Summary
Individuals born in Ethiopia constitute 4.5% of Seattle immigrants and refugees and 7% of tuberculosis (TB) cases in King County, WA as of 2024. Ethiopia has one of the highest HIV/TB burdens in the world. Given this, knowledge of TB disease is common among the Ethiopian community, although knowledge of latent TB is less familiar. TB care for this community must acknowledge values of collectivism, religion, and doctor-patient rapport to build trust.
Recommendations
- For all individuals from Ethiopia, screen for latent TB using blood tests (e.g., QuantiFERON) and maintain a high index of suspicion for active TB with a matching clinical picture given high endemicity of TB in this community
- Given unfamiliarity with preventative screening, establishing patient rapport may be required prior to counseling on latent TB diagnosis and treatment
- Normalize LTBI as being common, not contagious, and not requiring isolation to reduce stigma
- Social networks and churches are an important source of health care advocacy and resources, which the provider might leverage to optimize TB care
Methods
The following sections are based on interviews with Amharic-speaking Ethiopian community members in King County, Washington and supplemented by data from a literature review. The interviews were conducted by EthnoMed staff in 2025 with English translation as needed. Most respondents spoke fluent English with occasional interpretation in Amharic. One respondent had previously received treatment for active TB disease, one respondent was a physician who had worked at an MDR-TB center in Ethiopia, and the other two had recently attended an EthnoMed educational TB seminar.
Burden of TB Disease in Ethiopia
2024 TB Statistics in Ethiopia (1)
– Total TB incidence: 186,000
– Total TB incidence (rate per 100,000 per year): 141
– Total TB deaths: 21,800
HIV and TB:
– HIV-positive TB incidence (number): 12,000
– HIV-positive TB incidence (rate per 100,000): 9.3
– Total Population: 132 million
2024 TB Statistics in the USA
Proportion of TB cases in King County, WA among individuals born in Ethiopia: 7%
Language for TB in Ethiopia
Ethiopia is home to over 80 diverse languages. Amharic is the government’s official language, but Oromo, Tigrinya, and Somali are also widely spoken (2). Respondents used a few Amharic phrases when referring to TB. The most common phrase employed by both health providers and community members was Samba nekersa (Samba nəqərsa); Samba which translates to lung and nekersa which translates to cancer. The Americanized acronym of TB itself was commented to be frequently used in medical practice. In the community, the terms Ye-sal beshita (Ye-sal bǝššita) and Ye-bərd beshita (Ye-bərd bǝššita) are also used. Ye-sal translates to “cough”, Ye-bard to “chronic cold”, and beshita to “disease”. The four terms were noted to be used interchangeably. One respondent who worked as a physician pointed out the phrase Ye-bərd beshita can be misleading in terms of transmission for the community however.
“…you know, this name, Ye-bərd beshit, okay, associating it with some kind of cold draft air is also a big barrier for the transmission because people, they don’t want to leave their windows and doors open for ventilation. Usually they think it is associated with some cold draft coming through the window or something that is making them sick. So they tend to stay in a poorly ventilated condition…which is very favorable for transmission of TB or any other, you know, aerosol.”
English is the most common foreign language spoken in Ethiopia and many immigrants arrive with a basic command of British English (3). However, one individual still noted that language barriers can create gaps in health care, which has been corroborated by the literature (4).
Knowledge of TB Pathophysiology and Diagnosis
TB disease was recognized among all respondents and commonly described as a chronic cough, more severe than a common cold. Additional symptoms mentioned included coughing blood, weight loss, weakness, fever, night sweats, loss of appetite, and scrofula. Fewer respondents were aware of extrapulmonary TB, but mentioned TB in the bones or Pott’s disease, abdomen, or liver. There was some association between TB and smoking, but otherwise felt to be indiscriminate. Respondents noted that Ethiopians generally know about TB due to its high prevalence, dedicated TB centers locally, mandatory teaching for HCW, inclusion in school curricula, and increasing presence in the media.
