Author(s): Dr. Duncan Reid, Angshita Dutta

Contributor(s): Katie Budd and Franky Erra, Public Health - Seattle & King County; Esther Debrum, Public Health Community Navigator

Date Authored: March 20, 2024

© The Pacific Community (SPC), SPC.int, copyrighted image used with written permission.

Summary

The Marshall Islands have an extremely high incidence of tuberculosis (TB) disease, at least 100 times higher than in the U.S. as a whole.  Individuals who identify as Marshallese accounted for approximately 12% of all TB disease cases in Washington State in 2023. The prevalence of latent tuberculosis infection (LTBI) is estimated to be much higher (approximately 30% based on recent WHO testing). The history of nuclear testing by the U.S., lack of trust in the U.S. medical system, barriers to healthcare access, and stigma regarding TB can make individuals hesitant to undergo screening. There is confusion in the community regarding diagnosis of latent TB compared to active TB disease. There is also less awareness of blood testing (e.g. interferon gamma release assay, Quantiferon) as skin testing has been more prevalent in the Marshall Islands. Many recent immigrants will be familiar with the recent World Health Organization (WHO) TB campaign in the Marshall Islands which aimed for universal screening.

Recommendations

  • Recommend TB screening for all individuals from the Marshall Islands, consider screening for U.S. born members of the Marshallese Community.
  • Recommend screening with blood test (e.g. interferon gamma release assay, Quantiferon) rather than skin testing (e.g. tuberculin skin testing, Mantoux).
  • Recommend addressing other common health issues such as diabetes, obesity, and renal disease.
  • Recommend highlighting the impact of screening on community health, particularly that of children in the community.
  • Recommend explaining the difference between latent TB infection and TB disease.
  • Recommend starting short course LTBI treatment regimen as appropriate.
  • Recommend close follow-up in clinic once treatment has been initiated to ensure continued adherence  with regimen.

Methods

The following sections are based on transcripts from interviews with seven Marshallese community members who were identified by a Marshallese community navigator contracted with Public Health – Seattle & King County. Interviews were conducted either in English or Marshallese with a Marshallese community navigator providing interpretation. A supplemental literature review was also performed. 

Burden of Disease

Center for Disease Control (CDC) Rates for the Marshall Islands
Marshall Islands 2021 CDC Statistics
TB Disease Incidence (per 100,000 per year): 280.6
TB Disease Incidence (total number of cases reported): 118

United States 2021 CDC Statistics
TB Disease Incidence (per 100,000 per year): 2.4
TB Disease Incidence (total number of cases reported): 7882

Total population size of the Marshall Islands (2011) 53,158
Population proportion by island (2011): Majuro 52% / Ebeye 20% / Other islands 28%

Languages Spoken

Marshallese, also known as Ebon, is the official language of the Marshall Islands. There are two major dialects. Nanimej means “sick” in Marshallese, but this can also refer to TB disease. Many names for specific diseases are borrowed from English, and “TB” is typically used to refer to the disease. 

Most Marshallese recognize the English term ‘TB” or “tuberculosis” for TB disease. 

Bacillus Calmette-Guérin (BCG) Vaccination

RATES AND UNDERSTANDING

BCG vaccination was introduced in 2004 to the Marshall Islands. A single dose is administered at birth. Most people receive the vaccine, with an estimated BCG coverage estimate of 89% in 2019 (www.bcgatlas.org). Respondents did not mention a belief that the BCG vaccine was protective amongst adults though recognize that it confers protection to children.

Diagnosis and clinical features

RECOGNIZED BY THE COMMUNITY

Some respondents understood that TB could be either symptomatic (TB disease) or could be asymptomatic (latent TB infection). Some respondents referred to latent TB infection as “sleeping TB”). However, some respondents were not aware of the distinction between latent TB infection and TB disease and felt that there is a general lack of awareness in the community of the distinction between the two.

Commonly identified symptoms of TB disease include chronic productive cough, weight loss, fevers, and poor appetite. Most respondents were not aware of extrapulmonary TB disease. 

