Journal of Community Health Vol. 17, No. 4, August 1992
COMMENTARY
TUBERCULOSIS, AIDS, AND HOMELESSNESS
After a long period of decline, the annual number of tuberculosis cases reported to the Centers for Disease Control (CDC) began to rise in 1988. In 1990 alone, 25,701 cases were reported nationally, representing a 9.4 percent increase over the number of cases reported in 1989.' This one-year increase was the largest reported since 1953. During the six-year period, 1985-1990, reported cases rose by 15.8 percent. The groups significantly affected by this new epidemic are Hispanics, blacks, and Asians/Pacific Islanders. At the same times that prevalence rates have been rising among these groups, they have been falling among whites and American Indians/Alaskan Natives. * In New York City, the number of reported tuberculosis cases rose from roughly 2,500 in 1989 to 3,500 in 1990, when 250 death were also recorded. ~ Rates of tuberculosis infection in New York City are 4.5 to 5 times the national average. As in the past, tuberculosis in New York City is prevalent in those areas of the city characterized by poverty, substance abuse, and sub-standard housing. In some of these areas, the tuberculosis case rate is now tenfold the rate for the city as a whole just before the beginning of this epidemic.~ Nationally, the largest increase in reported cases has occurred in the 25 to 44 year age group. This may be due to increasing numbers of cases occurring among those with human immunodeficiency virus (HIV) infection, and the acquired immunodeficiency syndrome (AIDS).' The association between HIV infection and the current tuberculosis epidemic is particularly striking in New York City. It is estimated that from 25 percent to 40 percent of all tuberculosis cases in the city are HIV positive. ~ In New York City, most recent cases have been reported among those in the 35 to 45 year age group. Approximately 60% of the 3,500 cases reported in New York City in 1990 were among males. While the overall New York City rate for 1990 was 50 cases per 100,000 population, that for black men between 35 and 55 years of age was 510 per 100,000 population. The rate for Hispanic men in this age range was approximately 250 per 100,000 populationJ © 1992 Human Sciences Press, Inc.
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JOURNAL OF COMMUNITY HEALTH
From 1986 to 1990, the proportion of cases among foreign-born persons rose from 21.6 percent to 24.4 percent? A similar proportional increase has been observed in New York City. Such increases are attributable to the arrival of significant numbers of immigrants from high tuberculosis prevalence areas of the world in recent years. In New York City, approximately 25 percent of cases are occurring among those born outside of the continental United States/ While legal immigrants are screened for tuberculosis, illegal entrants are not. Illegal immigrants often avoid interacting with medical care facilities except for emergencies, and thus often escape early detection. Tuberculosis infection among the homeless is of particular concern since case finding, treatment, and follow-up are especially difficult. It is estimated that there may be from 600 to 1,000 homeless people in New York City with active tuberculosis. ~ Some efforts have been made in New York City to treat the homeless who are infected with tuberculosis. A special shelter for men with tuberculosis has been established, and additional ones have been proposed. Many of the homeless share the same social and economic determinants that affect those at risk in inner-city poverty areas. A very serious concern is the emergence of multiple drug-resistant strains. In New York City, for example, it was recently found that 34 percent of 400 specimens submitted were resistant to one or more drugs. This represents the highest resistance rate thus far found in the United States. 2 A major cause of drug resistance is non-compliance with treatment. The emergence of multiple drug-resistant strains and the increased prevalence of tuberculosis pose significant risks for health care workers, some of whom have already acquired recent infections. Effectively dealing with the current tuberculosis epidemic is not an easy task. Local health authorities, anxious to control the epidemic and stem the emergence of multiple drug resistance, will want to propose measures that will insure drug treatment compliance. Such measures, however, while within the statutory authorities of many local health agencies, will meet with stiff opposition from civil liberties groups. Ultimately, society will be faced with the choice of limiting the spread and preventing further drug resistance by curtailing the freedom of movement of those who will not voluntarily comply with treatment. There is nothing new in this approach, since it was implemented on a large scale for tuberculosis with the sanitorium movement in the early part of this century. However, the value placed on individual rights since then precludes facile implementation of statutory authori-
Pascal James Imperato
189
ties which would in any way compromise these rights. It is likely that this issue will be deliberated by task forces and blue ribbon committees, and ultimately decided by the courts. Pascal James Imperato, MD, MPH & TM Editor
REFERENCES 1. Tuberculosis morbidity in the United States: Final data, 1990. M M W R 41:86, 1992. 2. Adler, J, Report on tuberculosis in New York City before the Committee on Public Health of the New York Academy of Medicine, New York City, January 6, 1992.
