Nemesis revisited: tuberculosis infection in a New York City men's shelter

Care Cascade for targeted tuberculosis testing and linkage to Care in Homeless Populations in the United States: a meta-analysis

BACKGROUND

Homelessness increases the risk of tuberculosis (TB) disease and latent TB infection (LTBI), but persons experiencing homelessness often lack access to testing and treatment. We assessed the yield of TB testing and linkage to care for programs targeting homeless populations in the United States.

METHODS

We conducted a comprehensive search of peer-reviewed and grey literature, adapting Cochrane systematic review methods. Two reviewers independently assessed study eligibility and abstracted key data on the testing to care cascade: number of persons reached, recruited for testing, tested for LTBI, with valid test results, referred to follow-up care, and initiating care. We used random effects to calculate pooled proportions and 95% confidence intervals (CI) of persons retained in each step via inverse-variance weighted meta-analysis, and cumulative proportions as products of adjacent step proportions.

RESULTS

We identified 23 studies published between 1986 and 2014, conducted in 12 states and 15 cities. Among studies using tuberculin skin tests (TST) we found that 93.7% (CI 72.4-100%) of persons reached were recruited, 97.9% (89.3-100%) of those recruited had tests placed, 85.5% (78.6-91.3%) of those with tests placed returned for reading, 99.9% (99.6-100%) of those with tests read had valid results, and 24.7% (21.0-28.5%) with valid results tested positive. All persons testing positive were referred to follow-up care, and 99.8% attended at least one session of follow-up care. Heterogeneity was high for most pooled proportions. For a hypothetical cohort of 1000 persons experiencing homelessness reached by a targeted testing program using TST, an estimated 917 were tested, 194 were positive, and all of these initiated follow-up care.

CONCLUSIONS

Targeted TB testing of persons experiencing homelessness appears effective in detecting LTBI and connecting persons to care and potential treatment. Future evaluations should assess diagnostic use of interferon gamma release assays and completion of treatment, and costs of testing and treatment.

Contingency Management Interventions for HIV, Tuberculosis, and Hepatitis Control Among Individuals With Substance Use Disorders: A Systematized Review

Hepatitis, HIV and tuberculosis are significant and costly public health problems that disproportionately affect individuals with substance use disorders (SUDs). Incentive-based treatment approaches (i.e., contingency management; CM) are highly effective at reducing drug use. The primary aim of this report is to review the extant literature that examines the efficacy of CM interventions for the prevention, diagnosis and treatment of hepatitis, HIV and tuberculosis among individuals with SUDs. A literature search identified 23 controlled studies on this topic. In approximately 85% of the studies, CM produced significantly better adherence to prevention, diagnosis and treatment-related medical services, with adherence rates averaging almost 35% higher among patients receiving incentives vs. control condition participants. Findings from these studies parallel the results of a meta-analysis of CM interventions for the treatment of SUDs. The results also suggest that the principles that underlie the efficacy of CM generalize across infectious disease and substance abuse treatment behaviors. The application of additional principles from the literature on CM for treatment of SUDs to interventions targeting infectious disease control would be beneficial. Further development and dissemination of these interventions has the potential to greatly impact public health.

A population-based assessment of the health of homeless families in New York City, 2001-2003

OBJECTIVES

We compared estimated population-based health outcomes for New York City (NYC) homeless families with NYC residents overall and in low-income neighborhoods.

METHODS

We matched a NYC family shelter user registry to mortality, tuberculosis, HIV/AIDS, and blood lead test registries maintained by the NYC Department of Health and Mental Hygiene (2001-2003).

RESULTS

Overall adult age-adjusted death rates were similar among the 3 populations. HIV/AIDS and substance-use deaths were 3 and 5 times higher for homeless adults than for the general population; only substance-use deaths were higher than for low-income adults. Children who experienced homelessness appeared to be at an elevated risk of mortality (41.3 vs 22.5 per 100,000; P < .05). Seven in 10 adult and child deaths occurred outside shelter. Adult HIV/AIDS diagnosis rates were more than twice citywide rates but comparable with low-income rates, whereas tuberculosis rates were 3 times higher than in both populations. Homeless children had lower blood lead testing rates and a higher proportion of lead levels over 10 micrograms per deciliter than did both comparison populations.

