World TB Day is recognized annually on March 24 to mark the discovery of Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). This annual event serves to raise awareness of TB, educate the public about its impact worldwide, and highlight opportunities to combat the disease.

TB remains a leading cause of preventable infectious disease deaths worldwide, and the increasing global emergence of multi-drug resistant TB (MDR TB) further increases public health workload and the need to adapt to a changing landscape. According to the World Health Organization, 1.6 million people died from TB in 2021, making it the second most deadly preventable infectious agent after COVID-19. There were 600 reported TB-related deaths in the U.S. in 2020, and in 2021, there were 7,882 active cases and approximately 13 million latent tuberculosis infections (LTBI). Although anyone can contract TB, it disproportionately affects individuals who are immunocompromised, people experiencing homelessness (PEH), racial and ethnic minority groups, refugees, and newcomers. A stronger public health infrastructure is needed to maintain adequate infection prevention and control measures.

There are several challenges faced by refugee and newcomer communities when they arrive and settle in the United States. These challenges include cultural differences, language barriers, securing employment and housing, accessing culturally appropriate health services, screening processes, and navigating the complex healthcare system.

As part of infection prevention and control measures in the U.S., all refugee applicants ages two and older must undergo evaluation for TB prior to departure and upon arrival to the United States. Overseas TB screening results, treatment, and classifications are documented on the U.S. Department of State forms. In addition, all refugees, including those classified with a TB condition overseas, should receive a comprehensive domestic medical screening within 90 days of arrival to the U.S.. The goal of domestic screening for TB is to identify persons with LTBI to facilitate prompt treatment and control, as well as to find persons who may have developed TB disease since the overseas medical examination. However, overseas screening has become a challenge when addressing newcomers and refugees from Ukraine as civilian infrastructure, including healthcare facilities, have been partly destroyed due to an active war. Local health departments (LHDs) are on the frontline in combating TB and supporting these communities. They treat those who are infected, track the spread of the disease, and are responsible for testing high-risk individuals. Furthermore, LHDs are the first point of contact within the healthcare system to link individuals to necessary resources.

In August 2022, to support TB prevention and treatment for refugees and newcomers, CDC’s Division of Tuberculosis Elimination (DTBE) awarded $26 million in supplemental funding under (CDC-RFA-PS20-2001) to currently funded states, cities, and territories. This funding was to be used for screening, evaluation, and treatment of latent tuberculosis infection (LTBI) and TB disease among Ukrainians arriving into the U.S. through the Uniting for Ukraine (U4U) program. Within this program, local agencies, organizations, and partners collaborate to mitigate and prevent TB in the U.S.. NACCHO interviewed Dr. Janice K. Louie, Medical Director at San Francisco Department of Public Health (SFDPH), to learn more about their efforts to address TB and highlight their work with refugees as an example of local participation in this collaborative effort:

Your Refugee Health Assessment Program (RHAP) and TB Program have a long-standing partnership. What are some lessons learned from that partnership and its efforts to better serve the refugee population? How has the incorporation of an outreach worker on the efforts to reach out to the Ukrainian community impacted the outcomes of addressing TB within this community?

“Our RHAP is the SFDPH Newcomers Health Program located in an adjacent building to the SFDPH TB Clinic. In April 2022 when the U4U program was first announced, the SFDPH TB Clinic was excited to create a partnership with the Newcomers Health Program to specifically address TB screening in the Ukrainian parolee (temporarily admitted) population. We were aware of surveillance reports from the World Health Organization that TB incidence in Ukraine was high, with an associated high proportion of drug resistant TB. We also knew that there was no opportunity for overseas screening prior to arrival and wanted to make sure that we could be quick to jump on any potential cases of active TB before there was spread in the community. The Newcomers Health Program did all the heavy lifting as far as outreach to community, professional, and faith-based groups via phone calls, distributing multi-lingual flyers, field visits, and social media postings to encourage expedited no-cost TB screening information for U4U parolees. In TB Clinic, we created flyers in Ukrainian educating on the importance of testing for TB and how to take TB medications. We try to perform same-day screening once we get the referral from the Newcomers Health Program. All of our TB testing is provided at no cost to the clients. Importantly, we decided to add chest X ray screening in addition to symptom review and interferon gamma release assay testing, as we knew that chest X-ray was the most sensitive and quickest way to screen for infectious pulmonary TB. We have now screened 275 U4U parolees. Building on this program, we are also now ready to screen other at-risk immigrant and refugee populations Venezuelans, Nicaraguans, Cubans, and Haitians). We think this is a very successful collaboration.” 

As the conflict in Ukraine continues and refugees and parolees continue to arrive to many parts of the USA including San Francisco, what additional support, resources, or partnerships are needed to better address the health needs of the Ukrainian community?

“Some newcomers we have been seeing are not yet eligible for federal or state support programs. For example, we recently had a case of TB diagnosed in a Ukrainian asylum-seeker.  The Newcomers Health Program was so helpful in advising us on available community resources to support their overall health.  We were recently in contact with the Refugee and Asylum seeker Health Initiative at UCSF to help us get legal support for other asylum-seekers and survivors of torture.  We have just begun to understand the wealth of support out there. It has been amazing to see how communities come together to support and sponsor asylum-seekers from other countries.  However, some of these are not formal organizations- they seem more grass-roots- so having a single place dedicated to connecting with those newcomers not yet eligible for federal and state funding is a need.  Fortunately in San Francisco residents who are not qualified for Medicaid can have access to health care, however there is more support needed for housing, food, clothing, legal support, how to find employment and navigating the healthcare system. The Bay Area is an expensive place to live, and anything helps.”

SFDPH’s TB program serves as an example of a proactive approach to TB prevention and control measures, and it highlights the importance of cross-agency partnerships to support and address the unique needs of refugees and newcomers to the U.S. Eliminating TB in the U.S. requires a dual approach which includes increased testing and treatment for those at high-risk for LTBI, and continued case finding and treatment for active TB disease. LHDs play a pivotal role in accomplishing this as they continue to lead efforts to end TB in the communities they serve.

For the latest information on CDC’s Uniting for Ukraine, please visit Uniting for Ukraine: Tuberculosis Information and Resources. To learn about what other local health departments and local organizations are doing to end TB in their communities, check out the CDC’s 2023 CDC U.S. TB Elimination Champions. For additional resources and educational material regarding TB, please visit CDC’s World TB Day page -which includes more information on the CDC’s latest campaign, Think Test Treat TB.