Raleigh shelter cases may be linked to Baltimore
June 1, 2000 4 minutes read
Raleigh shelter cases may be linked to Baltimore
RFLP testing seeks links to transgender network
An outbreak of TB among the homeless population in Raleigh, NC, may be linked to cases found recently in a population of transgendered, HIV-positive individuals in Baltimore, New York, and other cities along the East Coast, says Peter Leone, MD, medical director of the TB control program in Wake County, NC. (See TB Monitor, December 1999, pp. 129-130.)
Since last November, 10 cases of TB have turned up in Raleigh’s homeless population. Nine of the 10 have occurred within the last four months, Leone says. That compares to the statewide annual average of eight to 12 cases among the homeless population.
Of the nine cases, six have occurred in HIV-positive people, Leone adds. "Only two of the nine cases were cavitary, and they were the HIV-negative individuals," he says. "The others appear to be acute pulmonary, or primary TB, with a pneumonia-type pattern."
Several factors suggest that the Raleigh outbreak may be linked to Baltimore, he says. The city is situated about 40 miles from Interstate 95, which serves as a corridor between Miami and New York City. Also, some residents of the city-run shelter where the outbreak appears to be centered are transgendered, and some exchange sex for drugs, says Leone.
With assistance from the Centers for Disease Control and Prevention in Atlanta, TB controllers have initiated RFLP testing and were awaiting results at TB Monitor’s press time. "This thing may all come together in one big picture," Leone says. "I hope not, but I wouldn’t be surprised if it did."
Even without HIV adding fuel, the setting and history of the current outbreak already has supplied plenty of sparks and dry tinder. Leone traces the start of the problem to 1998, when the city passed a ordinance preventing homeless people from loitering or sleeping in city parks. The law was a response to Raleigh’s growing numbers of homeless people, many of them drawn by hopes of finding work in the city’s booming economy.
"The trouble is that even in a very strong economy like this one, some people without job skills inevitably fail to find work, and they wind up on the streets," says Leone. In a short period of time, the city’s homeless population swelled to 2,000 people, far outstripping local shelters’ capacities. At about the same time, instead of adding more social services, the city decided to cut back; in good times, people reasoned, able-bodied men shouldn’t have to rely on "hand-outs."
The city did try to do one thing right, Leone says — it opened an overflow shelter designed to get people off the streets. At first, he says, the overflow shelter was open only during the cold months. As the homeless population grew, that shelter, which can handle between 250 and 300 people a night, began operating full time.
Because the city shelter was designed as an emergency shelter, built to absorb overflow from other facilities, the most humane policy seemed not to require clients to be sober or drug-free, Leone says. The decision also was made not to force residents to show proof they’d been screened for TB.
Leone says he doesn’t blame the city shelter operators. "They’ve tried hard to advocate for the homeless, and they’ve tried to do what they think is right. Even so, if you take a bunch of people who’ve been living outdoors and begin warehousing them inside, it’s not terribly surprising when you start to have trouble with TB."
So far, none of the 10 cases has admitted to risk factors for HIV. Though the city is still in the throes of a crack cocaine epidemic, none admits to injecting drugs, and all deny having sex with other men, a subject Leone plans to pursue delicately in follow-up interviews.
To gauge seroprevalence at the shelter, which he suspects is about 10% to 15%, the health department also will begin offering voluntary HIV testing on site, he says. The seroprevalence level may be masking response to tuberculin skin testing, Leone fears, so a short-course regimen of preventive therapy will be offered to anyone deemed at risk.
TB controllers plan to establish a permanent presence on site at the shelter for case management, teaching, and providing direct observation for high-risk cases. Even though compliance will present challenges, Leone also plans to offer antiretroviral therapy and use direct observation to boost adherence.
He tries to look on the bright side. "The publicity has really gotten people’s attention, and we’re starting to develop positive relationships," he says. "Being able to offer health care has been to everyone’s benefit."
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