Introduction to the Tuberculosis (TB) Profile Series:
The Tuberculosis, TB Cultural Profile series on EthnoMed is a resource intended for medical providers who test, treat, or counsel patients about TB. These profiles aim to cover some of the main immigrant populations in the greater King County area in Washington state. However, they should be generally applicable to providers working in other areas of the United States.
TB disease cases continue to be present in the U.S. with an incidence rate of about 2.5 per 100,000 (WHO 2023). In King County, the rate is about double that of the U.S. (2023 TB Program Summary (kingcounty.gov)). The majority of TB disease cases in King County occur in patients born outside the U.S. and represent reactivation of remote latent TB infection (LTBI).
In collaboration with the Public Health Seattle & King County TB Program, we have become aware of barriers to TB testing and treatment, particularly amongst immigrant populations. Multiple factors contribute to screening and treatment hesitancy across these communities, including incomplete understanding of testing and treatment options for TB disease and LTBI, stigma, other disease associations, language barriers, and difficulties accessing the health system in the U.S.
This project has been generously supported by the following funders:
TB Elimination Alliance (2023-2024 Mini-Grant Program)
Firland Foundation (2024-2025 Community Grant)
Library of TB Cultural Profiles
Here, we provide a resource with profiles for some of the largest immigrant communities in the greater King County region. Outlines of these profiles and definitions of terms are provided below.
Outline of TB Cultural Profiles
The outline of the TB Cultural Profiles follows the format below. Additional information contained in each section of the profiles is provided below this outline:
- Summary
- Recommendation
- Methods
- Burden of disease
- Languages spoken
- Bacillus Calmette-Guérin (BCG) Vaccination
- Diagnosis and clinical features (recognized by the community)
- Testing of TB disease and latent TB infection (in home country)
- TB treatment (in home country)
- Social factors and care delivery (in home country)
- Experience with TB and barriers to care in the U.S.
- Relevant historical factors
- Comorbidities / Other health concerns in the community
Explanations of each section of the TB Cultural Profile Pages
Summary
Provides essential points from the entire profile.
Recommendations
List of recommendations for screening, treating, and counseling for TB in the community.
Methods
Profiles are developed using a combination of semi-structured interviews with community members as well as a literature review. The number of community members interviewed and language used are provided here.
Burden of Disease
Listing of most recent TB statistics from the country discussed. These are typically obtained from the World Health Organization (WHO).
Languages Spoken
Lists of official and popular languages used and common terms for TB.
Bacillus Calmette-Guérin (BCG) Vaccination
Rates of BCG vaccination and the year the vaccination was introduced in each country is obtained from www.bcgatlas.org. This section also includes community perceptions regarding BCG vaccination.
Diagnosis and clinical features (recognized by the community)
Narrative of responses from community interviews regarding symptoms recognized by the community, as well as understanding of transmission. Awareness of HIV co-infection included here.
Testing of TB disease and latent TB infection (in home country)
Understanding of testing methods based on community interviews in addition to a literature review of systems of testing in place in home country. Most other countries do not conduct routine screening or treatment for latent TB infection (LTBI).
TB treatment (in home country)
TB treatment including traditional medicine and treatment system in home country.
Social factors and care delivery (in home country)
Physician access, cultural factors affecting access to health care, medical system in home country.
Experience with TB and barriers to care in the U.S.
Information regarding experiences of TB care in the U.S., barriers to care including health coverage, language access.
Relevant historical factors
Brief overview of select historical factors that have impacted various aspects of life in the home country, including political and economic issues.
Comorbidities / Other health concerns in the community
Additional health concerns and common medical conditions in the community.
Glossary of Terms
3HP
Abbreviation for short-course of LTBI treatment consisting of combination of rifapentine with isoniazid for weekly treatment for three months (3HP).
