AIDSWEEKLY Plus, 6 May 1996 issue; Published by Charles Henderson, Publisher. Editorial & Publishing Office: P.O. Box 5528, Atlanta, GA 30307-0528 / Telephone: (800) 633-4931; Subscription Office: P.O. Box 830409, Birmingham, AL 35283-0409 / FAX: (205) 995-1588
Salynn Boyles, Senior Editor

The rate of tuberculosis in a group of substance abusers on welfare in New York City was almost 15 times that of the city's general population in a study conducted by Connecticut's Yale University and the U.S. Centers for Disease Control and Prevention (CDC).

Researchers noted however that positive skin testing does not accurately assess the likelihood of developing active tuberculosis in this population.

"Among indigent alcohol and drug abusers in New York City, the rates of tuberculosis, AIDS, and death are extremely high," Lloyd N. Friedman and colleagues wrote ("TB, AIDS, and Death Among Substance Abusers on Welfare in New York City," The New England Journal of Medicine, March 28, 1996;334:828- 833).

"In this population, a single positive or negative skin test does not predict the development of tuberculosis, probably because both anergy and new infections are common. If programs to control tuberculosis and AIDS are to be effective in groups of indigent substance abusers, health services must be integrated into the welfare delivery system."

This study was first undertaken in 1978, and between that year and 1984 the number of new cases of tuberculosis in New York City increased from a low of 1307. During the study period 1984 through 1992, the number of TB cases more than doubled, from 1629 to 3811 new cases annually.

"There are no long-term prospective data from this period of resurgence in tuberculosis, and no studies have examined the incidence of tuberculosis among drug abusers, as compared with other high-risk groups such as indigent abusers of alcohol," Friedman et al. wrote.

"Our original cross-section study described the high prevalence of tuberculous infection and disease among substance abusers on welfare, especially those who abuse alcohol. The purpose of our follow-up study was to determine the incidence of tuberculosis, AIDS and death among welfare clients who abuse drugs, alcohol or both and to examine selected outcomes according to initial skin-test status, the type of substance abuse, race or ethnic group, sex and age."

The cohort of 18 to 64 year olds who abused drugs or alcohol was followed for eight years (1984-1992). Of the 858 subjects, tuberculosis developed in 47 (5.5 percent), 84 (9.8 percent) developed AIDS, and 183 (21.3 percent) died The incidence rates per 100,000 person-years were 744 for tuberculosis, 1323 for AIDS, and 2842 for death.

"In this group of welfare clients, the rate of newly diagnosed tuberculosis was 14.8 times that of the age-matched general population of New York City; the rate of AIDS was 10 times as high; and the death rate was 5.2 times as high," Friedman et al. wrote. "There was no significant difference in the rate of new cases of tuberculosis between subjects with positive skin tests and those with negative skin tests at examination in 1984."

The authors suggest that this lack of a correlation between prior skin test positivity and TB may be explained by the higher incidence of AIDS in the group with negative skin tests on examination. They note that there could have been a considerable number of anergic subjects who were infected with both HIV and M. tuberculosis and therefore were at higher risk of progression to tuberculosis. They further note that some subjects with an initially negative skin test may have been infected, or reinfected, after 1984 and thus were at higher risk for progression.

Friedman et al. noted that their population of drug- or alcohol-abusing welfare clients showed extremely high compliance (93 percent) with a two-part medical examination, under circumstances in which public assistance was contingent on completion of the examination.

"A similar, but expanded, incentive program could be part of a public policy to diagnose and treat tuberculous infection and disease," they wrote. "In a restructured welfare program, the provision of health services that include tuberculosis prevention and control, AIDS prevention, and the treatment of drug abuse and alcoholism could not only improve the health of welfare recipients, but also produce social and public health benefits accompanied by substantial cost savings."

The corresponding author for this study is Lloyd Friedman, Department of Intensive Care and Quality Management, Milford Hospital, 2047 Bridgeport Avenue, Milford, Connecticut 06460.

Copyright (c) 1995 - Charles Henderson, Publisher. All rights Reserved. Permission to reproduce granted to AEGIS by Charles W. Henderson. Authorization to reproduce for personal use granted granted by C. W. Henderson, Publisher, provided that the fee of US$4.50 per copy, per page is paid directly to the Copyright Clearance Center, 27 Congress Street, Salem, Massachusetts 01970, USA.

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Copyright © 1996 - Charles Henderson, Publisher. All rights Reserved. Permission to reproduce granted to AEGIS by Charles W. Henderson. Authorization to reproduce for personal use granted granted by C. W. Henderson, Publisher, provided that the fee of US$4.50 per copy, per page is paid directly to the Copyright Clearance Center, 27 Congress Street, Salem, Massachusetts 01970, USA.