U.S. News

03.01.13

L.A. Hunts for 300 Missing Tuberculosis Cases

An outbreak of the respiratory infection has hit the city's homeless population—and some 300 high-risk individuals are still at large. Christine Pelisek on the challenges of rooting out the disease in seedy Skid Row.

Los Angeles is scrambling to contain an outbreak of tuberculosis in the city’s seedy Skid Row area, which has become a giant Petri dish for the highly contagious bug.

So far, at least 60 homeless people living in shelters in the area have contracted the bacterial respiratory infection since 2007. Thousands more who inhabit Skid Row—known for its cardboard boxes, porta-potty outhouses, and camping tents that line the sidewalks—may have been exposed. Most urgently, health officials are trying to track down some 300 people who they believe had prolonged exposure to TB after staying in a downtown shelter for varying lengths of time in 2012.

Public-health officials have enlisted the help of the Centers for Disease Control and Prevention in their efforts to find the 300. But the same characteristics that make the homeless community so susceptible to the outbreak—transience, limited access to medical care, and problems with drugs and mental illness—are hampering the search.

“It is a difficult population because they can move around and they don’t necessarily comply with requests and they won’t necessarily take their medication on time,” says Jonathan Fielding, director of L.A. County’s department of public health. “It is a challenge working with the homeless population and that is why we continue to have cases there.”

Privacy and identification issues are also a factor. “We have to respect their privacies,” Fielding said. “These are all issues we are dealing with.” Fielding said they have already found a few of the 300 and “they were all in the same general area.”

Skid Row is home to nearly 12,000 homeless people. The majority sleep in overcrowded shelters, which makes the area an ideal breeding ground for the infection, which is easily spread through coughing and sneezing. The homeless are particularly vulnerable because many of them have compromised immune systems. So far, of 11 that have died from the infection, 20 percent were HIV positive.

“Anyone can get it,” said Dr. Mary Marfisee, the medical director of the Union Rescue Mission’s UCLA School of Nursing Clinic for the Homeless. “But compromised people are more at risk. The weaker your immune system the more at risk you are.”

Health officials say the persistent TB strain is unique to Los Angeles and can be cured with a six- to nine-month cocktail of antibiotics. Those that died passed away shortly before or just after starting the treatment. “They had the condition too long for the treatments to be able to reverse it,” said Herb Smith, the CEOand president of the Los Angeles Mission.

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Among the thousands of people who live in Skid Row there exists a small shadow population of homeless immigrants who bed down each nigh in parks, abandoned buildings and find refuge in camouflaged encampments under freeway overpasses and bridges. (Damian Dovarganes/AP)
“I don’t know if we have all the information they would like,” one shelter official said.

TB is a lung disease that was generally connected with the urban poor in 18th- and 19th-century England where it was called “consumption” because its victims would become thin and pale as their lungs slowly deteriorated before they died. Improvements in public health have greatly reduced the rates of TB in the United States, but the disease has not been eradicated. In 2011, there were more than 10,000 reported cases. In 2009, 529 people died from it, according to the Centers for Disease Control and Prevention. There are about 700 yearly cases of TB reported in Los Angeles County.

Among the homeless, there has been a troubling upswing in infections. Between 2007 and 2011, the CDC reported 28 outbreaks associated with homeless shelters, defined as “any situation where three people have an identical strain,” according to Dr. Jane Deng, a pulmonary physician with UCLA Medical Center.

Last year, the CDC investigated one of the largest outbreaks it had been involved with since the 1990s in Jacksonville, Florida, where 13 people died and 99 were infected. Local and state health officials were criticized for the way they dealt with the crisis after it was revealed they did not alert the public to the outbreak for months because they thought it only affected the homeless population. It was later discovered that over 3,000 people may have had some contact with the disease through the city’s homeless shelters, an outpatient mental-health clinic, and local jails. Florida health officials denied they covered up anything and said the general public was not at risk.

Los Angeles health officials are referring to the outbreak here as the largest in a decade. Seventy-eight people were originally diagnosed with the Skid Row strain—of those, 60 were homeless. The remaining 18 presumably “had contact with the patients in Skid Row,” said Fielding.

The Los Angeles Mission’s Smith said public-health officials contacted shelters last week looking for information including the medical records of everybody who has used their services since January of 2007. “They want to know who they were in contact with and where they may have gone,” he said.

But that’s easier said than done. Smith says some shelters don’t keep paperwork dating back that far, especially information about people who stayed in their emergency shelter. “I don’t know if we have all the information they would like,” he said. “We have a 12-month rehab program and I can tell them what room someone stayed in and who his roommate was but if Joe spent the night in the emergency dorm I don’t necessarily keep that on a long-term basis.”

Another factor that might hamper the investigation is the transient nature of the homeless population. “A lot of people in Skid Row use more than one name,” says Paul Gregerson, the chief medical officer of the JWCH Institute, which runs a homeless health-care program in the area. “One night they will sleep on the street, or at a mission, or they may get arrested and go to jail for a couple of days. It is very hard and time-consuming.”

“The sooner you eradicate the whole thing the less chance it will move out of the area that is quarantined right now,” added Gregerson. “If they are diligent in doing that the likelihood of it spreading is slim.”

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People sit on 6th Street in Los Angeles' Skid Row area on Wednesday, July 11, 2012. The city sponsored a recent clean up effort to remove health hazards in the area. (Grant Hindsley/AP)

Until then, the city, even the police, are taking extra precautions. Last week, the LAPD’s central station issued a written memo to its police officers patrolling the Skid Row area encouraging them to wear facemasks if they come across someone they suspect might have the disease.

Captain Horace Frank said officers are already accustomed to wearing latex gloves after an outbreak of MRSA a few years ago. “We aren’t going to stop doing our jobs,” he said. “There are precautionary measures we are taking. They say it is pretty tough to catch it. The last thing we want to do is create panic. The way we do that is by educating people.”

Marfisee operates the Union Rescue clinic. Since she started seven years ago she has seen a rise in cases of TB. Most of her patients live on the streets or in shelters. Marfisee said she stepped up testing efforts years ago after she learned a middle-aged man died from the disease. “I was shocked it occurred,” she said. “So I put emphasis on the screening. I worked in the developing world for a decade and I was amazed it happened in one of the wealthiest states in the country. He could have been treated.”

Two weeks ago, Marfisee says she expanded her screening efforts to emergency shelters across the city. “The trouble is finding the cases,” she said. “People who are sick with early signs can look like a bad respiratory infection. We are changing our approach. We want to be sensitive to what is out there.”