Preventing TB among Colorado’s refugee communities

At the age of 18, while in junior college and pursuing the dream of becoming a soccer star like most Ghanaian men, Theo Abbey witnessed the death of a beloved family friend.

It started with a dry cough, chest pain and fever—all symptoms of a common cold, his friend thought.  But the symptoms worsened, suddenly taking his life.  Later, Abbey would learn it was tuberculosis (TB) that took his friend’s life.

Theo Abbey a master of public health student at the Colorado School of Public Health is dedicated to preventing TB in Colorado.

Now more than 16 years later, Abbey is applying his passion for communicable diseases at Denver Public Health’s Denver Metro Tuberculosis Clinic.

As part of his practicum requirement for the Master of Public Health Program at the Colorado School of Public Health, Abbey spent a semester helping the clinic identify and contact organizations working with newly arrived immigrants and refugees—the population at highest risk for developing active TB.

“There is a perception among refugees, especially among Africans, that tuberculosis isn’t a serious health issue,” says Abbey. 

“Most refugees do not have the ability to correctly identify the symptoms associated with having tuberculosis and usually assume it may be a cold or just a headache. As a result, they will simply take cold medicine and not think anything about their real illness until it becomes serious.”

Approximately 1,100 refugees arrive in Colorado each year, the majority resettling in the Denver metro area.  Their countries of origin include Mexico, China, Somalia, Ethiopia, India, Vietnam, and the Philippines, among others.  

While all refugees go through an initial health screening for hepatitis B, TB and intestinal parasites, such as blastocystis and giradia, the need for additional follow-up, education and treatment is high.

“The screening requirements for new immigrants and refugees are very effective at identifying active TB quickly so that patients can get treatment and will not pose any threat,” says Dr. Robert Belknap, assistant professor at the University of Colorado School of Medicine and infectious disease specialist at Denver Public Health. 

“Persons with latent TB don’t pose any threat to the community now, but in the future [less than 5 percent] of these people will develop active TB and potentially transmit it to others,” he explains. “It’s these future cases that we are trying to prevent.”

The Denver Metro TB Clinic works to identify everyone with suspected or confirmed TB and provides appropriate treatment for those who do. Since nearly 75 percent of the individuals diagnosed at the clinic are foreign-born, Abbey was asked to conduct a needs assessment of health outreach programs for refugees and immigrants in the metro area.

“We need to connect better with organizations working directing with immigrants and refugees so that we can coordinate activities with them and ensure we are maximizing our efforts to prevent future TB cases,” says Belknap.

In order to do so, Abbey visited the Lowry Refugee Health Clinic, the Colorado Asian Health Education and Promotion’s Refugee Program and Ecumenical Refugee and Immigration Services, among others.  All offer preventive health education sessions and refer patients to the Denver Metro TB Clinic for screening and treatment.

While one would hope refugees are receiving and utilizing information about TB treatment, Abbey says there are many barriers. 

With no car, minimal English skills and no extra income, most refugees find it difficult to go to a clinic or outreach program.  Add on cultural beliefs about preventive medicine, educational pamphlets in English, and unfamiliarity with TB symptoms, and many refugees end up resisting treatment.

“Treatment is so cheap, yet tuberculosis is killing people throughout the world because they aren’t able to recognize the symptoms,” Abbey says. “There is a need for trained opinion leaders within the refugee communities that would be able to interact with them and create trust,” says Abbey.

“If there is trust the refugees may be more willing to adhere to their treatments.”

Adherence to treatment is difficult for all people, says Belknap. The recommended treatment regimen requires taking medication daily for nine months and there are many side effects, like fatigue and nausea.  Patients are also required to attend monthly check-ups.  “In addition to all this, they have the added stress of trying to find work and housing, and acclimating to a new culture,” Belknap says.

While there is much to be done to improve TB outreach programs in the metro area, Abbey’s practicum helped Denver Public Health identify many.  He believes there needs to be incentives for the refugees to attend the outreach programs, such as transportation or child care. Education and training opportunities for health care providers about prevention, diagnosis and treatment of TB are also needed.

“We can eliminate tuberculosis in the refugee community and stop it from spreading to other communities in the United States, but we need to follow people and get opinion leaders to explain the health risks,” states Abbey.  “We also need to provide more education about the risks of leaving the disease untreated and take language barriers into consideration.”

“Theo’s practicum helped to raise awareness about the risk for TB among workers in the organizations,” says Belknap. “The program will now have additional people on the lookout for patients with symptoms of active TB and advocates for getting tested and treated for latent TB.”