Knowledge of latent TB infection (LTBI) was limited. All respondents did not learn about LTBI until immigrating to the USA and undergoing screening. Upon arrival, it was felt that many Ethiopians are surprised to learn they are positive for TB because they don’t understand the difference between the active and latent forms. It was also not fully understood that LTBI is not contagious, that blood tests do not distinguish between latent or active TB, or that LTBI required treatment to prevent active disease.
Understanding the transmission of TB was more nuanced. While some respondents correctly identified TB spreads via aerosol transmission, one felt that TB is present from childhood and that his intentional weight loss for a surgical procedure is what led to his own TB becoming active. Some correctly identified that the bacteria is asleep and later activated by aging, other diseases, or low immunity. Another mentioned:
“In the villages, there is a belief that you get TB not from other people, but from certain spiritual thing in the sky, some star. In local areas. Particularly the older generations who lack education. Now, it is far better, people are more aware of transmission – mobile everywhere, radio communication, technology everywhere. But still [there is a] wealth problem, some people are poor.”
In terms of diagnosis, most remembered getting a blood test or skin test, though it was not clear if individuals recognized these tests represented latent vs active TB, or how the test worked. Indeed, two respondents were confused why the blood test would still be positive after treatment for LTBI. One respondent noted that chest x-ray and sputum testing were well-recognized to rule out active TB.
Testing and treatment of TB in Ethiopia
Screening and treatment of LTBI in Ethiopia is limited. The physician noted that the burden of TB is so high in Ethiopia that from a public health standpoint, only select individuals like those with HIV undergo screening and treatment for LTBI as described below. Indeed, according to the most recent National Guidelines in 2021, Ethiopia only screens and treats LTBI among TB household contacts ≤15 years old, or patients who: require anti-TNF therapy, dialysis dependent, pre-transplant, living with HIV, living with silicosis. In this case, screening is symptom based, or the use of adjunctive chest x-ray is recommended if available. Standard TB preventative therapy (TPT) in Ethiopia used to be six months of isoniazid, but more recently has changed to 3HP or three months of weekly rifapentine and isoniazid (5).
For active TB, individuals generally are familiar with the process of receiving a chest x-ray and sputum testing. Per the 2021 national guidelines, molecular based testing with PCR (Xpert MTB/RIF) is now also approved for rapid diagnostic confirmation and rifampin resistance testing (5). Respondents commented that people being treated for active TB would go to a hospital and two noted there is a dedicated TB hospital near Addis Ababa (the capital city). The national guidelines for treatment of drug-sensitive TB are to use the global standard of HRZE (rifampin, pyrazinamide, isoniazid, ethambutol) for an intensive, two-month phase followed by four months of HR (rifampin, isoniazid) alone. Of note, BPALM (bedaquiline, pretomanid, linezolid, moxifloxacin) is now also used in Ethiopia for treatment of MDR-TB. One respondent noted there are some local, homeopathic methods of TB treatment among rural communities such as consuming continuous raw eggs or eucalyptus tree ointment.
BCG Vaccination
Ethiopia initiated its National Immunization Program (NIP) for routine childhood immunizations in 1980 which included the Bacillus-Calmette-Guerin (BCG) at birth (6). Despite this, the overall national coverage of BCG between 2000-2019 was only 65.5% (7). As of 2024, 84% of live births in Ethiopia were vaccinated with one dose of BCG (8). The inadequate rates of vaccination have been sourced to issues with health care accessibility in rural or impoverished regions (7).
All respondents were familiar with BCG as a routine childhood vaccination, however, understanding of how the BCG worked was mixed. None of the respondents questioned how people acquire TB despite being vaccinated, and another commented BCG minimized risk of having TB again. One physician commented that in his experience there was also not much detailed awareness that the BCG caused a false positive tuberculin skin test (TST).
