Faculty Bibliography

We conducted a retrospective study to examine trends in latent tuberculosis infection (LTBI) and TB disease rates among homeless persons in shelters in New York, NY, 1992-2006. Although TB case rates fell from 1,502/100,000 population to 0, a 31% LTBI rate in 2006 shows the value of identifying and treating TB in the homeless.

Directly observed therapy (DOT) to enable completion of antituberculous therapy works. DOT is largely responsible for the recent improvement in tuberculosis case rates in New York City. Despite this favorable trend, the factors of significant HIV disease rates and of multidrug resistant forms of tuberculosis bacteria in the population are of grave concern. Therefore, in addition to DOT other means of preventing tuberculosis spread should be encouraged. These include directly observed preventive therapy (DOPT) programs, use of masks, improved ventilation in crowded settings such as homeless shelters, and ultraviolet light germicidal irradiation of upper room air in such locations.

The objective of this study was to determine the prevalence of tuberculous infection and the incidence of active tuberculosis in homeless men attending a shelter-based clinic and to examine risk factors for acquisition of infection and development of active disease. The design was a prospective cross-sectional survey. Men were evaluated by standardized interviews using a questionnaire. Where indicated, skin testing with PPD, collection of sputum for smear and culture for acid-fast bacilli, and chest x-ray films were performed. The setting was an on-site clinic at a men's shelter in New York City. The patients were men attending the clinic for physical examinations for the work program or requesting evaluation of various medical problems. A total of 1,853 men were evaluated over a 73-month period. The overall rate of infection was 42.8 percent, including 27.0 percent with a positive PPD test, 9.8 percent with a history of a positive PPD test, and 6.0 percent with active tuberculosis. Increasing age, length of stay in the shelter system, black race, and intravenous drug use were found to be independently associated with tuberculous infection. Age, length of stay in the shelter system, and intravenous drug use were independently associated with active tuberculosis. We achieved a compliance rate of 36 percent completing treatment and 13 percent receiving treatment at the conclusion of the study

Health care is generally unavailable for the homeless. This heterogeneous group of men and women, including long-term street dwellers, residents of shelters, the chronically mentally ill, the economically debased, and alienated youth, are subject to a broad range of acute and chronic diseases, intensified by unsuitable living conditions, stress, and sociopathic behavior. Trauma, pulmonary tuberculosis, infestations, and peripheral vascular disease are common problems among the homeless; incomplete and fragmentary medical care permits exacerbation of chronic disorders. Outreach programs imaginatively constructed by teams of physicians, nurses, and social workers can effectively reestablish and maintain health services for these disenfranchised persons.