Bureau of Epidemiology
Bureau of Epidemiology June 1999 Utah Department of Health
Community Winter Emergency Shelter TB Testing
Current Issues in Refugee Health
Infant Botulism
Monthly Morbidity Summary


Community Winter Emergency Shelter TB Testing

In April, 1998, the Utah Department of Health, Bureau of HIV/AIDS & Tuberculosis Control/Refugee Health, conducted a small study to provide a needs assessment and feasibility study for tuberculosis in the homeless population. There was particular concern with winter housing because of the close proximity in which people dwelt during the nights. The study showed that it was plausible and useful to do TB testing, using the Mantoux skin test, with this population.

Beginning in November of 1998, a full scale reproduction of the study began at the new Community Winter Emergency Shelter (CWES) facility in Midvale (Figure 1). Upon closure of the shelter on April 15, 1999, 466 people had been tested, consisting of a mix of families and men staying at the shelter. Of the 306 who returned, 33 people tested positive and were referred to the Fourth Street Clinic to receive chest x-rays and follow-up treatment. Of those 33, at least 15 received x-rays, all of which were negative (Table 1).

Figure 1.


Table 1


Totals (%)

Total Tested


Returned for results

306 (66%)


33 (11%)

The TB Control/Refugee Health Program coordinated the project and all testing was done by volunteers. During the first part of the project, university students from various colleges nearby were recruited to participate as volunteers. Unfortunately, it was extremely difficult for these students to commit on any sort of regular basis. Therefore volunteers from the Department of Health (DOH) were recruited to participate. Following intensive training and certification, volunteers signed up for testing and reading dates. These volunteers were extremely reliable.

Staff from the DOH worked closely with staff at theTravelers Aid Society (TAS) and the Fourth Street Clinic to make this project a success. The cooperation between all three agencies has been wonderful.

Some conclusionary comments concerning the project:

It was anticipated that the number of people would drop as the year progressed. However, the number of people tested remained constant.

There was an 11% positivity rate. As would be expected, follow-up of positive individuals was very difficult due to the transitory nature of this population. In the future, staff may need to increase the intensity of follow-up efforts for individuals who fail to receive further evaluation at the Fourth Street Clinic.

The possibility of doing preventive therapy and/or extending the project to include additional services (i.e. Sexually Transmitted Disease’s) has been discussed and will be further evaluated.

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Current Issues in Refugee Health

The newspaper headline read, "Kosovar refugees arrive in Salt Lake City". Radio announcers and television personalities spoke passionately to the citizens of Utah to assist these displaced individuals in beginning a new life in the USA. However, Utah has had an active refugee resettlement program since the first wave of Vietnamese and Cambodians arrived in the 1970's. For the past two years, over 2400 refugees have resettled in Utah, building on the rich ethnic diversity and cultures in the state. The Utah Department of Health Refugee Health Program, assures that all newly arriving refugees receive a health screening assessment to identify communicable diseases and health issues that could impair the efforts of a refugee to become self-sufficient. Currently, a network of six different clinics in Salt Lake County conduct this health screening assessment within 30 days of a refugee’s arrival to Utah.

Through the amazing efforts of Catholic Community Services, the International Rescue Committee, Jewish Family Services and other interested community groups and individuals, a total of 1161 refugees arrived in Utah from January through December 1998. These refugees were from the countries of Bosnia (67%), Egypt/Iraq/Iran (10%), Kenya (10%), Vietnam/Thailand (10%), Yugoslavia (5%) and Cuba (>1%). It is anticipated that over 1200 individuals will be resettled in Utah during 1999 from Bosnia and surrounding countries, the African continent, as well as new areas of civil strife and war.

"A total of 1161 refugees arrived in Utah from January through December 1998."

The Refugee Health Program maintains an aggregate data base of the results of each health screening. From January to December 1998, approximately 985 refugees received a health screening. Of this number, the program has received 548 (56%) health forms. Refugees are most frequently referred for immunization schedule completion (38%), continuing evaluation of tuberculosis (30%) an abnormal chest x-ray (4%), dental care (22%), ongoing medical care for hypertension, diabetes, enteric conditions or other issues (17%) and vision care (8%).