4R
Abbreviation for short-course of LTBI treatment consisting of daily rifampin for four months of (4R)
Bacillus Calmette-Guérin (BCG) Vaccination
An attenuated (weakened) strain of Mycobacterium bovis. Introduced in 1921, administered primary to newborns in countries with high TB prevalence. It protects against severe forms of TB, such as miliary and meningeal TB, particularly in children. Efficacy in preventing pulmonary TB in adults is variable and generally lower (Lange 2022). The BCG World Atlas provides details of immunization rates for most countries (www.bcgatlas.org, Zwerling 2011). BCG vaccine is not routinely administered in the U.S. BCG vaccination can result in false positivity of tuberculin skin tests.
Extrapulmonary TB
TB that occurs outside of the lungs. This cCan affect any organ, though commonly affects the lymph nodes, pleura, genitourinary system, bones and joints, gastrointestinal tract, central nervous system, and pericardium (Golden 2005).
Interferon-Gamma Release Assay (IGRA)
Blood test to detect TB infection by measuring the immune response to Mycobacterium tuberculosis antigens. Alternative to the tuberculin skin test. Benefits include no return visit for reading results, no cross-reactivity with the Bacillus Calmette-Guérin (BCG) vaccine, less likely false positive from non-tuberculous mycobacteria.
Isoniazid (INH)
Antibiotic used in the treatment of LTBI. Can be used in combination with rifapentine for weekly dosing for three months (3HP). Previously was the recommended agent for LTBI treatment as monotherapy for 6 to 9 months. Isoniazid alone is no longer a preferred therapy for LTBI treatment. Most notable side effect is the risk of liver injury.
Latent TB infection (LTBI)
Individual has been infected with Mycobacterium tuberculosis, but bacteria are inactive. Patient without symptoms and is not contagious. Also known as inactive TB, sleeping TB. About 25% of the global population has been infected with TB (WHO 2023).
Mantoux test
See tuberculin skin test. Also known as the tuberculin skin test (TST) or PPD test.
Non-tuberculous mycobacteria (NTM)
Group of mycobacteria related to the bacteria responsible for TB infection and disease (Mycobacterium tuberculosis). NTM can lead to pulmonary disease which resembles TB disease. Over 150 different species have been identified, though most are due to three types: Mycobacterium avium complex (MAC), Mycobacterium kansasii, and Mycobacterium abscessus. NTM are clinically important as they can lead to false positive tests with BCG and (less commonly) IGRA testing.
PPD test
See tuberculin skin test. Also known as the tuberculin skin test (TST) or Mantoux test.
References
– Golden MP, Vikram HR. Extrapulmonary tuberculosis: an overview. Am Fam Physician. 2005 Nov 1;72(9):1761-8. PMID: 16300038.
– Lange C, Aaby P, Behr MA, Donald PR, Kaufmann SHE, Netea MG, Mandalakas AM. 100 years of Mycobacterium bovis bacille Calmette-Guérin. Lancet Infect Dis. 2022 Jan;22(1):e2-e12. doi: 10.1016/S1473-3099(21)00403-5. Epub 2021 Sep 7. PMID: 34506734.
– Public Health Seattle & King County (2024). Tuberculosis in Seattle & King County, 2023 Program Summary. 2023 TB Program Summary (kingcounty.gov)
– World Health Organization. (2023). Global tuberculosis report 2023. World Health Organization. https://iris.who.int/handle/10665/373828
– Zwerling A, Behr MA, Verma A, Brewer TF, Menzies D, Pai M. The BCG World Atlas: a database of global BCG vaccination policies and practices. PLoS Med. 2011 Mar;8(3):e1001012. doi: 10.1371/journal.pmed.1001012. Epub 2011 Mar 22. PMID: 21445325; PMCID: PMC3062527.
Tuberculosis Awareness & Prevention Public Service Announcements in multiple languages, HERE
BCG Vaccine Information Videos Linked Here.
King County Public Health (KCPH) TB Community Navigators
In this video, KCPH introduces you to the navigators at the forefront of the TB prevention and treatment work and explore how this innovative program is leading the way for a TB free King County.
