Pan American Health Organization · 1st edition, 2021
Intercultural approach to implementing the End TB Strategy among indigenous peoples in Latin America and the Caribbean
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2021
- Audience
- National and subnational TB programme staff, health authorities, indigenous health leaders, traditional medicine practitioners, civil society organizations, public health professionals
- Evidence
- Expert consensus based on systematic literature review, regional best practices, and intercultural consultations
- Reviewed
- 19 Oct 2026 · GMJ
What this guideline says
GMJ summary
This 2021 guidance from PAHO provides a comprehensive framework for adapting the WHO End TB Strategy to indigenous populations across the Americas, who face TB incidence rates 2–10 times higher than general populations. The document emphasizes an intercultural approach that recognizes traditional medicine, indigenous worldviews, and the social determinants driving TB in these communities, including poverty, malnutrition, geographic isolation, and systemic discrimination.
The guidance is structured around the three pillars of the End TB Strategy—integrated patient-centered care, bold policies and supportive systems, and intensified research—with specific recommendations for each component adapted to indigenous contexts. Key interventions include incorporating the ‘indigenous’ variable into all TB surveillance data, establishing intercultural care routes that integrate traditional and Western medicine, ensuring universal access to rapid diagnostics (including Xpert MTB/RIF in remote areas), implementing community-based directly observed therapy (DOT), and addressing comorbidities such as HIV, diabetes, malnutrition, and substance use.
The document stresses that ending TB in indigenous populations requires multisectoral action beyond health systems, including social protection programs, poverty alleviation, housing improvements, and recognition of indigenous peoples’ territorial and cultural rights. It provides practical implementation steps, best-practice examples from countries including Colombia, Ecuador, Bolivia, and Paraguay, and emphasizes the essential participation of indigenous leaders, traditional healers, and community health workers in all aspects of TB prevention and control.
Key points
For clinicians — doses and thresholds as stated in the guideline
- All health records and TB surveillance systems must include the 'indigenous' variable to enable monitoring and targeted interventions in high-burden populations
- Implement Xpert MTB/RIF rapid molecular testing in remote indigenous areas to shorten time to diagnosis and treatment initiation, with proven feasibility and cost-effectiveness
- Administer BCG vaccination to all indigenous newborns shortly after birth (except those with HIV in high-prevalence settings), and provide latent TB infection (LTBI) treatment to all household contacts under age 5 and people with HIV without requiring tuberculin testing
- Establish intercultural care routes co-designed with traditional healers and indigenous authorities that integrate traditional and Western medicine, recognizing TB-related knowledge, attitudes, and practices specific to each indigenous group
- Implement community-based DOT delivered by trained community health workers or volunteers, which has demonstrated higher treatment success rates than facility-based DOT in indigenous populations
- Screen all TB patients for HIV, diabetes, malnutrition, and substance use disorders; provide nutritional support culturally adapted to traditional diets rather than standardized food packages
- Ensure catastrophic cost protection through social protection programs including transportation subsidies, conditional cash transfers (proven protective factor with OR=0.5), and support for patients and household members
- Train health workers in intercultural health competencies, prioritize indigenous-origin health professionals, and ensure availability of interpreters fluent in indigenous languages where needed
Tuberculosis incidence and relative risk in indigenous populations versus general population in six countries, 2016
Table extracted from the guideline
| Country | Indigenous population (%) | TB incidence general population (per 100,000) | TB incidence indigenous population (per 100,000) | Relative risk |
|---|---|---|---|---|
| Paraguay | 1.9 | 36.3 | 335.3 | 9.3 |
| Brazil | 0.4 | 36.3 | 117.1 | 3.2 |
| Venezuela (Bolivarian Republic of) | 2.7 | 26.0 | 81.3 | 3.1 |
| Panama | 1.0 | 25.9 | 79.0 | 3.1 |
| Colombia | 2.4 | 25.9 | 64.9 | 2.5 |
| Mexico | 9.6 | 17.4 | 12.0 | 0.7 |
Source: Pan American Health Organization, Guidance for Tuberculosis Prevention and Control in Indigenous Populations in the Region of the Americas. Reproduced in summary form.
