Tuberculosis knowledge among New York City injection drug users.

Public Health Briefs

References 1. Wechsler H, Davenport A, Dowdall G, Moeykens B, Castillo S. Health and behavioral consequences of binge drinking in college: a national survey of students at 140 campuses.JAMA. 1994;272:1672-1677. 2. Wechsler H, Isaac N. "Binge" drinkers at Massachusetts colleges: prevalence, drinking styles, time trends, and associated problems.JAMA. 1992;267:2929-2931. 3. Hanson DJ, Engs RC. College students' drinking problems: a national study, 19821991. Psychol Rep. 1992;71:39-42. 4. Presley CA, Meilman PW, Lyerla R. Alcohol and Drugs on American College Campuses: Use, Consequence, and Perceptions of the Campus Environment. Vol 1. 1989-1991. Carbondale, Ill: Core Institute; 1993. 5. Johnston LD, O'Malley PM, Bachman JG. National Survey Results on Drug Use from the Monitonng the Future Study, 1975-1993. Vol.1. Secondary School Students. Washington, DC: US Government Printing Office; 1994. NIH publication 94-3809. 6. National Household Survey on Drug Abuse: Population Estimates, 1992. Rockville, Md:

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US Dept of Health and Human Services; 1993. 7. Hingson RW, Strunin L, Berlin BM, Heeren T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J Public Health. 1990;80:295-299. 8. O'Brien R, Chafetz M. The Encyclopedia of Akoholism. New York, NY: Facts on File; 1982:49-51. 9. Frezza M, diPadova C, Pozzato G, Terpin M, Baraona E, Lieber CS. High blood alcohol levels in women: the role of decreased gastric alcohol dehydrogenase activity and first-pass metabolism. N Engl J Med. 1990;322:95-99. 10. Hetzler JE, Burnham A. Alcohol abuse and dependency. In: Robins LN, Regier DA, eds. Psychiatnic Disorders in America. New York, NY: Free Press; 1991. 11. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley & Sons; 1989. 12. Freier MC, Bell RM, Ellickson PL. Do Teens Tell the Truth? The Validity of Self-Reported Tobacco Use by Adolescents. Santa Monica, Calif: RAND; 1991. RAND publication N-3291-CHF.

13. Midanik L. Validity of self-reported alcohol use: a literature review and assessment. BntJAddict. 1988;83:1019-1030. 14. Reinisch OJ, Bell RM, Ellickson PL. How Accurate Are Adolescent Repois of Drug Use? Santa Monica, Calif: RAND; 1991. RAND publication N-3189-CHF. 15. Kupetz K, Klagsbrun M, Wisoff D, LaRosa J, Davis DI. The acceptance and validity of the Substance Use and Abuse Survey (SUAS).JDrugEduc. 1979;9:163-188. 16. Rachel JV, Guess LL, Hubbard RL, et al. Adolescent Drinking Behavior. Vol 1. Research Triangle Park, NC: Research Triangle Institute; 1980. 17. Room R. Survey vs sales data for the US. Drink DrugPract Sunr. 1971;3:15-16. 18. Celis W. Drinking by college women raises new concern. New York Times. February 16, 1994:A18. 19. Ettore E. Women and Substance Use. New Brunswick, NJ: Rutgers University Press; 1992. 20. Rodin J, Ickovics JR. Womens' health: review and research agenda as we approach the 21st century. Am Psychol. 1990;45:1018-1034.

Tuberculosis Knowledge among New York City Injection Drug Users Hannah Wolfe, MS, Michael Marnor, PhD, Robert Maslansky, MD, Stuart Nichols, MD, Michael SimberkoffJ MD, Don Des Jarlais, PhD, and Andrew Moss, PhD, MPH

Introdution In the past decade, New York City has witnessed a dramatic increase in pulmonary tuberculosis. Increases in human immunodeficiency virus (HIV) infection, homelessness, and poverty are responsible for much of this resurgence; all of these are prevalent among New York City injection drug users, who are among those at highest risk for tuberculosis.16 The present study sought to assess tuberculosis-related knowledge in this population. Virtually no public health education regarding tuberculosis has been done in the past 3 decades. A recent survey of injection drug users in Brooklyn, NY, suggests the presence of a high level of misinformation and fear about tuberculoSiS.7 The Centers for Disease Control and Prevention (CDC) recently called for public awareness campaigns to alert the

