PolicyLab

INTRODUCTION: Consider a hypothetical scenario: Rosa, a 35-year-old healthy woman, visits a primary care physician at a community clinic for a routine checkup. She immigrated to the United States one year ago from Mexico, a country with a higher prevalence of tuberculosis (27 cases per 100,000 people) [1] than the US [2]. The primary care physician recommends screening for latent tuberculosis infection (LTBI) based on established guidelines. Rosa’s purified protein derivative (PPD) skin test is positive, and she is started on isoniazid (isonicotinylhydrazide or INH). While taking it, she develops jaundice and lower extremity edema and is admitted to the hospital. She becomes critically ill and is found to have fulminant hepatic failure—acute liver failure—an iatrogenic consequence of INH treatment. A liver transplant would save her life, but Rosa is deemed not to be a good candidate for transplant because she is poor, uninsured, and undocumented. She dies of liver failure and sepsis. Here we consider the unique risks that undocumented immigrants incur when accepting LTBI therapy and the physician’s duty to disclose these risks, and we present policy and clinical solutions that would protect public health without placing undue burden on undocumented immigrants.