From the guideline
Verbatim
“In Paraguay, a person who identifies as indigenous is nine times more likely to have TB than a non-indigenous person.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked extensively with vulnerable populations in Georgia and the wider WHO European Region, I find this PAHO guidance particularly instructive for our context. While we lack indigenous populations in the Latin American sense, the intercultural principles apply directly to our work with Roma communities, internally displaced persons, and migrant populations from Central Asia who face systematic barriers to TB care. The most actionable recommendation for Georgian clinicians is the establishment of what PAHO calls 'intercultural care routes'—formalized pathways co-designed with community leaders and health mediators that respect cultural beliefs while ensuring evidence-based diagnosis and treatment. Our National TB Programme should immediately adopt the practice of systematically recording ethnicity and migration status in all TB surveillance data, as countries like Chile and Ecuador have done; without this variable we cannot measure disparities or target interventions effectively. The emphasis on community-based DOT rather than facility-based observation aligns with our pilot projects using community health workers in rural Kakheti and Samegrelo regions. One significant implementation challenge for Georgia will be training sufficient numbers of health workers in cultural competency—the document recommends prioritizing health professionals from the communities being served, but our medical education system has limited representation from minority groups, a structural issue requiring long-term educational policy reform alongside immediate training for current healthcare workers.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 19 Oct 2026
Applicability
Georgia and the South Caucasus
While Georgia does not have indigenous populations as defined in the Americas context, this guidance offers highly relevant lessons for addressing TB in vulnerable and marginalized ethnic minorities, including Roma populations, internally displaced persons from occupied territories, and migrant communities from the South Caucasus and Central Asia. Georgia’s TB incidence (95 per 100,000 in 2020) approaches levels seen in some indigenous communities described here, and the intercultural principles—recognizing cultural health beliefs, integrating community health workers, addressing social determinants, and ensuring catastrophic cost protection—are directly applicable. The National TB Programme should consider adapting the ‘indigenous’ variable concept to systematically capture ethnicity and migration status in surveillance systems, following successful models from Chile and Brazil. The emphasis on decentralized rapid molecular diagnostics and community-based DOT aligns with Georgia’s ongoing efforts to expand GeneXpert coverage and implement patient-centered care models under the Universal Health Care Programme.
Questions this guideline answers
Quick answers
Why do indigenous populations have higher TB rates?
Indigenous populations face TB incidence 2–10 times higher than general populations (up to 9.3 times in Paraguay) due to multiple intersecting factors: extreme poverty, malnutrition, overcrowded housing, geographic isolation limiting healthcare access, higher rates of comorbidities (HIV, diabetes, substance use), historical marginalization and discrimination, and barriers including language, lack of culturally appropriate services, and distrust of Western health systems. Social determinants and structural inequities are the primary drivers.
What is an intercultural care route for TB?
An intercultural care route is a co-designed pathway that integrates traditional medicine practitioners, indigenous authorities, and Western health services in a coordinated system for TB prevention, diagnosis, treatment, and follow-up. It is developed through knowledge dialogues with communities to understand their TB-related beliefs and practices, then maps roles for traditional healers (often the first point of contact), community health workers, and health facilities. The route respects both medical systems and ensures patients can move between them with proper referrals and counter-referrals.
How should TB treatment be delivered in remote indigenous communities?
Community-based directly observed therapy (DOT) delivered by trained community health workers or volunteers in patients' homes or communities is strongly recommended over facility-based DOT. This approach has demonstrated higher treatment success rates, reduces catastrophic costs from daily travel, respects cultural practices, and can integrate support from traditional healers. Where connectivity allows, video-observed therapy (VOT) via smartphones is feasible and acceptable, saving resources while maintaining daily observation. Mobile health units with Xpert MTB/RIF capacity should serve scattered populations, and social protection (transportation subsidies, food support adapted to traditional diets) is essential.
What specific steps are needed for LTBI treatment in indigenous populations?
Systematically provide LTBI treatment to all household contacts under age 5 and all people with HIV without requiring tuberculin testing first (per WHO guidelines). For older children, adolescents, and adults who are contacts, conduct systematic testing and treatment. Ensure BCG vaccination for all indigenous newborns, including through outreach since many births occur outside health facilities with traditional midwives. Use community health workers to identify and follow up contacts. Major barriers include access to health services, understanding of preventive treatment concepts, and ensuring 3–6 month treatment completion; these require community education, engagement of traditional healers, and support systems adapted to local contexts.
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, 2021
- Status
- Current
- Published
- 2021-01-01
- Languages
- English, Spanish, Portuguese
- Scope
- Indigenous populations in the Region of the Americas (Latin America and the Caribbean)
- Audience
- National and subnational TB programme staff, health authorities, indigenous health leaders, traditional medicine practitioners, civil society organizations, public health professionals
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-12277-8 (PDF)
- Evidence
- Expert consensus based on systematic literature review, regional best practices, and intercultural consultations
- Record history
- Created 19 Oct 2026 · updated 19 Oct 2026 · next check Apr 2027
Pan American Health Organization. Guidance for Tuberculosis Prevention and Control in Indigenous Populations in the Region of the Americas. Washington, D.C.: PAHO; 2021. (ISBN 978-92-75-12277-8).GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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