HIV/TB
Ethiopia has one of the highest TB and HIV coinfection rates globally (9). In fact, one respondent called HIV and TB coinfection, the “new TB.” The current national guidelines in Ethiopia recommend LTBI screening and TB preventative treatment (TPT) only among select, priority populations which includes people living with HIV (PWH) (5). Because TB is so endemic, additional lab or chest x-ray screens are not felt to add value in low-resource settings, so TB is screened by symptoms alone; if asymptomatic, PWH are treated for LTBI and if symptomatic, treated for active TB. In 2024, the CDC reported over 5,606 PWH were diagnosed and treated with TB, and 31,216 PWH received TPT, achieving an 86% completion rate (10).
However, one of the Ethiopian physicians interviewed noted the clinical symptom-based TB screening of PWH has mixed reception by Ethiopian providers. Some providers hesitate to screen based off clinical symptoms alone because TB symptoms may be less overt in PWH due to their impaired immune systems. This can result in delayed treatment and development of antimicrobial resistance:
“Physicians think that we don’t have enough diagnostics to rule out the presence of active TB. Because most HIV patients may not have overt symptoms, there were some circumstances that after isoniazid prophylactic therapy was started, patients developed symptoms and came with what looks like there was [active] TB which was not diagnosed and then was reactivated after [LTBI treatment] just started. So that created more fear like, oh, we don’t have adequate tools to really rule out active TB….”
Social factors and care delivery in Ethiopia
Stigma
Generally, stigma still surrounds TB to a significant extent, particularly in Ethiopia more than the U.S. While two respondents felt there was no shame or discrimination to having TB, other respondents felt it was stigmatized because it causes serious disease, which is consistent with the literature. One respondent who had TB disease previously noted that coughing too much in public places may cause discomfort and staring. Another noted people avoid being seen when retrieving TB medicines, or deny knowing anyone with TB. In a recent study of 3463 individuals living in Addis Ababa, one-third of participants reported stigma toward TB, with 20.5% stating TB patients are rejected by the community.
“If some people know that you have TB or tuberculosis, people scared to come to you and to talk with you and to eat with you, they’re scared. So that’s why [affected individuals] feel shame.”
This shame may translate into the initial shock of Ethiopian immigrants who receive a LTBI diagnosis. Providers may combat this stigma by counseling on the non-infectious nature of LTBI and normalizing the commonality of TB diagnosis worldwide.
Health Insurance and TB coverage in Ethiopia
Despite the high burden of TB in Ethiopia, the TB program only received 2.1% of total health expenditures in 2016/2017. The government only funds 11.7% of TB program funding, while the rest derives from external donor funding or out of pocket patient costs. A lack of a centralized, cohesive financial management system also challenges tracking expenditures to support greater budget advocacy (11).
On the individual level, the cost of TB care represented a catastrophic 21% of a person’s annual household incomes (11). While TB confirmatory lab tests and anti-TB drugs are free or exempt through public health facilities, any other lab tests, hospitalizations, nutrition, and medications for comorbidities are not and must be paid out-of-pocket by the patient. In 2011, Ethiopia introduced a community-based health insurance (CHBI) plan to expand health care coverage to communities in rural settings. This would likewise help cover the costs of non-TB services. However, as of 2019, only 28% of the population reported enrollment in CHBI for reasons which are multifactorial and outside the scope of this document (12). Most importantly, 54% of TB costs are indirect, such as missing work and difficulties in finding transportation, which cause significant disparities for vulnerable, low-income individuals (11).
To improve TB funding, six strategic initiatives were outlined by the Ethiopian government in 2022 including increasing the domestic allocation of government funds to TB programs, coverage of non-medical costs like nutritional supplements, and integration of TB services into CHBI packages.
Experience with TB and barriers to care in the U.S.
Some respondents felt their experience with American doctors was overall positive. They left positive feedback toward the TB informational sessions left by EthnoMed teachers on TB. Some themes did emerge as barriers to care in the U.S. however.
