Hospital Tuberculosis: Beyond the Inner City

Abstract

Tuberculosis (TB) today is not an equal opportunity infection. Occurrence of the disease has focused on the inner city, where dramatic increases of TB disease in the poor, the homeless, the victim of acquired immunodeficiency syndrome (AIDS), and the immigrant are most prominent. The focus is clear. For example, incidence of TB is 10 to 20 times greater in the South Bronx, Brooklyn, and Harlem in New York City than in the United States as a whole.1 In these large urban areas, population lifestyle as well as the disease make case detection difficult. In addition, many of the inner-city groups in which TB occurs today also are less likely to comply with antituberculous therapy. Such lack of follow-up greatly enhances the likelihood that drug resistance may emerge and increases the potential for transmission in this setting. Directly observed therapy (DOT) is a proven mechanism to deal with these problems.2 However, accomplishing DOT in these areas demands new cadres of case workers to implement programs. The inner city also is the most likely site for nosocomial TB. Some hospitals in these areas can account for sizable proportions of an area's cases. For example, at Grady Memorial Hospital in Atlanta, more than 250 new TB cases were diagnosed in 1992; if this metropolitan public hospital were its own state, it would have ranked about 26th in case total for the entire country.3 Because rates of TB are high in the patient population of large urban hospitals, and because these clients also are more likely to have AIDS or other associated diseases that make TB detection difficult, this setting is where risk of transmission to healthcare workers and other patients rises. In such an environment, it is logical and important to implement procedures for prevention of nosocomial transmission. Guidelines to accomplish this have emerged from investigations of several nosocomial outbreaks in urban hospitals in the past few years.4 Implementation of these procedures has proven effective in several urban hospitals.3,5 However, such guidelines have been extraordinarily cost y to implement.6 When one leaves the inner city, the best tactics to deal with TB are less certain. In the 1980s and earlier, the national plan for eradication of TB was aimed primarily at treating elderly individuals, who developed disease due to reactivation of long-ago infection. These cases could arise as easily in the suburbs or rural areas as i the city center. By contrast, recent national plans and guidelines to deal with multidrug-resistant TB (MDR-TB) dwell heavily (almost exclusively) on the inner-city constituency and on primary and directly transmitted infection.7 What to do with the cases outside these main centers of the battle against TB and MDR-TB is n t delineated clearly. Yet, national plans seem to assum that what is needed in the inner city should be implemented as well in suburban or rural se tings. This is not necessarily so. What makes medical and economic sense in the metropolitan area may not be either efficient or effective when the setting shifts and the target population changes.8