most affected by tuberculosis about its increasing incidence, and to provide knowledge and other resources needed to influence tuberculosis programs directed toward those communities.8 In 1994, the CDC added questions on tuberculosis transmission to

minority communities

Hannah Wolfe and Michael Marmor are with the Division of Epidemiology and Biostatistics, New York University Medical Center; Robert Maslansky is with the Department of Psychiatry, Bellevue Hospital; Stuart Nichols and Don Des Jarlais are with the Beth Israel Medical Center; and Michael Simberkoff is with the Manhattan Veterans Affairs Medical Center, all in New York, NY. Andrew Moss is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Requests for reprints should be sent to Michael Marmor, PhD, Department of Environmental Medicine, New York University Medical Center, 341 E 25th St, New York, NY 10010. This paper was accepted on October 4, 1994.

American Journal of Public Health 985

Public Health Bnefs

TABLE 1 Transmission Knowledge In a Sample of New York City Injection Drug Users (n = 494): "As You Understand It, How Is TB Spread from One Person to Another?"a %

Established mode of transmission 93 By breathing air someone with TB has coughed in Possible or indirect mode of transmission 31 From someone spitting in public 17 By sexual contact 22 Other (mentioned spontaneously): passing cigarettes/ crack pipes, sharing drinks/utensils, kissing, sneezing/colds Incorrect mode of transmission 13 Through food and water 8 Inherited from parents 2 Don't know

No.

458

154

82 109

63

41 11

aTransmission modes were read aloud; more than one response per subject was possible.

the National Health Interview Survey. But until these survey results are published, no data exist on tuberculosis knowledge in the general US population, which makes it impossible to compare tuberculosis knowledge as measured in this study with that in the general population.

Methods This survey was conducted between November 1992 and February 1993 as part of a cohort study of HIV infection among injection drug users. Subjects were enlisted between July and December 1992 from three New York City methadone maintenance treatment programs: one in Harlem, northern Manhattan (47%), and two (13% and 11%) in mid-Manhattan. Additionally, 145 subjects (29%) were recruited through a community flyer outreach campaign or recalled from previous studies of injection drug users. Subjects were recalled at three monthly intervals for interviews and testing via enzymelinked immunosorbent assay with western

986 American Journal of Public Health

TABLE 2-Knowledge and Beliefs about Tuberculosis (TB) in a Sample of New York City Injection Drug Users

Area of Knowledge/Item as Read by Interviewer Infection vs disease If you have a positive TB skin test, you will get sick with TB.a Just because you have a positive skin test for TB doesn't mean you will get sick with TB. If someone has a positive TB skin test, they can give TB to other people.a AJI three items correct Adherence You can stop taking TB medication when you stop feeling sick.a If people don't take their TB medication as long as prescribed, it will be harder for them to be treated. People with a positive TB skin test sometimes need to take TB medication even if they aren't feeling sick. All three items correct TB and HIV If you have HIV, it's easier to get sick with TB. Seriousness TB is a disease that can kill you. Drug resistance There is a new kind of TB around that is not easily treated with drugs. Treatability If someone has TB it can be treated pretty easily.

Agree

Disagree Don't Know No.

%

No.

Total No.

45 219 52 252

3

15

486

70 340 26

126

4

19

485

56 271 38

184

5

26

481

40 86 418

6

28

486

% No. %

25 8

6

29

1

5

485

75 361 20

97

5

25

483

93 451

61 91 443

4

20

5

22

485

91 380

8

34

1

6

420

66 322 15

71

19

93

486

74 363 23

114

3

13

490

Note. Denominators vary owing to missing data. aReverse coded (i.e., "disagree" is correct).

blot confirmation. Because subjects were interviewed during recruitment for an HIV vaccine feasibility study targeting HIV seronegative subjects, population seroprevalence was underrepresented. Self-reported histories of tuberculin skin test results and active tuberculosis were obtained. To ascertain the reliability of self-reported skin test results, medical records of a subsample of methadone maintenance treatment program patients were reviewed. Subjects were asked items developed for the 1994 AIDS Knowledge and Attitudes Supplement to the CDC National Health Interview Survey measuring transmission knowledge (Table 1). They were also presented with ten agree/ disagree statements that were developed to assess their knowledge of the difference between a reactive skin test and active tuberculosis, the importance of medication adherence, and perceived seriousness and pathogenesis (Table 2).

