Epidemiology
From the Seattle-King County Annual Tuberculosis Report 2004:
“The number of foreign-born TB cases increased to 97 in 2004. The highest case numbers came from Vietnam, Ethiopia, the Philippines, Somalia and Sudan. The increase in numbers among East African countries can largely be traced to a TB outbreak among mostly young males of East African origin. 12 cases were diagnosed with TB matching the outbreak strain. This group was generally involved in drug selling and use, and had a history of incarceration and hospitalizations due to gun or knife injuries. Patients were mostly male, East African immigrants in their 20s, of Amhara, Eritrean, Ethiopian, Oromo, Somali, or Tigrinyan ancestry. Most had a combination of social risk factors such as drug use, incarceration history, and unemployment. All had pulmonary disease, and one was infected with HIV. Cases generally showed a very rapid progression to disease and overt TB symptoms, including cough and weight loss. All cases were either genotypically linked with a matching strain type, or had an epidemiologic link to a patient with an isolate matching the outbreak pattern.”
From Morbidity and Mortality Weekly, Thursday, October 3, 2002 (51(39); 882-883):
“The proportion of tuberculosis (TB) cases among foreign-born persons in the United States has increased steadily, accounting for half of reported cases in 2001 for which country-of-origin information was available. During 1998 — 2001, the annual number of TB cases among African immigrants and refugees in Seattle and all of King County increased approximately threefold to that during 1993 — 1997. Findings indicate that in Seattle-King County, persons at risk for TB who have arrived recently in the United States were primarily from the African-Horn countries of Eritrea, Ethiopia, and Somalia.During 1993 — 1997, fewer than 10 cases of TB in African immigrants were reported each year (5% — 10% of the annual total). The number of cases began increasing in 1998…In 2001, of 139 TB cases reported in Seattle-King County, 28 (20%) were among African immigrants. During 1998 — 2001, of Seattle-King County’s 486 TB cases, 79 (16%) were among African immigrants, 67 (85%) of whom were from Eritrea, Ethiopia, and Somalia.
“The World Health Organization estimates that the TB rate is 260 per 100,000 population for Ethiopia and 229 for all of Africa ( 3 ), rates almost identical to those observed in Seattle-King County. Increases in African immigration and TB are occurring elsewhere; in the United States, the number of refugees from Africa increased from 6,662 in 1998 to an estimated 18,979 in 2001.”
References
Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. Global burden of TB: estimated incidence, prevalence, and mortality by country. JAMA 1999;282:677 — 86.
Adair R, Nwaneri O. Communicable disease in African immigrants in Minneapolis. Arch Intern Med 1999;159:83 — 5.
U.S. Committee for Refugees. Regional refugee ceilings and admissions to the United States, FY 1989 — 2002. Refugee Reports 2002;12:9.
Methods
TB is one of the medical problems most commonly seen in newly arriving refugees from the African-Horn countries of Eritrea, Ethiopia and Somalia. Managing illness cross-culturally depends on communication, but communication depends on understanding the socially and culturally determined references and performances associated with a diagnosis and its treatment (Jackson C., 1996). To investigate Ethiopian community members’ knowledge and understanding of TB, two semi-structured focus group discussions were held at an Ethiopian mutual assistance association / community center. A staff person at the community center recruited 13 participants who had grown to adulthood in Ethiopia and who speak Amharic as their primary language. All participants reported that they speak Amharic at home; two people also speak Tigrinya; one person speaks Oromo as well. Four women and nine men participated, ages ranging from 30 to 79. Eleven participants grew up in rural environments, and two were raised in urban areas. Their arrivals in the US happened between 1982 and 2000.
The discussions were interpreted in Amharic and English by an interpreter/project coordinator recommended by the community organization. A research coordinator from Harborview facilitated the discussion using questions prepared by a public health TB nurse and reviewed by four Ethiopian interpreters, to guide/prompt the group conversation. A medical doctor from Harborview was present during the discussions, asking several questions of the group and answering participants’ health-related questions at the end of the meeting. The discussions were recorded, the English portions of the tapes were transcribed, and research coordinator, medical doctor, and interpreter/project coordinator analyzed the transcripts for themes, outlined below.
