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Pacific Islanders living in America are more than three times as likely to contract tuberculosis than the overall population, the Centers for Disease Control and Prevention found, as health disparities for minority communities and the coronavirus pandemic complicate TB eradication efforts.

An analysis of TB cases across the previous decade revealed nearly 10 out of every 100,000 Pacific Islanders and Native Hawaiians living in the United States tested positive for the disease every year, .

This is compared to a nationwide infection rate of just three cases for every 100,000 people during the same period.

Complicating Factors

The infection rate soared to nearly 97 cases per 100,000 people for Pacific Islanders in the U.S. territories of Guam and American Samoa, the U.S. Commonwealth of the Northern Mariana Islands and the three Compact of Free Association nations.

“TB is one of the world’s leading infectious disease killers,” research team member and CDC epidemiologist Maryam Haddad wrote in an email. “Although anyone can get TB … several factors contribute to the higher rates of TB disease among Native Hawaiian and other Pacific Island people.”

Those from outside the 50 states were more likely to encounter TB, Haddad wrote, with 95% of Pacific Islander and Native Hawaiian TB cases examined in the study recorded among patients who were born in U.S.-affiliated Pacific islands.

The data was presented at the CDC’s annual Epidemic Intelligence Service conference on Thursday.

“The Covid-19 pandemic has reversed years of progress in providing essential TB services and reducing TB disease burden.” — WHO

High rates of diabetes and other health disparities that Pacific Islanders face heighten the risk of TB infection. “Poverty, limited access to quality health care, unemployment, housing, and transportation can directly or indirectly increase the risk of TB disease,” Haddad said.

“Language and cultural barriers, including health knowledge, stigma, values and beliefs, may place certain populations at risk. Stigma may deter people from seeking medical or follow-up care,” she added.

These risk factors for TB reflect wider challenges in caring for Pacific Islander populations both in and outside Hawaii, disparities that worsened with the onslaught of Covid-19 in March 2020.

The Covid Link

While Hawaii largely managed to keep Covid case counts low near the beginning of the pandemic, infections raged among non-Hawaiian Pacific Islanders, who often struggled to find basic necessities such as food, water, diapers and masks.

In 2015, Gov. David Ige cut off Med-QUEST funding to migrants from the COFA nations of Palau, the Marshall Islands and the Federated States of Micronesia, leaving an estimated 25,000 COFA citizens in Hawaii without access to Medicaid as the coronavirus spread.

Conditions at home play a factor as well, University of Hawaii Health Policy professor Victoria Fan said, as Pacific Islanders tend to live in larger, multigenerational households with increased risk of exposure to airborne diseases such as Covid and TB.

“It is well known that TB is a respiratory disease that disproportionately affects the poor and those living in crowded housing conditions with poor ventilation,” Fan wrote in an email. “TB is a bacterium that can linger in the air even an hour after a person has left the room.”

The Hawaii Department of Health said overall rates of TB in the state have decreased, but that may be due to fewer health screenings and health care visits amid the pandemic.

“Our public health nurses were heavily engaged in pandemic activities, so some of our TB control efforts were curtailed,” Dr. Glenn Wasserman, chief of the department’s communicable disease and public health nursing division, said in a statement.

“With the resumption of regular public health activities and health care visits, we may see an uptick in TB cases,” Wasserman added.

Social Factors

The pandemic also has directly hindered local and global efforts to stamp out the TB bacteria – one of the deadliest pathogens in the world.

Tuberculosis most commonly manifests as a lung disease and is extremely infectious. The bacteria can lie latent for years before attacking the body during periods of weakened immunity.

While worldwide reported cases of TB fell from 7.1 million in 2019 to 5.8 million in 2020, the World Health Organization the decrease was artificial, the result of a health system overwhelmed by Covid.

Instead, the WHO estimated reduced access to TB tests and treatment caused an additional 100,000 fatalities in 2020, for a total of 1.5 million deaths. While effective therapies exist, barriers to health care mean that 15% of infections end in death.

“The Covid-19 pandemic has reversed years of progress in providing essential TB services and reducing TB disease burden,” the WHO report wrote. “Global TB targets are mostly off-track … and actions to mitigate and reverse these impacts are urgently required.”

Cases are concentrated in South and Southeast Asia and the Pacific. There is a type of TB vaccine, but it only protects against certain severe disease and , so reduction strategies center around early diagnosis and access to treatment.

The drug regimen required to cure TB is costly and can be difficult to tolerate, taking up to six months to complete, which makes adequate funding and medical care essential, according to Fan. But improving the housing situation remains central to the TB fight back home.

“In Hawaii, the shared risk factor for Covid and TB being crowded housing conditions remains a critical area to be systematically addressed,” Fan wrote. “Stamping out TB will require integrated medical, psychological and social approaches.”

Civil Beat’s health coverage is supported by the , Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and .