One common theme seen in the literature (4) and our interviews was how the U.S. health care system emphasizes screening for preventable or chronic diseases which is unfamiliar to Ethiopians who are accustomed to seeking out medical care only when sick. Specific to TB, respondents did not undergo screening for LTBI until immigrating to the USA. At this juncture, it was felt that many Ethiopians experience surprise and distress from testing positive when they do not understand the difference between latent and active TB. Consequently, one physician highlighted that when first meeting a patient from Ethiopia, building trust may be more important than diagnosing or treating LTBI or other health screenings to improve care retention:
“I think that was one of the tricky things that was happening that public health noticed, was some people’s first interaction with healthcare is after they get a diagnosis for latent TB in other communities, and they don’t have an existing relationship with that provider, and then it’s kind of a traumatizing event. So, then it’s much more difficult, I think, for the provider in that situation to be able to have their recommendations accepted. Yeah, yeah. I think if something goes wrong at some point, then the tendency to label that doctor or that clinic as not good and ruin their reputation is very high. They can label the doctor or the clinic as not doing a good job.”
Furthermore, respondents agreed that while members of the Ethiopian community may be open to LTBI screening, they may be more resistant to LTBI treatment. One community member explained that this is because the TB treatment is not 100% guaranteed by physicians to prevent active TB, so they felt the side effects of preventative treatment were not worth it. This sentiment was further fueled by the inability of the Quantiferon to distinguish treated vs untreated LTBI. Another noted that lack of symptoms is a barrier to receiving LTBI treatment resulting in patients being lost to follow-up or not swallowing the pills.
“We asked the doctor there, are you sure that we can be treated 100%. They said, no, we cannot assure you. Then if you are not assuring me that 100%, then I will come when it will wake up. If it is sleeping, let it sleep! (laughs)”
Culturally, it was explained that physicians in Ethiopia can be more authoritative, sometimes referred to as “next to God”, so individuals may place less value or trust in the less directive and more consultative recommendations of an American physician.
One respondent also expressed concern over the high health care costs in the U.S. despite having insurance, particularly for medication and surgery. Exact health care coverage data for Ethiopian-born U.S. citizens is unavailable, but it is estimated that in Seattle roughly 5.0% of uninsured, non-U.S. citizens are Ethiopian/Amharic speaking compared to 0.3% nationwide (13). Fortunately, within Washington state, health insurance is available for purchase on the marketplace regardless of documentation or immigration status as of January 2024 (13). Regardless, obtaining insurance is confusing and challenging among Ethiopian immigrants unfamiliar with the new healthcare system (4). Connecting patients with a social worker or community navigator may help navigate this gap.
Other relevant cultural or historical factors to TB care
Diasporas
As of 2022, 356,000 individuals in the U.S. are either born in Ethiopia or of Ethiopian heritage. Most have settled in Washington D.C., but other states including California, New York, Minnesota, Texas, and Washington as well.
The first diaspora occurred after the 1974 Ethiopian Revolution when people were fleeing political repression and violence under the authoritarian, Derg regime (14). This period of the Red Terror saw the execution or imprisonment of thousands of political opponents. The second wave of immigration occurred in the 1990s when people fled famine and economic hardship during the transitional period after Derg fell. A more recent diaspora occurred in 2022 when a civil war broke out resulting in the U.S. Department of Homeland Security announcing eligibility to apply for temporary asylum (3).
Cultural Pearls
In a qualitative analysis of Ethiopian immigrants, cultural beliefs important to maintaining health included preserving one’s cultural heritage, family and friend social support, religion, freedom, and respectful health care interactions (15). Many Ethiopians have religious roots in Christianity or Islam and view the church as an important community space for exchanging information (3,4). Some might view illness as punishment from God (15). As a collectivist society, individuals might live in large family groups and make joint health decisions with a spouse or other family member. Translated to TB care, providers might inquire if the patient would like the provider to discuss the diagnosis and treatment with any other family members. Clinics might partner with community navigators like religious leaders to deliver health lectures.
