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...

Housing Patterns and Correlates of Homelessness Differ by Gender among Individuals Using San Francisco Free Food Programs

“…While these situations may render the individual Bsheltered^by some standards, it is unlikely that the shelter is stable or even safe in many circumstances, and may increase exposure to violence and sexual risk behaviors. An emphasis on temporary arrangements captures transitions in and out of homelessness, 28 and expansion of this concept should be considered for future homeless studies, particularly those focused on women. Additional limitations include potential bias from self-reported information and the absence of data on victimization, which has been linked to homelessness in a variety of studies.…”

Tuberculosis Knowledge, Perceived Risk and Risk Behaviors Among Homeless Adults: Effect of Ethnicity and Injection Drug Use

“…1 Homeless people are at high risk for both latent and active TB because they live in homeless shelters and other congregate facilities and are more likely to engage in risk behaviors, such as the use of injection drugs and other substances of abuse. [2][3][4] Moreover, several studies have demonstrated high rates of substance abuse among tuberculin positive individuals or those at high risk for infection. [5][6][7] In a recent study, Howard et al 8 reported independent associations for tuberculin positivity and crack cocaine use, as well as alcoholism, among participants seronegative for human immunodeficiency virus (HIV).…”

“…Although TB testing is an effective means of case finding, the temporary nature of homeless living situations often hinders outreach opportunities. Moreover, with survival concerns tending to take primacy over other matters, 3 homeless persons may not regard TB prevention as an important priority, particularly when TB knowledge is lacking. Poor knowledge about TB and its transmission may impact perceived risk of acquiring the disease and create treatment delays.…”

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

“…However, we found very little information in our included studies regarding the intersection of these two critical risk populations in our included studies. Only one study stated the proportion of the study population that was born abroad; this study found that 17.3% of 260 homeless persons tested for TB in Los Angeles in the early 1990’s were non-US born [ 16 ].…”