There is consensus that TB disease is transmitted by cough/breathing. Participants noted that it is dangerous to be in the same area as others with TB disease, especially indoors. They noted that they would be reluctant to meet someone outdoors with TB disease unless they were a close family member. Several respondents highlighted the importance of social gatherings in Marshallese culture and that it would be difficult to decline invitations to participate in communal activities based on health concerns.

TB disease is considered to be a serious disease and it is known to have the potential of being fatal. 

Testing of TB disease and latent TB infection

PRACTICES IN THE MARSHALL ISLANDS

Testing in the Marshall Islands historically focused on diagnosis of TB disease in those who were symptomatic. The World Health Organization (WHO) supported mass screening of TB disease for the entire population of Ebeye Island (part of Kwajalein Atoll) in 2017. Screening for active and latent TB was started on Majuro Island in 2018 (http://open.who.int/2018-19/country/MHL). Ebeye Island and Majuro Atoll are two most populous islands of the archipelago and represent nearly 75% of the population of the country.  Nearly 80% of the population was reached during these two campaigns with the identification of 302 cases of TB disease (representing 1.6% of the population) and 4,700 cases of latent TB infection (about 29% of those tested). 

Regular TB testing and screening is done community-wide in the Marshall Islands as part of the WHO effort and is done in public settings such as schools, community gatherings, and churches. Most testing consists of tuberculin skin testing followed by chest radiograph and sputum testing if the patient is symptomatic. Overall, Marshallese are willing to be tested for TB in the Marshall Islands as testing has become accepted as a regular, communal event. However, treatment of latent TB infection is not mandatory so some people elect not to be treated. 

© Stefan Lins, Creative Commons License

TB Treatment in the Marshall Islands

In the Marshall Islands, only symptomatic individuals (those with TB disease) were treated until the start of a WHO initiative in 2018 to screen and treat cases of latent TB infection on Majuro Atoll. During the 2017 and 2018 WHO campaigns, supervised active TB treatment was offered through Community Health Outreach Workers. Latent TB infection was introduced for the first time and consisted of supervised isoniazid and rifapentine regimen. About 92% of those diagnosed with latent TB started treatment(http://open.who.int/2018-19/country/MHL). This has led to some confusion among our respondents about whether individuals were diagnosed with latent TB infection or TB disease since screening and treatment are carried out for both.

Practice of traditional medicine is less common among the Marshallese, particularly among the younger generation. However, there remain some community members who prefer to use traditional healing techniques and will be less likely to access care from Western medical providers.

Social factors and care delivery in the Marshall Islands

Marshallese society emphasizes collectivism with multigenerational households and frequent community events. Sharing of food is also an important part of social activities. There is a strong stigma in the community regarding TB. Respondents stated that they would avoid community members who were suspected of having TB. On the Marshall Islands, respondents noted that it was obvious and public when your neighbors and other community members were being screened for TB. When the health department followed up with a household and delivered medications for directly observed therapy (DOT), many community members assumed that this was due to a diagnosis of TB disease requiring treatment. However, the WHO began treatment of latent TB infection with DOT starting in 2018 in Majuro island. Therefore community members would be unable to distinguish whether their neighbors were being treated for latent TB infection or TB disease. Because of confusion regarding the clinical difference between TB disease and latent TB infection and the risks of transmission in both cases, stigma in the community extends to individuals diagnosed with latent TB infection.

There is recognition that treatment is available for TB and cure is possible. Respondents felt that the social stigma towards a community member would clear once treatment had been completed. However, they note that it would be difficult to ensure if treatment was completed, and there would likely be lingering concern that an individual would remain an infectious risk. Respondents noted that the closeness of the relationship with the person diagnosed with TB would determine how much distance one could keep from them. For intimate friends or close family members, maintaining distance would not necessarily be seen as being socially acceptable. This could lead to possible disease transmission in the case of TB disease.