Results Thirty-one percent of subjects were female. The median age was 38 years (range = 18 to 66). The racial breakdown was 39% African American, 33% Hispanic (primarily Puerto Rican), and 26% Caucasian. HIV seroprevalence was 8%. The mean years of full-time education completed was 12 (median 12). Seventy-three percent were unemployed with government benefits. Additionally, 66% lived in their own or a partner's residence, 15% lived with relatives or friends, 10% lived in a shelter, 4% lived in a hotel or room rented on a weekly basis, and 3% lived on the streets. All subjects reported a history of illegal drug injection. The mean age at first injection was 20 years. In the 6 months prior to interview, 57% had injected drugs and 41% had used crack; 18% had used crack daily. =

July 1995, Vol. 85, No. 7


Thirty-one percent (155) reported a history of purified protein derivative skin test reactivity; of these, 32 (6% of the total sample) reported a history of active tuberculosis. A medical record review of 71 methadone maintenance subjects found that 7 subjects had misclassified their skin test status (kappa = .73). As Table 1 shows, almost all subjects identified tuberculosis as an airborne infection. Over half of the subjects also identified possible indirect methods of transmission; one in five subjects identified incorrect routes. Table 2 shows that one fourth of the subjects understood the distinction between infection and active disease, but that subjects reporting a history of a reactive skin test were more than twice as likely (40% vs 18%, P < .0001) to respond correctly to all three relevant items. In a multivariate analysis controlling for sex, race, age, and education, the strongest predictor of infection versus disease knowledge was self-reported skin test status (odds ratio [OR] = 2.9; 95% confidence interval [CI] = 1.8, 4.7; P < .0001). More than half of the subjects responded correctly to all three medication adherence items (Table 2); subjects were least likely to understand the necessity of prophylaxis for skin test positives. Hispanic subjects were less aware of the importance of medication adherence than non-Hispanics (52% vs 74%, P < .05), as were subjects under age 35 compared with those over age 35 (49% vs 64%, P < .01). In a multivariate analysis controlling for sex, purified protein derivative status, and education, age remained independently significant (OR = 1.8; 95% CI = 1.4, 2.2; P < .01). Table 2 shows that most subjects perceived tuberculosis as potentially fatal and understood that HIV-infected persons are more susceptible to it. Two thirds were aware of drug-resistant tuberculosis. The following variables-sex, crack use, living situation, education, and HIV status-were not significantly associated with any of the areas of knowledge

measured.

Discussion Among subjects enlisted from a population at high risk for tuberculosis, 75% misunderstood the distinction between tuberculosis infection and active disease. Knowledge regarding the importance of medication adherence was better; nonetheless, 40% of subjects were weak in this area. One third were unaware July 1995, Vol. 85, No. 7

of the problem of drug-resistant tuberculosis. Given the absence of tuberculosis education in recent years, these findings likely reflect a population-wide lack of tuberculosis-related knowledge. More than 90% of subjects interviewed understood that tuberculosis can be contracted by breathing contaminated air. Some of the other modes of transmission mentioned by subjects, even though not "technically" correct, may significantly increase the likelihood of transmission. Smoking of any substance can induce coughing. "Shotgunning" (inhaling smoke and then exhaling it directly or through a tube into someone else's mouth), which is associated with smoking marijuana and crack cocaine, is probably a particularly efficient mechanism of tuberculosis transmission. Investigation of a community outbreak of tuberculosis found that contacts who had smoked marijuana with the index case were the most likely to be infected.9 An association between tuberculosis and the use of crack cocaine was recently reported.'0 The independent association between subjects' skin test positivity and their knowledge of the difference between infection and disease most likely reflected education they received during the administration and reading of their tuberculosis skin tests. This, along with the high reliability of self-reported skin test status, suggests that some effective education is occurring when the skin test results are being read. Subjects with a history of skin test reactivity, however, did not know any more about medication adherence or transmission than other subjects, suggesting the need for more complete education. At the time of this survey, each of the three participating methadone maintenance treatment programs had the policy of performing annual tuberculosis skin test screening of all patients and referring reactive patients for chest x-rays. Higher levels of medication adherence knowledge among older subjects, even when controlling for skin test status and education, may reflect knowledge gained in the pre-1970s era. This underlines the particular need to educate young persons about tuberculosis. Some of the misconceptions revealed in this survey may stem from the overgeneralization of knowledge about HIV: the assumption that all persons with a reactive skin test can transmit the disease to others and will invariably develop active tuberculosis, and the belief in sexual transmission of tuberculosis. Effective education in populations knowledgeable