CONCLUSIONS

Morbidity and mortality levels were comparable between homeless and low-income adults; homeless children's slightly higher risk on some measures possibly reflects the impact of poverty and poor-quality, unstable housing.

The impact of New York City's 1975 fiscal crisis on the tuberculosis, HIV, and homicide syndemic

In 1975, New York City experienced a fiscal crisis rooted in long-term political and economic changes in the city. Budget and policy decisions designed to alleviate this fiscal crisis contributed to the subsequent epidemics of tuberculosis, human immunodeficiency virus (HIV) infection, and homicide in New York City. Because these conditions share underlying social determinants, we consider them a syndemic, i.e., all 3 combined to create an excess disease burden on the population. Cuts in services; the dismantling of health, public safety, and social service infrastructures; and the deterioration of living conditions for vulnerable populations contributed to the amplification of these health conditions over 2 decades. We estimate that the costs incurred in controlling these epidemics exceeded 50 billion US dollars (in 2004 dollars); in contrast, the overall budgetary saving during the fiscal crisis was 10 billion US dollars. This history has implications for public health professionals who must respond to current perceptions of local fiscal crises.

Outbreak of tuberculosis among homeless persons coinfected with human immunodeficiency virus

We investigated a cluster of patients with tuberculosis (TB) in North Carolina and determined the extent of transmission of 1 strain of Mycobacterium tuberculosis. A retrospective cohort study was conducted. Homeless shelter attendance and medical records for 1999 and 2000 were reviewed. The period of exposure to M. tuberculosis was determined, and shelter residents were offered TB screening. DNA fingerprinting was performed on 72 M. tuberculosis isolates. In addition to the initial index cluster of 9 patients, another 16 patients were identified. Isolates of M. tuberculosis from all 25 patients shared a matching DNA fingerprint pattern. All but 1 patient was male, 22 (88%) were African American, and 14 (56%) were human immunodeficiency virus-infected. An epidemiological link to a single shelter was identified for all but 1 patient. Earlier recognition of this shelter as a site of M. tuberculosis transmission could have been facilitated through innovative approaches to contact investigation and through genetic typing of isolates.

Crack cocaine use and other risk factors for tuberculin positivity in drug users

Two-step tuberculin testing and standardized interviews of 793 current and former drug users were performed to determine the risk factors for tuberculin positivity. The prevalence of tuberculin positivity was 25%. Factors independently associated with tuberculin positivity among participants seronegative for human immunodeficiency virus (HIV) included crack cocaine use (adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.5), employment as a home health aide (adjusted OR, 2.1; 95% CI, 1.0-4.1), birth in Puerto Rico (adjusted OR, 2.2; 95% CI, 1.3-3.6), foreign birthplace (adjusted OR, 4.7; 95% CI, 1.6-13.6), African American race (adjusted OR, 2.5; 95% CI, 1.2-5.0), reported tuberculosis exposure (adjusted OR, 2.3; 95% CI, 1.2-4.4), and older age (adjusted OR, 2.9; 95% CI, 1.2-6.7). Additional risk factors among HIV-infected participants included alcoholism (adjusted OR, 2.4; 95% CI, 1.0-5.8) and high CD4(+) lymphocyte count. Identification of and administration of appropriate chemoprophylaxis to drug users with these risk factors should be given high priority.

