban of HIV-positive immigrants, allowing admittance into the United States regardless of HIV/AIDS status (Preston 2009). As mentioned above, a large number of TB/HIV co-infections occur across the world. As of 2009, over one-third of the 33.2 million HIV-positive persons were co-infected with tuberculosis. In fact, people with HIV have roughly a 2030 times greater likelihood of contracting TB (WHO 2009b). Therefore, allowing people who are HIV positive to enter the U.S. will increase the number of persons who either have TB, or are more susceptible of activating it in the U.S. Additionally, many of the top 50 high-TB incidence countries in our study also have an extremely high HIV prevalence. Since a large fraction of TB cases in these countries are also co-infections of HIV, many people infected with TB from these countries have historically been denied access to the U.S. Thus, our data contain no HIV-positive immigrants, showing that only HIV-negative immigrants positively affect foreign and native-born TB in the U.S. Elasticities, and thus the magnitude of

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transmission, estimated in this study will soon become understated when the HIVpositive immigrants from these countries are allowed to enter. At the least, it is crucial for the government to ensure that all HIV-positive immigrants are tested for both active and latent infections of TB. As this study has found, it would be relatively cost effective to require all immigrants take a TST before arrival to the U.S.
Acknowledgments We are grateful to Terra McKinnish and Lori Hunter for comments on an earlier draft of this paper. Two reviewers for this journal also made a number of helpful suggestions, for which we are grateful. Carla Jeffries and Valerie Robison of the Centers for Disease Control provided assistance with the TB data and John Simanski of the Department of Homeland Security helped with immigration data; without their assistance this study could not have been conducted in the preferred manner.

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