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No. 3, 2011


TB in Indigenous Peoples

Among the 9.2 million new cases of TB and 1.7 million deaths due to TB globally each year,1 the absolute magnitude of TB among the estimated 370 million indigenous people worldwide2 is not known because few disaggregated surveillance data exist. However, evidence from nations where data are available, such as the United States, Canada, Australia, and New Zealand, suggests that the rates of TB are higher among indigenous than non-indigenous people.3,4,5,6,7 In November 2008, indigenous leaders and TB experts from around the world met in Canada to develop a strategy for reducing the burden of TB among indigenous people globally.8 Poverty and other social determinants of health were acknowledged as factors influencing indigenous peoples’’ vulnerability to TB.9 Furthermore, participants highlighted the need for documenting and monitoring the burden of TB in indigenous people and better understanding the social realities of these groups  to design more effective TB interventions. To help address these needs and to inform public health approaches to address TB disparities, two projects were undertaken to measure and better understand TB in indigenous peoples in the United States.

Tuberculosis in indigenous peoples in the United States, 2003–2008 *
We examined TB trends and epidemiology of American Indians and Alaska Natives (AIAN) and Native Hawaiians and Pacific Islanders (NHPI) relative to other racial/ethnic groups during 2003–2008.  We analyzed cases in the U.S. National Tuberculosis Surveillance System (NTSS) and calculated TB case rates among all racial/ethnic groups from 2003 to 2008. Socio-economic and health indicators for counties where TB cases were reported came from the Health Resources and Services Administration Area Resource File.

We found that, among the 82,836 TB cases, 914 (1.1%) were in AIAN and 362 (0.5%) were in NHPI. In 2008, TB case rates for AIAN and NHPI were more than five and 13 times greater than for non-Hispanic whites. From 2003 to 2008, AIAN had the largest percentage decline in TB case rates for any racial/ethnic group, but NHPI had the smallest percentage decline. AIAN were more likely than other racial/ethnic groups to be homeless, have excessive alcohol use, and come from counties with a greater proportion of persons living in poverty and without health insurance; they were also more likely to be prescribed totally directly observed therapy. A greater proportion of NHPI had extrapulmonary disease and came from counties with a higher proportion of persons with a high school diploma.

Determinants of health extend beyond individual-level traits and behaviors, and involve social and economic factors that operate at the community or population level.10,11 Disparities in health, including differences in TB risk and burden,  between indigenous and non-indigenous peoples, may be the result of the complex interplay among the individual, the community, and the social determinants of health.12,13 Results from this project showed that there is a need to develop flexible TB control strategies that address the social determinants of health, and are tailored to the specific needs of AIAN and NHPI in the U.S.

Estimating the burden of TB among American Indians and Alaska Natives in the US, 2006-2009: a surveillance evaluation
The second project aimed to evaluate the completeness and accuracy of the Indian Health Service (IHS) National Patient Information Reporting System (NPIRS) for identifying active TB cases among AIAN. Another aim of the project was to evaluate whether TB cases identified by IHS providers are reported to state public health authorities, and would therefore be captured in the National TB Surveillance System.

A multistage sampling approach was used to select IHS units and health facilities proportional to the population of AIAN using the IHS for health care. A total of 24 IHS units, each containing several health facilities, were included in the sample, located across 8 states. Line listings were generated from the IHS NPIRS for all patients recorded with a diagnosis of active TB at selected facilities between 2006 and 2009, based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM). Up to 30 patients were selected from each inpatient and outpatient listings in the NPIRS for each facility. For all selected patients, medical records were reviewed to identify and capture data on TB symptoms, screening, diagnosis, and treatment using standardized forms.

Data have been collected from all facilities in 22 of the 24 selected IHS service units. Data collection from the remaining health facilities and linkage of the TB cases verified by chart review at the IHS facilities to the state database is projected to be completed by August 2011. Preliminary analysis suggests that the IHS system using ICD-9CM codes for identification of patients with active TB disease greatly overestimates the burden of TB in the AIAN population. Approximately 10%-30% of patients with an ICD-9CM code for active TB disease in the NPIRS could be validated as having active TB based on information recorded in the medical record. Furthermore, there is no direct mechanism for IHS health facilities or units to report cases of TB disease directly to the National TB Surveillance System, and the extent to which IHS facilities and providers interrelate and report to the local and state public health authorities is variable in different regions. Information from this evaluation will help guide policies and activities for the IHS and CDC to promote the accuracy and completeness of federal reporting and recording of nationally-notifiable diseases, including TB, to CDC.

Collectively, findings from these studies will help to improve our understanding and highlight the importance of accurately measuring the burden of TB and of TB programs and initiatives to address both individual-level and community-level social determinants of TB, especially among indigenous groups in the United States.

—Reported by Emily Bloss, PhD, Laura Podewils, MS, PhD,
John Jereb, MD, and Eugene McCray, MD, Div of TB Elimination;
Timothy H. Holtz, MD, MPH, Div of HIV/AIDS Prevention;
John T. Redd, MD, MPH, and James E. Cheek, MD, MPH, Indian Health Service


  1. World Health Organization. Global tuberculosis control - epidemiology, strategy, financing. Geneva: World Health Organization; 2009. WHO/HTM/TB/2009.411.
  2. UN Permanent Forum on Indigenous Issues. State of the world’s indigenous peoples. New York: United Nations; 2009. Also available from URL: [cited 2011 Mar 29].
  3. Das D, Baker M and Calder L. Tuberculosis epidemiology in New Zealand: 1995-2004. N Z Med J 2006; 119: U2249.
  4. Fanning A. Tuberculosis: 1. Introduction. CMAJ1999; 160: 837-9.
  5. FitzGerald JM, Wang L, Elwood RK. Tuberculosis: 13. Control of the disease among aboriginal people in Canada. CMAJ2000; 162: 351-5.
  6. Centers for Disease Control and Prevention. Trends in tuberculosis--United States, 2008. MMWR 2009; 58: 249-53.
  7. Barry C, Konstantinos A; National Tuberculosis Advisory Committee. Tuberculosis notifications in Australia, 2007. Commun Dis Intell 2009; 33: 304-15.
  8. Assembly of First Nations and Inuit Tapiriit Kanatami. A strategic framework for action on tuberculosis control in indigenous communities:a global indigenous peoples’ initiative to stop TB. 2009 [cited 2010 Apr 7]. Available from: URL:
  9. Assembly of First Nations and Inuit Tapiriit Kanatami. A Global Indigenous Peoples’ Initiative to Stop TB: Our Children, Our Future. Executive Summary.2009  E/CN.19/2009/CRP.5 [cited 2010 7 April 7]. Available from: URL:
  10. World Health Organization. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. 2008 [cited 2010 7 April 7]. Available from: URL:
  11. King M, Smith A, Gracey M. Indigenous health part 2: the underlying causes of the health gap. Lancet 2009; 374: 76-85.
  12. Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med 2009; 68: 2240-2246.
  13. Basta PC, Coimbra CE Jr, Escobar AL, Santos RV, Alves LC, Fonseca Lde S.Survey for tuberculosis in an indigenous population of Amazonia: the Suruí of Rondônia, Brazil.Trans R Soc Trop Med Hyg 2006; 100: 579-85.

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