Infections in the homeless

Homeless people in developed countries have specific problems predisposing them to infectious diseases. Respiratory infections and outbreaks of tuberculosis and other aerosol transmitted infections have been reported. Homeless intravenous drug users are at an increased risk of contracting HIV, and hepatitis B and C infections. Skin problems are the main reason the homeless seek medical attention, and these commonly include scabies, pediculosis, tinea infections, and impetigo. Many foot disorders are more prevalent in the homeless including ulcers, cellulitis, erysipelas, and gas gangrene. The louse transmitted bacteria Bartonella quintana has recently been found to cause clinical conditions in the homeless such as urban trench fever, bacillary angiomatosis, endocarditis, and chronic afebrile bacteraemia. Treatment of homeless people is complicated by financial constraints, self-neglect, and lack of adherence. Patients with serious and contagious illnesses should be hospitalised. Physicians should be aware of these specific issues to enhance care.

Mycobacterial disease of the parotid gland

Mycobacterial disease is an unusual but important condition that should be considered in the differential diagnosis of a discrete parotid gland swelling or mass. The management of this condition involves exclusion of neoplastic disease and combined medical and surgical therapy. We present 5 cases of mycobacterial involvement of the parotid gland and discuss issues surrounding the diagnosis and treatment options.

Disease patterns of the homeless in Tokyo

In recent years, homelessness has been recognized as a growing urban social problem in various countries throughout the world. The health problems of the homeless are considerable. The purpose of this study was to elicit, with sociodemographic profiles, the disease patterns among Tokyo's homeless. The subjects were 1,938 men who stayed at a welfare institution from 1992 to 1996. Diagnosed diseases/injuries and sociodemographic profiles were analyzed. The disease patterns of the homeless were compared to those of the male general population. Of the subjects, 8.3% were admitted to the hospital; 64.0% received outpatient care. Their observed morbidity rates by disease category were greater than those of the male general population in both Japan and Tokyo. Comorbidity of alcoholic psychosis/alcohol-dependent syndrome to both liver disease and pulmonary tuberculosis were greater than the average (P < .01). Construction work brought a higher risk of pulmonary tuberculosis (odds ratio = 2.0) and dorsopathies (odds ratio = 1.4) than did other jobs (P < .05). Disease patterns among the homeless in Tokyo were characterized by alcoholic psychosis/alcohol-dependence syndrome; liver disease; pulmonary tuberculosis; diabetes mellitus; fractures, dislocations, sprains, strains; hypertension; and cerebrovascular disease. Although the sociodemographic backgrounds of Tokyo's homeless have become more diverse, the principal occupation of the homeless was unskilled daily construction work, which underlay the characteristics of their disease patterns.

Methods for successful follow-up of elusive urban populations: an ethnographic approach with homeless men

Public health is paying increasing attention to elusive urban populations such as the homeless, street drug users, and illegal immigrants. Yet, valid data on the health of these populations remain scarce; longitudinal research, in particular, has been hampered by poor follow-up rates. This paper reports on the follow-up methods used in two randomized clinical trials among one such population, namely, homeless men with mental illness. Each of the two trials achieved virtually complete follow-up over 18 months. The authors describe the ethnographic approach to follow-up used in these trials and elaborate its application to four components of the follow-up: training interviewers, tracking participants, administering the research office, and conducting assessments. The ethnographic follow-up method is adaptable to other studies and other settings, and may provide a replicable model for achieving high follow-up rates in urban epidemiologic studies.

Evaluation of a social health intervention among homeless tuberculosis patients

SETTING

Homeless and other fringe groups are a priority in the global strategies of tuberculosis prevention and control in big cities, as a consequence of their generally poor adherence to treatment and concurrent multiple social and health problems.

OBJECTIVE

To evaluate a social care and health follow-up programme targeting homeless tuberculosis patients in Ciutat Vella District, Barcelona, which covered 210 patients from 1987 to 1992. During directly observed treatment, primary health care and, if necessary, accommodation was provided.

DESIGN

The differential tuberculosis incidence rate between Ciutat Vella and the other districts of Barcelona, the percentage of successfully completed treatments and the days of hospitalization saved by the programme were measured.