Experience with TB and barriers to care in the United States

Regarding provision of health care, there is a preference for translators who are the same gender as the patient. Several respondents have experience working as translators for Marshallese patients and noticed that patients would minimize symptoms and hold back information if they were with an unfamiliar provider or with a patient of different gender than the translator. Due to difficulties in accessing care and limitations in health insurance coverage, members of the Marshallese community are often establishing care for the first time when they receive a diagnosis of TB disease or latent TB infection. With the absence of a prior therapeutic relationship, communication regarding TB diagnosis and treatment can be more complicated. 

There is more privacy for Marshallese community members in the U.S. given the greater distance between households.  In addition, screening events are typically not done in public. Respondents noted that there was less social pressure to follow-up with medical providers given this increased level of privacy. However, news and rumors still travel quickly within the relatively small Marshallese community. 

In the U.S., Marshallese are less likely to be tested for TB due to financial and travel barriers to accessing healthcare. TB testing is also not a regular, community-wide event in the U.S. as it has been in the Marshall Islands. Among individuals who test positive for latent TB infection, it is simple to decline treatment and maintain anonymity within the community. In cases of TB disease, the local health department traces cases and provides treatment. Respondents felt that community members receiving treatment for TB disease in the U.S. had greater privacy and anonymity than they would have in the Marshall Islands.

Although there have been community screening events organized by the department of public health, many Marshallese community members have been reluctant to go since it was seen as optional and there was concern of being stigmatized by attendance. Respondents noted that members of the community would not share a diagnosis of TB disease or latent TB infection outside of their immediate family and closest friends. Although several interview participants noted that members of their community were hesitant to be screened for TB, they noted that most people are very sensitive and protective of their children. They knew of community members who were aware of the elevated infection risks of young children and were more motivated to be tested as a result. They recommended health care providers to highlight the community-wide benefits, particularly to young children, when recommending screening and treatment.

Additional barriers to screening include concerns that a positive TB test could jeopardize their employment, particularly as workers in the childcare or health care fields. The stigma of having a family member who tests positive for TB is also seen as possibly placing social relations between the community and the family at risk. Several respondents also noted that many Marshallese live in multigenerational households where a positive TB test could jeopardize their housing with limited affordable housing alternatives available.

Regarding treatment, respondents felt that medication regimens are poorly understood in the Marshallese community. Treatment for latent TB as part of the WHO initiative in the Marshall Islands used the combination of isoniazid and rifapentine taken weekly. Daily rifampin is another short course regimen which is used by many providers in King County and other parts of the U.S. Some respondents mentioned concerns about side effects from medication regimens, particularly gastrointestinal, renal, and hepatic complications.

Relevant Historical Factors

The Marshall Islands served as the site of 67 nuclear tests by the United States on various atolls from 1946 to 1958 as part of the Pacific Proving Grounds. Testing began in 1946 on Bikini Atoll following the forced relocation of inhabitants. The first hydrogen bombs were tested on the islands, including the Castle Bravo nuclear test in 1954 on Bikini Atoll. Significant nuclear fallout was detected on islands of the archipelago with continued dangerous levels of radiation on Bikini Atoll. A medical study, Project 4.1, was launched to study the effects of radiation on people exposed to fall-out in the wake of the Castle Bravo test. This research was conducted without the informed consent of Marshall Islanders and without translation of the information into the Marshallese language (Barker 2013).

© International Campaign to Abolish Nuclear Weapons, Creative Commons License

The classified nature of this study on members of the Marshallese population exposed to radiation has been a potential source of distrust with medical providers. Recent analyses of the study reveal a dose-dependent effect of radiation exposure to risk of cancer. Radiation exposure accounts for around half of all cancers in the most heavily exposed inhabitants of Rongerik Atoll, though radiation exposure was calculated to account for less than 2% of past and future cancer diagnoses among the exposed Marshall Island population as a whole. (Land et al. 2010)

Several trust funds were established for the Marshallese people, though payouts only amounted to a few hundred dollars per year. Citizens of the Republic of the Marshall Islands are not citizens or nationals of the United States. However, they are entitled to apply for admission to the United States as nonimmigrants without visas. They may reside, work, and study in the United States. They do not have the status of lawful permanent residents but can apply for permanent residence status once they come to the U.S.. Marshallese were entitled to Medicaid until the 1990s. Access was reinstated in 2020.
This history of nuclear testing has created lingering distrust amongst the Marshallese population towards the U.S. government and medical providers due to exposure to radioactive fallout, the initially classified Project 4.1 medical study, and the limited status provided to migrants who travel to the U.S. 

