LTBI and TB: Screening and Testing Barriers
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.
There are an estimated 13 million individuals living with LTBI within the United States. Unlike TB, LTBI is not a nationally notifiable condition (although it is in some states), meaning, the CDC relies on national estimates and local organizations and health departments to develop estimates. Taking into account that 80% of TB cases in the U.S. are the result of reactivated LTBI, TB elimination is contingent on early detection and treatment in order to prevent future TB cases and transmission. To implement proactive screening and testing procedures, community health centers, serving as vital community partners in LTBI/TB intervention for at-risk communities, must have the necessary support to engage and identify those at-risk for LTBI/TB. Therefore, to support CHC efforts within their communities, we must identify CHC’s areas of LTBI/TB need. To provide this context, this post will discuss common barriers to both patients and community health centers for LTBI/TB screening and testing.
In-House Program Structure and Guidelines
At health center sites with no standardized TB protocol, screening decisions are ultimately left to the individual provider, leading to a lack of consistency in patient screening and testing among providers. To support screening consistency and information accessibility for providers, many electronic health record (EHR) systems incorporate LTBI/TB screening questions. However, many health centers face continual challenges in implementing LTBI/TB guidelines into their EHR systems. Therefore, for health centers with immense gaps in their EHR capacities and/or no established-EHR system, their providers face limited/no access to these recommendations.
Even if a health center site understands who is recommended to be screened and tested, they face additional challenges in implementing screening and testing. Commonly cited barriers in implementing health center screening and testing protocols involved funding and staff limitations, gaps in LTBI/TB knowledge, and competing health priorities (e.g., COVID-19). For example, health center sites serving multiple at-risk communities with limited access to funding, find themselves prioritizing which communities to screen and treat first as noted by our needs assessment. With limited funding and staff, health centers often lack the capacity to meticulously identify which patients are at-risk for LTBI/TB, and perform the necessary outreach efforts to screen and test all at-risk patients. Outreach also poses a unique barrier and may demand the use of in-language and culturally-reflective outreach, many of which not all health centers have access to.
As mentioned, limited dedicated funding to in-house LTBI/TB programs and protocols impedes proactive screening and testing within health center sites. However, the general cost of testing poses an additional barrier to both patients and community health centers alike. The most common LTBI testing methods include the Mantoux Tuberculin skin test (TST) and the Interferon-Gamma Release Assays (IGRAs) blood test. Both indicate the presence of mycobacterium tuberculosis if positive. For underinsured/uninsured individuals, the cost* to obtain a TST or IGRA may deter and prevent an individual from being tested. For example, at CVS pharmacies, a standard TST will cost $35 for the initial visit and an additional $39 for the follow-up reading if negative. However, a positive follow up reading will cost $99–139. Furthermore, to conduct a TB risk assessment, it will cost patients an additional $59. In comparison, the IGRA test is typically more costly than a TST. According to 2020 UDS data, of the total patients served by community health centers, 21.82% (6,239,691) were uninsured.
Furthermore, among A/AA and NH/PI communities, non-U.S. born individuals in areas with high TB prevalence typically receive the bacille Calmette-Guerin (BCG) vaccine (an antibacterial vaccine). Individuals who are BCG vaccinated may receive a false positive induration (a deep thickening of the skin that can result from edema, inflammation, or infiltration) for a TST skin test. As a result, community health centers serving largely non–U.S.-born individuals must opt for the more costly IGRA blood test which is unaffected by the BCG vaccine. Serving largely at-risk communities, TB testing is financially demanding to both health centers and patients. Furthermore, the TST is a two-step process requiring individuals to return for their reading within 48–72 hours following the initial test. As a result, individuals with limited transportation may be unable to return for their reading. In turn, transportation along with other sociocultural barriers poses a challenge to LTBI and TB testing. Therefore, the cost to test poses a significant financial burden to both patients and health centers.
*Cost varies from health site to health site
Educational barriers from both the provider and patient stance was a commonly cited challenge among our 2022 needs assessment respondents. For example, among A/AA and NH/PI communities, there is a common patient educational barrier surrounding the efficacy of the BCG vaccine, where patients often see no need to be tested if they’ve received the BCG vaccine in the past. The BCG vaccine, although typically given in areas with high TB incidence, will often provide protection for young children. However, the BCG vaccine does not protect older individuals from contracting TB.
Providers and community health center staff face shared educational barriers. Notably, there is the common misconception that LTBI and TB can be used interchangeably. Distinguishing the two is essential. For example, individuals with LTBI do not present symptoms whereas individuals with TB do. Therefore, in screening for active TB disease, a provider will look for the presentation of symptoms, but using the terms LTBI and TB synonymously then promotes misinformation on TB presentation, thus miscommunicating this to their patients. As noted by one needs assessment respondent, staff’s lack of LTBI/TB knowledge can be detrimental to patients. For example, this respondent explained that CHC staff may struggle to explain that individuals with the BCG vaccine may exhibit a false positive response, and that a positive induration does not always indicate the presence of mycobacterium tuberculosis. Unless this is explained to the patient, this can cause immense stress and fear. Therefore, gaps in LTBI/TB knowledge among CHC staff and patients must be addressed to prevent a continuous cycle of misunderstanding that limits LTBI/TB screening and testing.
Besides TSTs and IGRAs, additional diagnostic testing can be used to rule out active TB disease including chest x-rays, sputum and smears if the chest x-ray is abnormal, rapid PCR assays, physical examinations, and medical history charting. Although all federally-qualified health centers (FQHCs) are mandated to use sliding-scale coverage, the extent to coverage varies from site to site. Therefore, if a site is unable to provide coverage for on-site testing or does not offer additional testing, and will have to refer patients out, this poses additional barriers to financial coverage and physical accessibility. For patients with limited access to transportation, often relying on family members for transportation to medical appointments or shared cars, additional testing and furthermore, treatment becomes inaccessible. On-site limitations also limit CHCs’ capacities to accommodate patients’ diverse social needs. For example, chest x-rays are an additional TB diagnostic method; however, for health center sites lacking an on-site radiologist or radiology services, they will often have to refer patients off-site. With patients’ limited transportation, this may prevent a patient from obtaining their final results. Additionally, within health centers and referral sites, not all sites offer in-language services. Therefore, as a result of sociocultural barriers, A/AA and NH/PI patients face an additional educational barrier in accessing culturally and linguistically-conscious LTBI/TB education that can reaffirm patients’ understanding of the need for LTBI and TB screening, testing, and treatment.
Contextualizing this conversation within the vibrancy, fortitude, and challenges of A/AA and NH/PI communities, it is necessary to understand the unique barriers and risk factors patients face in accessing culturally and socially-conscious LTBI/TB screening, testing, and treatment. However, this post also examines the multiple structural, financial, and educational barriers community health centers face in serving their patients’ diverse needs. In conclusion, these challenges and barriers are deeply interconnected, and yet multi-faceted.
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 firstname.lastname@example.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 email@example.com today!