RESULTS

There was a significant decrease in the tuberculosis incidence rate among homeless patients in Ciutat Vella (from 32.4 per 10(5) inhabitants in 1987, to 19.8 per 10(5) in 1992, P = 0.03), compared to an unchanged rate elsewhere (1.6 per 10(5) inhabitants in 1987, compared to 1.7 per 10(5) in 1992, P = 0.34). A smaller than expected proportion, 19.6%, of patients failed to complete their treatment, and a decrease in the mean period of hospitalization for tuberculosis in the district hospital was recorded, falling from a mean 27.1 days in 1986 to a mean 15.7 days in 1992.

CONCLUSION

The programme appears to be both effective and efficient, as it has enabled a large number of homeless patients to complete their treatment successfully, at the same time saving twice the amount of funds invested.

Tuberculosis, AIDS, and death among substance abusers on welfare in New York City

BACKGROUND

In New York City, the incidence of tuberculosis has more than doubled during the past decade. We examined the incidence of tuberculosis and the acquired immunodeficiency syndrome (AIDS) and the rate of death from all causes in a very-high-risk group--indigent subjects who abuse drugs, alcohol, or both.

METHODS

In 1984 we began to study prospectively a cohort of welfare applicants and recipients 18 to 64 years of age who abused drugs or alcohol. The incidence rates of tuberculosis, AIDS, and death for this group were ascertained through vital records and New York City's tuberculosis and AIDS registries.

RESULTS

The cohort was followed for eight years. Of the 858 subjects, tuberculosis developed in 47 (5.5 percent), 84 (9.8 percent) were given a diagnosis of AIDS, and 183 (21.3 percent) died. The rates of incidence per 100,000 person-years were 744 for tuberculosis, 1323 for AIDS, and 2842 for death. In this group of welfare clients, the rate of newly diagnosed tuberculosis was 14.8 times that of the age-matched general population of New York City; the rate of AIDS was 10.0 times as high; and the death rate was 5.2 times as high. There was no significant difference in the rate of new cases of tuberculosis between subjects with positive skin tests and those with negative skin tests at examination in 1984.

CONCLUSIONS

Among indigent alcohol and drug abusers in New York City, the rates of tuberculosis, AIDS, and death are extremely high. In this population, a single positive or negative skin test does not predict the development of tuberculosis, probably because both anergy and new infections are common. If programs to control tuberculosis and AIDS are to be effective in groups of indigent substance abusers, health services must be integrated into the welfare delivery system.

Tuberculosis among the homeless at a temporary shelter in London: report of a chest x ray screening programme

STUDY OBJECTIVE

To estimate the prevalence of active pulmonary tuberculosis in a homeless population in London and to assess whether those with suspected disease could be integrated into the existing health care system for further follow up and treatment.

DESIGN

Voluntary screening programme based on a questionnaire survey and chest x ray. SETTING AND CASES: Screening programmes were set up over the Christmas period in 1992 and 1993 at a shelter for the homeless in London. An offer of screening was made to all individuals who visited the centre and an interviewer administered questionnaire was completed on those who volunteered for the screening. Chest x rays were carried out, developed, and read on site. Individuals with chest x rays features suggestive of tuberculosis or other medical problems were referred to a hospital of their choice. RESULTS AND OUTCOME: In 1992 nearly 1600 people visited the centre, of whom 372 volunteered for the screening and 342 were x rayed. Nineteen of the 342 (5.6%) had radiological features suggestive of active tuberculosis. In 1993 around 2000 homeless people visited the centre, of whom 270 volunteered for the screening and 253 were x rayed. Eleven (4.3%) had features consistent with active tuberculosis on the basis of the chest x rays and clinical examination by a chest physician. Overall, of 595 people x rayed in the two surveys, 30 (5%) had changes suggestive of active tuberculosis. Further investigations confirmed nine (1.5%) with active pulmonary disease and eight with no active tuberculosis. In 13, the diagnosis was not determined as four declined further investigation and nine did not attend their hospital appointment.

CONCLUSION

Tuberculosis among the homeless remains a cause for concern. Follow up and treatment present unique difficulties. Services for the homeless need to include mechanisms for timely diagnosis and monitored treatment. Control programmes designed for the needs of the homeless are required.