Prevalence of HIV infection among psychiatric patients in a New York City men's shelter.

We report on the prevalence of human immunodeficiency virus (HIV) infection among psychiatric patients in a New York City shelter for homeless men. We reviewed the records of all 90 men discharged from the shelter psychiatry program to community housing over a 2-year period. HIV serostatus was recorded for 62 of the 90 men. Of these 62, 12 (19.4%) were positive. There were 28 men whose serostatus was not recorded. Data on the HIV risk behaviors of these 28 men suggested that seroprevalence could have been similarly high among them. The results indicate an urgent need to develop and apply preventive interventions for HIV in this population.     

Mortality among homeless shelter residents in New York City

OBJECTIVES: This study examined the rates and predictors of mortality among sheltered homeless men and women in New York City. METHODS: Identifying data on a representative sample of shelter residents surveyed in 1987 were matched against national mortality records for 1987 through 1994. Standardized mortality ratios were computed to compare death rates among homeless people with those of the general US and New York City populations. Logistic regression analysis was used to examine predictors of mortality within the homeless sample. RESULTS: Age-adjusted death rates of homeless men and women were 4 times those of the general US population and 2 to 3 times those of the general population of New York City. Among homeless men, prior use of injectable drugs, incarceration, and chronic homelessness increased the likelihood of death. CONCLUSIONS: For homeless shelter users, chronic homelessness itself compounds the high risk of death associated with disease/disability and intravenous drug use. Interventions must address not only the health conditions of the homeless but also the societal conditions that perpetuate homelessness.     

A survey of latent tuberculosis infection among laboratory healthcare workers in New York City.

OBJECTIVE: To determine the prevalence of positive tuberculin skin tests (TSTs), incidence of TST conversion, risk factors for positive TSTs, and history of active TB among HCWs in microbiology laboratories in New York City. DESIGN: Two-year survey from May 1999 to June 2001. SETTING: Nineteen microbiology laboratories. RESULTS: During the first year, interviews were conducted with 345 laboratory HCWs (mean, 18 HCWs per site; range, 2 to 51) to assess the prevalence of positive TSTs, but 3 (1%) could not recall their result and were excluded from further analyses. The mean age of the remaining 342 HCWs was 48 years; 68% (n = 233) were female, 54% (n = 183) received bacille Calmette-Guerin (BCG) vaccination, and 71% (n = 244) were foreign born. The prevalence of a positive TST was 57% (n = 196), but only 20% (n = 39) of the HCWs received isoniazid. The incidence of TST conversion in the second year of the study was 1% (1 of 108). Multivariate analysis identified age (odds ratio [OR] per year, 1.05; 95% confidence interval [CI95], 1.02-1.08), foreign birth (OR, 3.80; CI95, 1.98-7.28), BCG immunization (OR, 4.89; CI95, 2.72-8.80), and employment in a mycobacteriology laboratory (OR, 2.14; CI95, 1.25-3.68) as risk factors for a positive TST. Only one HCW had been treated for active TB. CONCLUSIONS: The prevalence of positive TSTs was high among laboratory HCWs, but the TST conversion rate was low. Higher rates of treatment for latent TB infection are desirable.     

The status of tuberculosis control in New York City.

Problems in tuberculosis control still exist in New York City. They range from an increase in the incidence of the disease to the discovery of new cases in children under 5 years of age. Ninety-three percent (1,395) of the cases reported in 1980 were verified by cultures positive for tuberculosis. The rest of the cases in the 1980 tuberculosis disease count were verified by histology or a physician''s recommendation for treatment with two or more antituberculosis drugs. Of the tuberculosis at extrapulmonary sites, pleural meningeal and miliary tuberculosis, as well as genitourinary tuberculosis, ranked high in incidence in 1980. New tuberculosis cases occurred in all age groups, but the 37 cases in the age group 0-4 years is alarming and indicates a high rate of transmission of tuberculosis from parents to children. Performance indicators of the Centers for Disease Control show that in terms of drug continuity, completion of treatment, and bacteriological conversions to negative, a great deal needs to be done in New York City. The tuberculosis mortality rate for the city has been showing a steady decline over the years; it was 1.8 per 100,000 population in 1980.     

Predictors of homelessness among families in New York City: from shelter request to housing stability.

OBJECTIVES: This study examined predictors of entry into shelter and subsequent housing stability for a cohort of families receiving public assistance in New York City. METHODS: Interviews were conducted with 266 families as they requested shelter and with a comparison sample of 298 families selected at random from the welfare caseload. Respondents were reinterviewed 5 years later. Families with prior history of shelter use were excluded from the follow-up study. RESULTS: Demographic characteristics and housing conditions were the most important risk factors for shelter entry; enduring poverty and disruptive social experiences also contributed. Five years later, four fifths of sheltered families had their own apartment. Receipt of subsidized housing was the primary predictor of housing stability among formerly homeless families (odds ratio [OR] = 20.6, 95% confidence interval [CI] = 9.9, 42.9). CONCLUSIONS: Housing subsidies are critical to ending homelessness among families.     

Factors associated with tuberculosis treatment interruption in New York City.