Characteristics of Good Health and Disease
People recognized good health as a condition characterized by absence of disease or illness, absence of complaints, and presence of good appetite, work, shelter, hygiene and sleep/rest. Mental, physical and spiritual stability, along with balanced nutrition, were emphasized as being important to having good health. Ethiopians’ diet was described as healthier than a typical American diet, because it includes less fat, butter and meat. People reported that the practice of fasting, common among Ethiopians, also contributes to having good health. People described a person’s inability to eat and get out of bed, the presence of pain, and the loss of senses as characteristics of disease. People understand the presence of no symptoms to mean there is no illness. Nutrition is emphasized in maintaining good health. Participants said, in general people wait until the last minute, until they are really sick, before they seek help. People try not to believe they are sick, believing instead that they will get better tomorrow. Knowledge of modern medicine, including health prevention, is low.
Translation or Language Equivalents
TB is a recognized disease in Ethiopia. The Amharic words for TB disease are samba necarsa. Samba means lung. Necarsa means a very chronic illness, or cancer. Cancer is called necarsa, or sometimes the English word cancer is used instead. Several participants said the word necarsa also has been used to describe TB of the neck when there is a visible growth.
Disease Recognition
People recognize TB by the symptoms of dry, chronic cough and weight loss. Fatigue, blood coming in the saliva, and feeling chilled are recognized as additional signs of TB. It can be hard to distinguish between the coughing symptom of a common cold, bronchitis and pneumonia, versus early coughing that is TB. Most people are not aware that TB can occur outside of the lungs. Very few people have knowledge of TB of the bone or kidney, and few people have knowledge of TB of the neck. Most people are not aware of latent TB infection neither do they clearly understand the meaning of a positive PPD test as it relates to TB. Confusion can occur when a person is told they have TB as determined by a PPD test, while the patient knows that an x-ray showed no signs of TB and he/she is in fact feeling fine. Reportedly, there is no concept for TB germ or bacteria, except perhaps among the educated. Participants reported that many Ethiopians – both in Ethiopia and in the United States – are not fully aware which illnesses are curable and which are not, including TB. Recovery from TB is recognized in someone’s weight and appetite gain.
Causes
People reported various causes of TB:
- God
- Draft
- Wind
- Clash of cold and hot air
- Strong Heat
- Sunlight
- Bad sanitation
- Progression from other illnesses, like pneumonia or a common cold
- Mich (mich is sickness due to the clash of cold and hot air)
- Contagion by sweat, human touch, spit in the air
- Fault, bad behavior, vices
- Curse, taboo behavior
- Runs in a particular family (“Their family has this kind of problem”)
Other factors were reported as contributing to causing TB, including:
- Malnourishment
- Weak immune system
- Stress
TB is sometimes perceived to affect a person or family as a consequence or curse resulting from bad or taboo behavior, like ignoring the advice of a healer, not observing a healthy lifestyle and habits, fighting, having enemies, drinking alcohol, smoking cigarettes, chewing chat, prostituting, frequenting prostitutes. Some participants mentioned that some of these behaviors contribute to a weakened immune system.
Participants reported that most Ethiopians understand that TB is communicable. Urban people have more awareness about transmission of the disease because of health education campaigns in the cities. Reportedly, there are still too few clinics and little health education in rural areas.
People may accept that it transfers by air, but may still believe TB happens to certain families or comes from God. Because TB attacks a person slowly, worsens over time, and appears to attack persons at different times, people might think it is not fast in transferring and they might not always take isolation precautions.
Treatment
People follow and have faith in the referrals received from their friends, families and fellow community members in regards to caring for their health. Advice is given and accepted based on what has worked before and who has been identified as a successful healer. The community cares about and shares in the pain of the person sick with TB. This is true despite the isolation and stigma experienced with this disease. The sick person usually has a companion in seeking treatment, a relative or close friend who accompanies on journeys to the traditional healer or doctor and helps provide necessities like food and washing for the sick person. This companion care is considered very important.