The ecological destruction, population displacement, and economic dependency which occurred as a result of this nuclear testing has led to high population densities on a number of islands and high rates of diabetes which has contributed to the spread of tuberculosis (Yamada 2001).

Co-morbidities / Other health concerns in the community

Several respondents mentioned nutrition, diabetes, and kidney disease as prominent concerns in the Marshallese Community. They noted the difficulty in accessing vegetables and fruits in the Marshall Islands because of the high cost. Although access to these fresh foods is better in the U.S., they noted that many members of the community have been habituated to a diet rich in carbohydrates, fats, and salt. Diabetes and kidney disease were raised as concerns since several respondents were familiar with community members who presented to the hospital with progressed forms of both diseases. 

A survey in the Marshall Islands of 3045 Marshallese between 15-64 years of age was conducted in 2002 (WHO 2007). Of these respondents, 23% were current smokers, 62.5% were obese or overweight, 10.5% were hypertensive, and 19.6% were diabetic. Diabetes rates have been estimated at 400% higher than the U.S. population as a whole (McElfish et al 2016). Health assessments in the United States revealed diabetes prevalence rates in Marshallese living in Hawaii and Arkansas at greater than 40% (McElfish et al 2015).

References

Barker HM. Bravo for the Marshallese: Regaining Control in a Post-Nuclear, Post-Colonial World. 2nd ed. Independence, KY: Cengage Learning; 2013

Fact Sheet – Status of Citizens of the Freely Associated States of the Federated States of Micronesia and the Republic of the Marshall Islands (uscis.gov)

Land CE, Bouville A, Apostoaei I, Simon SL. Projected lifetime cancer risks from exposure to regional radioactive fallout in the Marshall Islands. Health Phys. 2010 Aug;99(2):201-15. doi: 10.1097/HP.0b013e3181dc4e84. PMID: 20622551; PMCID: PMC3892964.

McElfish PA, Hallgren E, Henry LJ, Ritok M, Rubon-Chutaro J, Kohler P. Health Beliefs of Marshallese Regarding Type 2 Diabetes. Am J Health Behav. 2016 Mar;40(2):248-57. doi: 10.5993/AJHB.40.2.10. PMID: 26931757; PMCID: PMC5304418.

McElfish PA, Bridges MD, Hudson JS, et al. Family Model of Diabetes Education with a Pacific
Islander Community. The Diabetes Educator. 2015 Dec; 41(6):706–15.

The BCG World Atlas, 3rd Edition: BCG World Atlas (bcgatlas.org)

World Health Organization, Western Pacific Region and the Ministry of Health, Republic of the Marshall Islands, author. NCD Risk Factors STEPS Report: Ministry of Health, Republic of the Marshall Islands, 2002. Suva Fiji: World Health Organization; 2007

Yamada S, Palafox N. On the biopsychosocial model: the example of political economic causes of diabetes in the Marshall Islands. Fam Med. 2001;33(9):702–704.

Yanagawa M, Morishita F, Oh KH, Rahevar K, Islam TA, Yadav S. Epidemiology of tuberculosis in the Pacific island countries and areas, 2000-2020. Western Pac Surveill Response J. 2023 Feb 22;14(1):1-12. doi: 10.5365/wpsar.2023.14.1.996. PMID: 36923784; PMCID: PMC10008724.

Other Resources

The Global Burden of Latent Tuberculosis Infection: A Re-estimation Using Mathematical Modelling | PLOS Medicine

Estimating the long-term effects of mass screening for latent and active tuberculosis in the Marshall Islands | International Journal of Epidemiology | Oxford Academic (oup.com)

Why Nuclear Justice for the Marshall Islands is the Biggest US-China Issue You’ve Never Heard Of – Union of Concerned Scientists (ucsusa.org)