By Deena Beasley and Julie Steenhuysen
Reuters
Los Angeles county health officials have asked for federal assistance to analyze and contain an outbreak of tuberculosis within the city's homeless population, a spokeswoman for the county agency said on Friday. 

Los Angeles County Health Department spokeswoman Mabel Aragon said the agency is still in the process of confirming the number and type of TB cases in the county.

"The CDC is helping us with surveillance and statistic gathering," she said.

CDC spokesman Scott Bryan confirmed that the federal health agency has been asked by local and state TB officials to assist with the outbreak investigation. Bryan said the CDC plans to dispatch staff to the state in the next two weeks.

The Los Angeles Times reported that health workers have identified about 4,650 people who were probably exposed to a persistent outbreak of the contagious disease on downtown Los Angeles' skid row.

The newspaper said that over the past five years, county officials have identified 78 cases of a unique strain of the contagious disease, including 11 deaths. Sixty of those cases were homeless individuals leaving in the skid row area.

In an interview posted on the Los Angeles health department's website, Kiren Mitruka of the U.S. Centers for Disease Control and Prevention said: "Although progress has been made toward eliminating TB in the U.S., TB outbreaks continue to occur and remain a challenging issue."

The United States had about 10,528 cases of tuberculosis in 2011 and there were 529 deaths from the disease in 2009, according to the latest full year CDC statistics.

The CDC responds to TB outbreaks only when state and public health departments exceed their surge capacity to control it, Mitruka said.

"We don't go in unless we're asked," she said in the online interview.

Typically, the CDC will conduct an onsite investigation lasting two to three weeks, working closely with state and local public health partners, Mitruka added.

The cluster of TB cases going on in Los Angeles follows a pattern of infection. A review of 51 TB cases which the CDC investigated between 2002 and 2008 published in Emerging Infectious Diseases found substance abuse was the most common risk factor, with 58 percent of outbreak patients reporting substance abuse.

Tuberculosis infection destroys lung tissue, causing patients to cough up the bacteria which then spreads through the air and can be inhaled by others.

Most cases can be cured with a six-month cocktail of antibiotics, but rates of drug-resistant TB have been spreading fast, causing alarm among public health officials and prompting calls for more research into new treatments.

"I think it's a wake up call that highlights the fact that this is still a major, major problem," said Dr. Mel Spigelman, chief executive of the TB Alliance, a non-profit research group based in New York.

"Even in the U.S., where we have one of the lowest rates in the world, we still have over 10,000 patients every year who get TB."

Spigelman said that number pales in comparison to the 9 million people globally who get TB.

"It's still in the U.S., we just don't recognize it." 

By Scott Malone
Reuters

Overdoses of drugs, particularly prescription painkillers and heroin, have overtaken AIDS to become the leading cause of death of homeless adults, according to a study of homeless residents of Boston released on Monday.

The finding came from a five-year study of homeless adults who received treatment from the Boston Health Care for the Homeless Program, though its broad conclusions apply to homeless populations in many urban parts of the United States, the study's author and homeless advocates said.

The tripling in the rate of death by drug overdose reflects an overall rise in pain-killer abuse, said Dr. Travis Baggett of Massachusetts General Hospital, the lead author of the study, to be published next month in the journal JAMA Internal Medicine.

"This trend is happening across the country, in non-homeless populations too," Baggett said. "Homeless people tend to experience in a magnified way the health issues that are going on the general population."

The study, which tracked 28,033 homeless adults from 2003 through 2008, found that of the 17 percent who died during the study period died of drug overdoses while 6 percent died of causes related to HIV, the virus that causes AIDS.

That is a rough reversal of the trend found in a similar study 15 years earlier, when 6 percent of deaths were due to drug overdose and 18 percent due to AIDS.

After the drug overdoses, the second- and third-leading causes of death in the most recent study were cancer, which accounted each for about 16 percent of the deaths.

Homeless people are significantly more likely to die in a given year than their peers in the rest of the population, with those aged 25 to 44 nine times more likely, and those aged 45 to 64 four-and-a-half times more likely to die.

The decline in AIDS-related deaths reflected an overall decline in infection rates, as well as improvement in care and services for patients since the prior study, which was conducted during the peak years of the U.S. AIDS epidemic.

Regional variations
The study looked at a small slice of the roughly 2.3 million to 3.5 million Americans who go through a period of homelessness each year, according to data from the Urban Institute.

While drug abuse is not an uncommon problem among homeless people, the drugs most commonly used vary by region. Heroin and opiate painkillers are the most available and most used drugs along the coasts, while methamphetamine is more common through the middle of the country and prescription painkillers tend to be abused around large military bases, said Neil Donovan, executive director for the National Coalition for the Homeless.

"Fifteen years ago we were talking about homeless people drinking Listerine and that being a leading indicator, and now it's Oxycontin and heroin and it's a very different reality," said Donovan, whose group was not involved in the study.

Prescription painkiller abuse is somewhat more common in Boston than other cities due to the high concentration of hospitals and doctors, which make it easier for users to gain access to the drugs, he said.

Changes in treatment
The rise in deaths related to drug overdoses prompted the Boston Health Care for the Homeless Program to change the way it approaches care, said Dr. Jessie Gaeta, the group's medical director.

"We have to become expert in integrating addiction services into the rest of medical care," Gaeta said. "We have decided to take a very thoughtful and critical look at the way that we prescribe these opiods."

The nonprofit group is considering changes including reducing the overall amount of painkillers it prescribes and providing patients with another drug, naloxone, which can be used as an antidote to overdose, Gaeta said.

Chronic pain, related to causes ranging from cancer to arthritis, is a common problem among the homeless and the groups doctors continue to prescribe painkillers to some of their regular patients, Gaeta said. They have stepped up their efforts to counsel those patients on properly using their drugs and also how to protect them from being stolen.

The relationship between homelessness and drug abuse is a self-reinforcing one, advocates noted. Drug abuse can increase the odds of a person becoming homeless, by making it more likely that they lose a job or fall out with family members, and also makes it harder for the homeless to find shelter as some agencies will not house drug users.

"It's easier to be clean and sober in a bed than on the streets," said Donovan.