COMMENTARY
TUBERCULOSIS, AIDS, AND HOMELESSNESS
After a long period of decline, the annual number of tuberculosis cases reported to the Centers for Disease Control (CDC) began to rise in 1988. In 1990 alone, 25,701 cases were reported nationally, representing a 9.4 percent increase over the number of cases reported in 1989.' This one-year increase was the largest reported since 1953. During the six-year period, 1985-1990, reported cases rose by 15.8 percent. The groups significantly affected by this new epidemic are Hispanics, blacks, and Asians/Pacific Islanders. At the same times that prevalence rates have been rising among these groups, they have been falling among whites and American Indians/Alaskan Natives. * In New York City, the number of reported tuberculosis cases rose from roughly 2,500 in 1989 to 3,500 in 1990, when 250 death were also recorded. ~ Rates of tuberculosis infection in New York City are 4.5 to 5 times the national average. As in the past, tuberculosis in New York City is prevalent in those areas of the city characterized by poverty, substance abuse, and sub-standard housing. In some of these areas, the tuberculosis case rate is now tenfold the rate for the city as a whole just before the beginning of this epidemic.~ Nationally, the largest increase in reported cases has occurred in the 25 to 44 year age group. This may be due to increasing numbers of cases occurring among those with human immunodeficiency virus (HIV) infection, and the acquired immunodeficiency syndrome (AIDS).' The association between HIV infection and the current tuberculosis epidemic is particularly striking in New York City. It is estimated that from 25 percent to 40 percent of all tuberculosis cases in the city are HIV positive. ~ In New York City, most recent cases have been reported among those in the 35 to 45 year age group. Approximately 60% of the 3,500 cases reported in New York City in 1990 were among males. While the overall New York City rate for 1990 was 50 cases per 100,000 population, that for black men between 35 and 55 years of age was 510 per 100,000 population. The rate for Hispanic men in this age range was approximately 250 per 100,000 populationJ © 1992 Human Sciences Press, Inc.
187
188
JOURNAL OF COMMUNITY HEALTH
From 1986 to 1990, the proportion of cases among foreign-born persons rose from 21.6 percent to 24.4 percent? A similar proportional increase has been observed in New York City. Such increases are attributable to the arrival of significant numbers of immigrants from high tuberculosis prevalence areas of the world in recent years. In New York City, approximately 25 percent of cases are occurring among those born outside of the continental United States/ While legal immigrants are screened for tuberculosis, illegal entrants are not. Illegal immigrants often avoid interacting with medical care facilities except for emergencies, and thus often escape early detection. Tuberculosis infection among the homeless is of particular concern since case finding, treatment, and follow-up are especially difficult. It is estimated that there may be from 600 to 1,000 homeless people in New York City with active tuberculosis. ~ Some efforts have been made in New York City to treat the homeless who are infected with tuberculosis. A special shelter for men with tuberculosis has been established, and additional ones have been proposed. Many of the homeless share the same social and economic determinants that affect those at risk in inner-city poverty areas. A very serious concern is the emergence of multiple drug-resistant strains. In New York City, for example, it was recently found that 34 percent of 400 specimens submitted were resistant to one or more drugs. This represents the highest resistance rate thus far found in the United States. 2 A major cause of drug resistance is non-compliance with treatment. The emergence of multiple drug-resistant strains and the increased prevalence of tuberculosis pose significant risks for health care workers, some of whom have already acquired recent infections. Effectively dealing with the current tuberculosis epidemic is not an easy task. Local health authorities, anxious to control the epidemic and stem the emergence of multiple drug resistance, will want to propose measures that will insure drug treatment compliance. Such measures, however, while within the statutory authorities of many local health agencies, will meet with stiff opposition from civil liberties groups. Ultimately, society will be faced with the choice of limiting the spread and preventing further drug resistance by curtailing the freedom of movement of those who will not voluntarily comply with treatment. There is nothing new in this approach, since it was implemented on a large scale for tuberculosis with the sanitorium movement in the early part of this century. However, the value placed on individual rights since then precludes facile implementation of statutory authori-
Pascal James Imperato
189
ties which would in any way compromise these rights. It is likely that this issue will be deliberated by task forces and blue ribbon committees, and ultimately decided by the courts. Pascal James Imperato, MD, MPH & TM Editor
REFERENCES 1. Tuberculosis morbidity in the United States: Final data, 1990. M M W R 41:86, 1992. 2. Adler, J, Report on tuberculosis in New York City before the Committee on Public Health of the New York Academy of Medicine, New York City, January 6, 1992.
