LTBI and TB: Risk Factors and At-Risk Communities

By Tiffany Hirokawa

For Asian, Asian Americans (A/AAs), Native Hawaiians, and Pacific Islanders (NH/PIs), tuberculosis (TB) and latent TB infection (LTBI) disproportionately impacts these communities. A/AAs accounted for nearly 36% and NH/PIs accounted for nearly 2% of all U.S. TB cases in 2021. To address the disproportionate impact of LTBI/TB, community health centers (CHCs) play a pivotal role as essential safety net providers serving the frontlines of prevention and treatment for at-risk communities. However, CHCs face substantial barriers in implementing and conducting LTBI/TB screening, testing, and treatment for their patient populations often as a result of limited funding and staffing, unclear/non-applicable TB guidelines, provider and patient educational barriers, and sociocultural patient barriers.

The Tuberculosis Elimination Alliance’s limited blog series, “Addressing LTBI and TB at Community Health Centers Serving Asian, Asian Americans, Native Hawaiians, and Pacific Islanders,” aims to shed a light on the impact of LTBI and TB on A/AA and NH/PI communities and the community health center providers that serve them. Learn about TB/LTBI basics, the critical role CHCs play in community care, and the importance of providing resources and support to TB/LTBI providers.

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LTBI and TB, although treatable diseases, continue to impact communities across the United States and its territories. In particular, communities with limited access to affordable and comprehensive healthcare including immigrants, refugees, farmworkers, those living in correctional facilities, and those that are unhoused are disproportionately impacted by LTBI and TB. These often disregarded communities face additional barriers to identifying LTBI and TB and completing treatment, further perpetuating TB transmission and occurrence within these communities. Therefore, recognizing which communities are at increased risk for LTBI and TB is key in promoting preventative screening and early treatment interventions. At-risk communities, indicating groups of individuals with increased risk of contracting LTBI and/or TB and developing active TB disease, include individuals who are immunocompromised (e.g., diabetes mellitus, HIV, organ transplants, substance use, or autoimmune conditions), recent immigrants from areas with high TB incidences, those living in congregate settings (e.g., single room occupancy units, homeless shelters, assisted living facilities, or correctional facilities), healthcare workers, individuals with previous TB, individuals engaging in frequent travel, and relatives of those with increased exposure to TB. For additional information regarding LTBI and TB risk factors and screening recommendations, please refer to the CDC’s latest 2020 guidelines featured in the Latent Tuberculosis Infection: A Guide for Primary Health Care Providers and the Who Should be Tested recommendations featured on the CDC’s TB page.

How do these risk factors play into the lives and experiences of A/AA and NH/PI communities? Consider the role of housing in terms of LTBI and TB contraction and transmission. For example, individuals who live and/or work in congregate settings, including but not limited to multi-generational housing, healthcare sites, assisted living facilities, correctional facilities, and homeless shelters, face increased risk for TB transmission given their congregate living situation. Multigenerational housing, as defined by 3 or more generations of family living in one residence, is common among A/AA and NH/PI communities as defined through cultural ties and financial limitations. According to a study by Pew Research in 2021, 24% of Asian Americans lived in a home with two or more adult generations or grandparents and grandkids under 25. For Native Hawaiian and Other Pacific Islander communities, 25.3% of children lived in a multigenerational household in 2018. With multiple generations living under one roof, including older individuals and young children, and considering the course of TB transmission as an airborne disease, congregate living situations increase the risk for TB transmission. As exemplified through the COVID-19 pandemic, living in a multi-generational household impedes social distancing while increasing exposure to all members living in one residence.

Furthermore, frequent travel to areas of high TB incidence and frequent return visits increase the risk for TB contraction and transmission. Transnationalism or transnational migration, which defines the process of migration in which individuals continue to maintain and build connections to their country of origin while settling in a new country (Fouron & Glick-Schiller, 2001), is common among A/AA communities. In maintaining cultural ties, individuals often engage in frequent travel to their country of origin. With minimal testing requirements for frequent flyers re-entering the U.S. from areas of high TB incidence, this poses unique risk factors to A/AA travelers and their families. Additionally, in areas with high TB incidence, recent immigrants are at increased risk for LTBI and TB, and without treatment interventions may reflect future TB cases unless identified and treated. In 2020, the most common countries of birth for non-U.S.-born Asian individuals with reported TB disease included the Philippines (12.5%), India (10.4%), Vietnam (8.2%), China (5.1%), and Myanmar (1.6%). To encourage early identification and treatment of individuals at risk for LTBI and TB, the CDC proposes targeted testing as a major TB control strategy. Targeted testing efforts further mitigate the spread of TB among communities by identifying LTBI cases early and preventing the development of active TB. In reality, the majority (80%) of the U.S. TB cases arise from longstanding, untreated latent TB infection.

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Given this background on TB disease and LTBI, this poses the question: what are the associated barriers for LTBI and TB eradication? Furthermore, how does the general public’s lack of TB awareness and widespread common TB misconceptions worsen these barriers? In future posts, we will discuss some of the associated patient, provider, and community health center barriers to LTBI/TB screening, testing, and treatment. To learn more about the associated LTBI and TB patient and health center barriers, mark your calendars for our upcoming needs assessment report releasing this late July 2022. In identifying TB risk factors and individuals at risk for LTBI and TB, this calls for increased culturally and linguistically conscious LTBI/TB awareness building, patient and provider education, and on-the-ground outreach efforts to promote early screening and intervention. TEA recognizes community health centers and local community partners as key players in TB intervention, and in aiding these efforts, encourage health centers to visit the CDC’s TB page for the most updated TB guidelines, the TB Centers of Excellences, and TEA’s webinars and training events and resource page.

For additional LTBI and TB resources, please visit TEA’s updated resource page today! If you have any questions about the content above, please contact tea@aapcho.org or visit the tbeliminationalliance.org for more information.

Want to get involved? Become a local TEA partner today! We invite state and local TB control programs, community-based organizations, and community health centers to consider becoming a TEA partner today.

We also encourage you to apply to our upcoming mini-grant cycle. For the 2022–2023 TEA Mini-Grant Program, TEA will be offering up to fifteen (15) Mini-Grants to organizations serving A/AA- and NH/PI-communities to enhance LTBI/TB community engagement and education, provider education, and quality improvement. Deadline to apply is Friday, August 5 by 5:00pm local time. Learn more from the RFP: https://bit.ly/TEA22RFP

For more information, please visit www.tbeliminationalliance.org and contact tea@aapcho.org today!

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AAPCHO

AAPCHO

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The Association of Asian Pacific Community Health Organizations — dedicated to promoting advocacy, collaboration and leadership to improve AA and NHPI health.