Mandated tuberculosis screening in a community of homeless people.

BACKGROUND

To examine the effects of a community program on tuberculosis incidence, prevalence, and transmission requiring users of public facilities to carry cards certifying their compliance with a tuberculosis screening, prophylaxis, and treatment program. Community knowledge of tuberculosis and costs and benefits of the program are described.

SETTING

A West Coast "skid row" community with historically high rates of tuberculosis, homelessness, poverty, and use of drugs and alcohol.

DESIGN

Analysis of tuberculosis activity in communities in Oregon using Oregon Health Division Tuberculosis Data Bank data. Description of community response and cost considerations.

MAIN OUTCOME MEASURES: Rates of active disease, mortality, and skin-test response. Compliance with card use and understanding of tuberculosis control measures. Program expenditures.

RESULTS

An 89% drop in active disease in the highest-risk community in Oregon occurred over the first 10 years of the program. Compliance with the program permitting the use of public facilities, based on cooperation with skin testing, radiology, sputum collection, and therapy has been between 33% of converters completing prophylaxis in the worst year to 100% of active cases completing 4-drug therapy in the best. Facilities that provide services have been almost universal in requiring cooperation for participants. Costs have been reduced.

CONCLUSION

A program of mandated compliance with tuberculosis skin testing, radiologic and sputum examination and treatment, coupled with education and outreach, succeeded in drastically reducing active tuberculosis, transmission, deaths, and cost in a homeless community.