Variation by Race and Ethnicity in the Population Attributable Fractions Associated With Key Tuberculosis Risk Factors in the United States

OBJECTIVE: Although the overall incidence of tuberculosis (TB) in the United States has declined in the last 2 decades, the incidence among racial and ethnic minority populations remains elevated. The objective of this study was to estimate the contributions of 4 risk factors to the incidence of TB, stratified by race and ethnicity and recent transmission in the United States. METHODS: We estimated the population attributable fractions (PAFs) of TB and TB attributed to recent transmission (RT-TB) associated with HIV, diabetes, current incarceration, and past-year experience of homelessness in the United States during 2011-2015 and 2016-2019, stratified by race and ethnicity. RESULTS: The 4 risk factors contributed modestly to TB and RT-TB in the overall US population. During 2016-2019, the estimated PAFs for HIV were 5.0% of all TB cases (6.0% among RT-TB), 6.7% (6.0% among RT-TB) for diabetes, 2.8% (3.9% among RT-TB) for incarceration, and 4.1% (11.3% among RT-TB) for homelessness but varied substantially by race and ethnicity. Diabetes-associated PAFs for RT-TB were >10% among Asian, Hispanic, and Native Hawaiian or Other Pacific Islander populations but 0% among other populations. By contrast, PAFs for RT-TB associated with homelessness were <2% among Asian and Native Hawaiian or Other Pacific Islander populations but >10% among Hispanic, Black, American Indian or Alaska Native, and White populations. CONCLUSIONS: Efforts to reduce TB disparities in the United States should consider race and ethnicity and associated context.