SETTING: Large urban tuberculosis control program. OBJECTIVES: To determine the frequency and characteristics of treatment interruptions, and the factors associated with the different types of treatment interruptions. DESIGN: This was a case-control study using culture-positive tuberculosis (TB) patients verified in 1998-1999. Case patients included those in whom any of the following mutually exclusive categories of treatment interruption: default with return to therapy, directly observed therapy nonadherence, default without return to therapy, or multiple types of interruptions. Controls were selected randomly from the cohort. RESULTS: Overall, 6.0 percent of patients had treatment interruptions. All types of treatment interruption were associated with prolonged treatment course and decreased treatment completion rates. The median number of months to treatment interruption was 4.0 (range, 0.5-28.9 months). Two factors were significantly associated with every type of interruption: homelessness and lack of awareness of the severity of TB disease. In multivariate analysis, only lack of awareness of the severity of disease remained independently associated with all interruption types. CONCLUSION: Efforts to improve patients' understanding of TB disease and related treatment issues may be an important TB control program strategy and should be emphasized at the initiation of therapy and at intervals throughout the treatment course to minimize treatment interruption.     

The resurgence of tuberculosis in New York City: a mixed hierarchically and spatially diffused epidemic.

For New York City from 1978 to 1990, plotting the 3-year running averages of citywide new tuberculosis cases against the middle year yielded an S-shaped curve, with the inflection point at 1983 between early slow and late rapid rise. The inflection in the S curve appears to be associated with hierarchical establishment of secondary epicenters, and the phase of rapid rise in new cases seems to be associated with spatial diffusion from both the primary and secondary epicenters.     

Incidence of tuberculosis infection among New York State prison employees.

OBJECTIVES: This study examined tuberculosis skin test conversions among 24,487 New York State prison employees in 1992. METHODS: Conversions were analyzed by prison and by job category. RESULTS: The conversion rate was 1.9%. Employees in prisons with low and high numbers of prisoner cases had odds ratios for conversion of 1.67 (95% confidence interval [CI] = 1.27, 2.19) and 2.20 (95% CI = 1.69, 2.87), respectively, relative to employees in prisons with no prisoner cases. In prisons with cases, guards and medical personnel had odds ratios of 1.64 (95% CI = 1.11, 2.43) and 2.39 (95% CI = 1.40, 4.08), respectively, relative to employees with little prisoner contact. CONCLUSIONS: In 1992, approximately one third of new infections among New York State prison employees were due to occupational exposure.     

The contribution of recently acquired Mycobacterium tuberculosis infection to the New York City tuberculosis epidemic, 1989-1993

Current theory in the molecular epidemiology of tuberculosis holds that tuberculosis cases harboring Mycobacterium tuberculosis strains with a common deoxyribonucleic acid (DNA) fingerprint are the result of recent M. tuberculosis transmission. Here we propose a mathematical approach independent of DNA fingerprinting to estimating the percentage of recent transmissions responsible for current tuberculosis incidence. The "short-term reproductive number" of tuberculosis is defined as the average number of tuberculosis cases developing within 1 year of infection. Multiplying the short-term reproductive number by the number of tuberculosis cases in each year and dividing by the subsequent year's tuberculosis case burden equals the proportion of tuberculosis cases in the subsequent year that are due to recent transmission. We carried out separate calculations for human immunodeficiency virus (HIV)-negative and HIV-positive tuberculosis cases. We applied the model to pulmonary (infectious) tuberculosis cases diagnosed in New York City during 1989-1993, using tuberculosis and AIDS surveillance data. Model-based estimates of the proportion of tuberculosis due to recent transmission were lower than estimates based on DNA fingerprints. Reconciliation of these divergent estimates may require the re-estimation of model parameters from data collected de novo, additional model development, and further advances in DNA fingerprinting methods.     

Rising number of tuberculosis cases among Tibetans in New York City

Tuberculosis among Tibetans increased in New York City between 1995 and 1999. We examined characteristics of 68 Tibetan patients compared to 702 non-Tibetan patients from Nepal, India, or China, diagnosed between January 1995 and December 1999. The number of Tibetan patients increased each year after 1995 whereas non-Tibetans remained stable during the same period. Tibetans were younger (27 vs. 44 years), more likely to be infectious (63% vs. 46%), have multidrug resistance (7% vs. 2%) and shorter time to diagnosis after arrival (9 vs. 79 months, p < 0.01). For Tibetan patients, 68% of identified contacts were evaluated. The prevalence of tuberculosis infection was 65%. In contrast, among non-Tibetan patients 88.8% of contacts were evaluated and 45.2% were infected. Outreach efforts with community leaders and educational presentations at community events have been implemented in an effort to ensure continuity of care and completion of treatment.     

Creation of a tuberculosis directly observed therapy provider network in New York City: a new model of public health.

A 1990-1991 New York State Department of Health (NYSDOH) assessment of the ongoing tuberculosis (TB) epidemic in New York City (NYC) led to legislative enactment of policy recommendations to help stem the epidemic. The principal strategy entailed mobilization of community resources for TB directly observed therapy (DOT) to supplement the DOT available from the NYC Department of Health (NYCDOH). For implementation, the NYSDOH engaged a coalition of public and private health care providers in a TB DOT Provider Network. Network participants include freestanding facilities, many of which already have preexisting affiliative relationships through which DOT can be extended. The number of individuals receiving DOT in NYC has increased more than 10-fold in two years. Over 1,000 individuals have completed their anti-TB treatment while enrolled in the network.