It is important to note that no refugee is allowed into the U.S. with active tuberculosis disease that is not under medical treatment. Long standing health regulations, supported through the efforts of the Centers for Disease Control and Prevention (CDC), have been quite successful at limiting the admission of individuals with an active, communicable disease. However, many refugees are from nations where tuberculosis is endemic in the population. The World Health Organization estimates that 33% of the world population is infected with the air-borne bacteria that causes tuberculosis. Therefore, it is not surprising that 30% of newly arriving refugees test positive for latent tuberculosis infection or healed disease (4%) during the health screening process. However, no case of active tuberculosis disease has been diagnosed in a newly arriving refugee since 1990.

"...it is not surprising that 30% of newly arriving refugees test positive for
latent tuberculosis infection or healed disease (4%) during the health screening process."

Healthcare providers and others who work with refugee populations have an important public health role with the knowledge that 30% of refugees have latent tuberculosis infection. Preventive therapy is a relatively simple, yet clinically effective, treatment option that should be encouraged and promoted where clinically indicated. With a growing number of active cases found in foreign-born populations, the active use of preventive therapy is an investment in the future health of Utah.

For more information, please contact Teresa Garrett, RN MS, Program Manager TB Control/Refugee Health, Utah Department of Health at (801) 538-6246 or email tgarrett@doh.state.ut.us.

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Infant Botulism

With 70 to 100 cases reported annually, infant botulism is the most common form of botulism in the United States. In Utah an average of two cases per year are reported. As of May this year, two cases have been reported to the Bureau of Epidemiology.

Infant botulism is a rare paralytic disease caused by the microorganism Clostridium botulinum. It occurs when an infant swallows C. botulinum spores which colonize in the large intestine, multiply, and produce toxin. The toxin is absorbed into the body and carried to the nerve endings, which results in muscular impairment. Infant botulism differs from foodborne botulism in which the toxin is pre-formed in food and absorbed in the small intestine.

The majority (94%) of hospitalized infant botulism cases are 6 months of age or younger at onset. Symptoms include poor feeding, constipation, lethargy, diminished gag reflexes, subtle ocular palsies, generalized weakness, and hypotonia ("floppiness"). The clinical spectrum of the disease ranges from mild illness with gradual onset to sudden infant death. The case fatality rate of hospitalized cases in the United States is less than 1%, however, without access to hospitals with pediatric intensive care units, the rate would be much higher. Treatment consists of intense supportive care. Botulinum antitoxin and antibiotics do not improve the course of the disease and may actually worsen it.

Suspect cases can be laboratory confirmed by demonstration of botulinum toxin or by culture of C.botulinum from the infant’s stool. The Utah Public Health Laboratory is equipped to perform these tests.

Person-to-person transmission of infant botulism has not been documented. Botulinum spores are naturally present in dust and dirt, and most infants, children, and adults will come into contact with the spores sometime. Children and adults with normally functioning digestive systems are not susceptible to this form of botulism. It is not known how many spores are needed to cause infant botulism or why only some infants become ill. Epidemiological studies following the discovery of infant botulism identified honey as a risk factor for the disease and determined that honey can contain spores that cause botulism. This finding led to the recommendation by the Centers for Disease Control and Prevention and the American Academy of Pediatrics that honey should not be fed to infants under one year of age.

For more information on infant botulism, contact your local health department or the Bureau of Epidemiology (801)538-6191.

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 Utah Department of Health, Bureau of Epidemiology
Monthly Morbidity Summary - June 1999 - Provisional Data

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The Epidemiology Newsletter is published monthly by the Utah Department of Health, Division of Epidemiology and Laboratory Services, Bureau of Epidemiology, to disseminate epidemiologic information to the health care professional and the general public.

Send comments to:  The Bureau of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104, or call (801) 538-6191
Approval 8000008:  Appropriation 3705

Rod Betit, Executive Director, Utah Department of Health
Charles Brokopp, Dr.P.H.. Division of Epidemiology and Laboratory Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director Bureau of Epidemiology
Cristie Chesler, BA, Managing Editor

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