In Ethiopia, people will visit traditional healers, and also medical doctors where they are available. Wide use of herbal medicines is very common in rural areas. Some people do not believe in traditional treatments and will choose modern medicine first if available. Traditional medicines are believed to work depending on the healer’s capabilities and specialties, and some very skilled healers have a wide following. There are licensed traditional practitioners in Ethiopia.
Traditional healers have been known to recommend abstinence for saving a person’s strength during illness, including TB.
Tasma is a special honey used for healing, made by insects and gathered from the soil. It is liquid, dark in color, and thick like syrup. Tasma is used to treat coughing, including TB coughing, to make a person feel better. Nutritional treatments include diets especially rich in protein and fats – eggs, milk, meat and butter. Plants, roots, herbs and spices are used for healing various ailments. Traditional treatments for a common cold include tea, garlic, ginger, lemon and honey. Mokmoku is a root used in a medicinal tea, often taken even when a person isn’t sick. Holy Water and prayers are used often as integral parts of treating illness. Traditional medicines are not usually brought to the United States, with the exception of Holy Water. People return to Ethiopia to seek other traditional care.
In Ethiopia, barriers to modern medical treatment for TB include lack of money, transportation, and clinic availability. The most common experience is that people with TB can’t get medicine and they die. Many times the treatment of illness involves a combination of modern and traditional remedies. Availability aside, each person makes decisions about which medicines and treatments they will use.
In both the United States and in urban areas of Ethiopia, modern medicine is commonly used to treat illness. People generally want immediate relief and may switch off a medicine mid-course if they perceive it isn’t working or if the medicine makes them sick. They may throw pills away if they believe they don’t need them. This is true in the United States. People have a preference for injections as opposed to pills. This is based on their experience with antibiotics being prescribed for many illnesses back home, and the immediate relief that came with those treatments.
Isolation and Stigma
There is a heavy stigma associated with having TB and the consequent isolation. The sick are isolated and, for the most part, outcaste. “People avoid people with TB”.
In rural Ethiopia, neighbors isolate patients with TB. The community makes a fence around the family’s house. People deliver water and food to the fence. Fencing a whole neighborhood or village (4-5 houses) also occurs.
The stigma of social isolation lingers even after treatment is completed. Both the community and the individual are deeply challenged to move beyond the social stigma. The isolation and stigma is a powerful blow for Ethiopians whose cultural identity is strongly linked with community participation and connectivity.
Even in the United States, people do not want to tell others if they are diagnosed with having TB, even if they are successfully treated and recover. Some people consider that getting treatment at Harborview Medical Center (county hospital with public health TB clinic in Seattle) is too central and visible to their community, so they may avoid getting treatment there as a way of guarding their identity and avoiding stigma.
Recommendations for Providers
- Follow HIPPA requirements protecting confidentiality.
- Be extra careful to respect patient privacy and confidentiality.
- Emphasize the treatable nature of tuberculosis.
- Reassure patient that during and after treatment for latent TB infection (LTBI) family and community life can continue as normal without isolation.
- Take the time to explain the difference between tuberculosis infection and tuberculosis disease.
- Especially during the first few weeks of treatment for LTBI, solicit feedback on side effects and tailor the regimen to the patient’s needs.
- Encourage the use of a nutritious diet and traditional therapies to better tolerate the side effects of Western medication.
Patient Education Materials
There are a number of sites that have TB patient education materials in other languages including Amharic, Oromo and Tigrinya. See external resources in the Infectious Disease Patient Education section.
References and Further Reading
Seattle-King County Annual Tuberculosis Report 2007 by Tuberculosis Control Program
CDC’s Morbidity and Mortality Weekly Report, October 4, 2002 / Vol. 51 / No. 39 Increase in African Immigrants and Refugees with Tuberculosis — Seattle-King County, Washington, 1998 — 2001
Linguistic and Cultural Aspects of Tuberculosis Screening and Management for Refugees and Immigrants, March 1996, Carey Jackson, MD, MPH, MA, Medical Director International Medicine Clinic, Co-Director Community House Calls, Harborview Medical Center, Seattle, WA
Refugee Health ~ Immigrant Health: Ethiopians & Eritreans, 1999-2005 by Charles Kemp & Lance Rasbridge (website is no longer accessible)