RTI International study offers guidance for public health workers in ongoing fight against tuberculosis

RESEARCH TRIANGLE PARK — A new study by RTI International offers insights to public health officials aiming to combat tuberculosis among African-Americans in the Southeast.

The study, was published in the Journal of Racial and Ethnic Health Disparities.

Tuberculosis, or TB, is an airborne bacterial infection that can be fatal if not treated properly. Although many Americans believe TB to be a thing of the past, this curable and preventable disease killed 1.5 million people worldwide in 2014, though TB mortality has fallen 47 percent worldwide since 1990.

TB incidence and mortality in the United States have fallen each year, but still greatly exceed the Healthy People 2020 goals, especially for racial and ethnic minorities.  Among people born in the United States, African-Americans contract the disease at seven times the rate of whites. This disease reflects progression from a latent infection acquired on average two or more years prior so there is a relatively long window of opportunity to prevent disease. People with HIV infection are at particularly high risk for rapid progression of TB infection to TB disease.  Some people carry a latent TB infection for years before it becomes active.

A nationwide effort to eliminate TB is one of the major drivers of this line of research, said lead author and principal investigator Rachel Royce, Ph.D., a senior research epidemiologist at RTI.

"There's no reason why we should still have cases of tuberculosis and especially TB deaths if our public health system is operating as it should be," she said. "This is one health disparity that should be amenable to public health intervention but we need to know more about it to be effective. This is the first study of its kind among this population".

The researchers zeroed in on two urban counties and one rural one — Davidson County, Tennessee; DeKalb County, Georgia; and Montgomery County, North Carolina — all with high rates of tuberculosis among U.S.-born African-Americans. They conducted in-depth interviews with five groups: people with TB, people with latent TB infections, people at risk for TB, community leaders, and health department staff members to learn more about how knowledge, stigma, and communication between health departments may contribute to maintaining TB in these communities. Study participants shared their knowledge and experiences with TB including their thoughts about services and information given to patients.

"Although the geographical settings varied from rural to urban, people's experiences were similar. They related a high level of fear of TB in the community," said co-author Tammeka Swinson Evans, a health services researcher at RTI who conducted many of the interviews.

The study shed light on some common misunderstandings of how TB spreads, and led to a better understanding of how health officials can reach people with or at risk for TB. For example, Royce said, researchers found that patients strongly prefer to get information about TB verbally, rather than through written material.

"Giving people pamphlets should be secondary to talking to patients one on one, where they can get their questions answered," she said.

Contrary to popular belief, the researchers found that patients said they trusted the health department care providers and did not experience stigma, though fear of stigma was prevalent. This contrasted with the viewpoint of community leaders, who assumed trust might be lacking. Community leaders are a crucial part of the fight against TB, Royce said, so solidifying their support is key to working together to stop TB.

The findings are timely in light of a recent TB outbreak in rural Alabama, where health officials are struggling to reach out to the affected population. Two people in a community of 3,600 died of the disease last year.

Royce said the deaths are a sign that TB patients are being missed by the public health system — an oversight that puts entire communities at risk.

"These outbreaks are going to bubble up time and time again," Royce said, "until we effectively intervene to reduce the pool of latent TB infections and stop the spread of infections."