Tuberculosis Skin Testing Among Homeless Adults

Abstract

OBJECTIVE:To document the prevalence of tuberculosis (TB) skin test positivity among homeless adults in Los Angeles and determine whether certain characteristics of homelessness were risk factors for TB. DESIGN:Cross-sectional study. SETTING: Shelters, soup lines, and outdoor locations in the Skid Row and Westside areas of Los Angeles.PARTICIPANTS: A representative sample of 260 homeless adults. MEASUREMENTS AND MAIN RESULTS:Tuberculosis tine test reactivity was measured. The overall prevalence of TB skin test positivity was 32%: 40% in the inner-city Skid Row area and 14% in the suburban Westside area. Using multiple logistic regression, TB skin test positivity was found to be associated with living in crowded or potentially crowded shelter conditions, long-term homelessness, geographic area, history of a psychiatric hospitalization, and age. nderstanding the epidemiology of tuberculosis (TB) among the homeless, as well as other high-risk populations, is critical. Despite relatively recent predictions that TB could be eradicated in the United States by the year 2010, 1-3 we have been confronted by a sharp rise in active TB (10% increase between 1985 and 1994) 4 and an increase in multidrug-resistant TB since 1985 when reported cases of TB reached their lowest levels since national reporting began in 1953. [4][5][6][7] This increase in active TB has also led to increased numbers of individuals with newly acquired asymptomatic TB infection resulting from contact with persons with active contagious disease. Such individuals are at increased risk of developing active disease: the 1-year risk of becoming an active case is 3% within 1 year of infection and 0.5% in each subsequent year after 2 years of infection. 8 A multiplicity of factors, including the HIV/AIDS epidemic, increasing poverty and homelessness in America's cities, illicit drug use, budgetary constraints on local health departments, immigration from high-prevalence nations, and high rates of noncompliance among TB patients, have contributed to the resurgence of TB. [9][10][11][12][13][14][15][16][17][18][19][20][21][22] Previous research on homeless adults demonstrated their elevated risk of asymptomatic TB infection, active disease, and multidrug-resistant TB. [23][24][25][26][27][28] Further, reports have cited outbreaks of TB in emergency shelters for the homeless in Boston and Ohio,29,30 as well as in a neighborhood bar frequented by a homeless person with active disease. 31 Why is the risk of TB increased among homeless persons? Among the homeless, men outnumber women approximately four to one and ethnic and racial minority groups, especially African Americans, are overrepresented. [32][33][34] A disproportionate number of individuals with serious mental health problems (including previous psychiatric hospitalization), or a history of substance dependence, have been found among the homeless, and a significant number of homeless persons have dual diagnoses of mental illness and substance dependence. [35][36][37][38] Further, homeless persons have gr...

Latent Tuberculosis among Persons at Risk for Infection with HIV, Tijuana, Mexico

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Management and control of tuberculosis control in socially complex groups: a research programme including three RCTs

“…The primary outcome was the proportion of participants with a positive QuantiFERON-TB Gold assay result. Based on previous US studies, 4,5,15 we expected a minimum of 10% of participants to test positive for latent tuberculosis infection. We required 500 participants to measure this within 95% confidence intervals (CIs) between 8% and 13%.…”

“…Individuals experiencing homelessness have high rates of tuberculosis infection and often present late to health-care services. 3 Latent tuberculosis infection is common in homeless populations in low-burden countries, 4,5 although limited data are available in the UK.…”

HIV Risk Reduction in a Nurse Case-managed TB and HIV Intervention among Homeless Adults

“…While the prevalence of active TB is approximately 4.9 per 100,000 in the general population of the United States (Centers for Disease Control and Prevention (CDC), 2005), rates in homeless populations are estimated to be 20-30-fold higher. Estimates of latent TB infection, as indicated by purified protein derivative (PPD) positive skin tests, range from 13 percent to 32 percent in shelter-and clinic-based studies of homeless populations (Gelberg et al, 1997;Griffin & Hoff, 1999).…”