See Ethiopian Cultural Profile for more details.
Additional health concerns in the community
Obesity and diabetes were identified among the respondents and literature as major comorbidities in the Ethiopian community since living in the U.S. This was attributed to American foods containing more sugar and chemicals, insufficient sleep, and long work hours in sedentary jobs (4). Other respondents were concerned about comorbidities like hypertension, back pain, or vision problems. In contrast, back home, respondents mentioned the main health concerns were poverty and malaria. Within the literature, other comorbidities to consider are mental health concerns or substance use which may not be spoken about openly (4). This has been sourced to the stress of immigration, social isolation, financial stressors, and assimilating to a new culture with unfamiliar customs (4).
References
1. World Health Organization. Tuberculosis profile: Ethiopia [Internet]. 2026 [cited 2026 Mar 6]. Available from: https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&tab=%22tables%22&lan=%22EN%22&iso3=%22ETH%22&entity_type=%22country%22
2. Language data for Ethiopia. CLEAR Global [Internet]. [cited 2026 Mar 6]. Available from: https://clearglobal.org/language-data-for-ethiopia/
3. EBSCO [Internet]. [cited 2026 Mar 13]. Ethiopian immigrants | Social Sciences and Humanities | Research Starters | EBSCO Research. Available from: https://www.ebsco.com
4. Kassa MH, Vaughn LM, Amsalu B, Schnadower Z, Jorga I, Habte A, et al. Community Health Needs Assessment of Ethiopian American Immigrants in Two Nontraditional Migration Cities. J Health Care Poor Underserved. 2025 Aug;36(3):830–54. doi:10.1353/hpu.2025.a967335
5. Ministry of Health – Ethiopia. Guidelines for Clinical and Programmatic Management of TB, TB/HIV, DR-TB and Leprosy in Ethiopia – 7th edition. Addis Ababa, Ethiopia; 2021.
6. Federal Ministry of Health, Addis Ababa, April 2015. ETHIOPIA NATIONAL EXPANDED PROGRAMME ON IMMUNIZATION.
7. Atalell KA, Alemayehu MA, Teshager NW, Belay GM, Alemu TG, Anlay DZ, et al. Mapping BCG vaccination coverage in Ethiopia between 2000 and 2019. BMC Infect Dis. 2022 Jun 23;22:569. doi:10.1186/s12879-022-07547-4 PubMed PMID: 35739462; PubMed Central PMCID: PMC9219134.
8. Immunization Data [Internet]. [cited 2026 Mar 12]. WHO Immunization Data portal – Detail Page. Available from: https://immunizationdata.who.int/global/wiise-detail-page
9. World Health Organization. Global Tuberculosis Report 2025 [Licence: CC BY-NC-SA 3.0 IGO] [Internet]. Geneva; 2025 [cited 2025 Dec 16]. Report No. Available from: https://iris.who.int/server/api/core/bitstreams/e97dd6f4-b567-4396-8680-717bac6869a9/content
10. CDC. Global HIV and TB [Internet]. 2025 [cited 2026 Mar 12]. HIV and TB Overview: Ethiopia. Available from: https://www.cdc.gov/global-hiv-tb/php/where-we-work/ethiopia.html
11. Lang E. Tuberculosis Domestic Resource Mobilization and Sustainability Roadmap for Ethiopia.
12. Ethiopian Public Health Institute, The DHS Program ICF Rockville, Maryland, USA. Ethiopia Mini Demographic and Health Survey 2019: Final Report. 2021.
13. Buettgens M, Ramchandani U. The Health Coverage of Noncitizens in the United States, 2024.
14. EBSCO [Internet]. [cited 2026 Mar 13]. Red Terror in Ethiopia | History | Research Starters | EBSCO Research. Available from: https://www.ebsco.com
15. Chiatti BD. Culture Care Beliefs and Practices of Ethiopian Immigrants. J Transcult Nurs. 2019 Jul 1;30(4):340–9. doi:10.1177/1043659618817589