Differences in Clinical Presentation among Persons with Pulmonary Tuberculosis: A Comparison of Documented and Undocumented Foreign-Born versus US-Born Persons

Background. Most cases of tuberculosis (TB) in the United States are diagnosed in foreign-born persons, and undocumented foreign-born persons may face particular barriers to timely access to health care services. This study investigates whether differences in clinical presentations among persons with pulmonary TB are associated with foreign birth or documentation status. Methods. In this cross-sectional study, we reviewed the medical records of patients who had received a diagnosis of microbiologically proven pulmonary TB at a New York City public hospital during the period April 1999 through March 2005. Three groups of patients with pulmonary TB (US-born persons, foreign-born persons with documents, and undocumented, foreign-born persons) were defined and compared at presentation. Odds ratios (ORs)for a symptom duration >= 8 weeks before hospital admission for each group were estimated using logistic regression. Results. Among 194 subjects with newly diagnosed pulmonary TB, 61 (31%) were US born, 62 (32%) were documented foreign-born persons, and 71 (37%) were undocumented foreign-born persons. Undocumented foreign-born persons presented with significantly higher frequencies of cough (P = .020) and hemoptysis (P = .012) and had a significantly longer median duration of symptoms, compared with US-born persons (8 vs. 4 weeks; P = .023). No statistically significant differences between documented foreign-born and US-born persons were observed. Multivariate analysis revealed that undocumented status (compared with being US born; adjusted OR, 4.1; 95% confidence interval, 1.7-10.2; P = .002) and being unemployed (adjusted OR, 2.2; 95% CI, 1.1-4.5; P = .023) were independently associated with a prolonged symptom duration (i.e., >= 8 weeks). Conclusions. Undocumented status was associated with an increased frequency of cough and hemoptysis and a longer duration of symptoms before medical evaluation for pulmonary TB. Whether reducing barriers to health services for undocumented foreign-born persons could enhance TB control deserves additional study.