about HIV must highlight the differences between the two diseases. The CDC has recommended that anergic HIV-seropositive patients from groups with high tuberculosis prevalence be considered for isoniazid prophylaxis."1 Others have suggested that all HIVinfected injection drug users would benefit from chemoprophylaxis.12,1' However, widespread prophylaxis is generally not undertaken for fear of poor compliance. Thus, education about tuberculosis is urgently needed if such campaigns are to succeed. The high level of the perceived stigma of tuberculosis, as we reported previously, in conjunction with misinformation regarding transmission and disease, is likely to harm screening efforts and medication adherence.'4 The American Public Health Association considers education of the public to be vital to tuberculosis prevention efforts.15 Studies have found tuberculosisrelated knowledge to predict medication adherence.16'17 Injection drug users are the population most likely to be dually infected with tuberculosis and HIV. Drug treatment programs are often their primary source of contact with the health care system. As this survey demonstrates, tuberculosis prevention and education, like HIV efforts, must be integrated into drug treatment programs. Ol

Acknowledgments

This work was supported by Grant DA06001 from the National Institute on Drug Abuse; Grant HL51517 from the National Heart, Lung, and Blood Institute; Center Grant 2P30AI27742 from the National Institute of Allergy and Infectious Diseases; and General Clinical Research Center Grant M01 RR009096-31 from the National Institutes of Health Center for Research Resources. Additional support was derived from the Consolidated Edison Company of New York. We wish to thank Esther Sumartojo, PhD, in the CDC Division of Tuberculosis Elimination, for assistance with instrument design, and our interviewer-phlebotomists Barbara Cox, Cynthia Harrison, Anthony LaPorte, Christina Obasi, Annabel Manning, and Evyan CordCruz. For data entry and management, thanks to Marc Waldman and Donna Belmonte; for statistical support, thanks to Stephen Titus. We are also grateful for the cooperation provided by Bellevue Hospital Center, the Health and Hospitals Corporation, the Manhattan Veterans Affairs Medical Center, and the Beth Israel Medical Center.

References

1. Theur CP, Hopewell PC, Elias D, et al. Human immunodeficiency virus infection in tuberculosis patients. J Infect Dis. 1990;

162:8-12.

American Journal of Public Health 987


2. Selik RM, Starcher ET, Curran JW. Opportunistic diseases reported in AIDS patients: frequencies, associations, trends. AIDS. 1987;1:175-182. 3. Reichman LB, Felton CP, Edsall JR. Drug dependence, a possible new risk factor for tuberculosis disease. Arch Intem Med. 1979;139:337-339. 4. Tuberculosis in New York City 1990. New York, NY: New York City Dept of Health; 1990. 5. Selwyn PA, Hartel D, Lewis VA. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med. 1989;320:545-550. 6. Graham NMH, Nelson KE, Solomon L, et al. Prevalence of tuberculin positivity and skin test anergy in HIV-1-seropositive and -seronegative intravenous drug users. JAAM. 1992;267:369-373. 7. Curtis R, Friedman SR, Neaigus A, Jose B, Goldstein M, Des Jarlais DC. Implications

8.

9.

10. 11.

12.

of directly observed therapy in tuberculosis control measures among IDUs. Public Health Rep. 1994;109:319-327. Prevention and control of tuberculosis in US communities with at-risk minority populations. Recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1992;41(RR5):1-11. Livengood JR, Sigler TG, Foster LR, Bobst JG, Snider DE. Isoniazid-resistant tuberculosis: a community outbreak and report of a rifampin prophylaxis failure. JAIv4. 1985;253:2847-2849. Crack cocaine use among persons with tuberculosis-Contra Costa County, California, 1987-90. MMWR 191;40:485-489. Purified protein derivative (PPD)-tuberculin anergy and HIV infection: guidelines for anergy testing and management of anergic persons at risk of tuberculosis. MMWR. 1991;40(RR-5):27-32. Jordan TJ, Lewit EM, Montgomery RL, Reichman LB. Isoniazid as preventive

13.

14.

15.

16.

17.

therapy in HIV-infected intravenous drug abusers.JAAL4. 1991;265:2987-2991. Selwyn PA, Sckell BM, Alcabes P, Friedland GH, Klein RS, Schoenbaum EE. High risk of active tuberculosis in HIV-infected drug users with cutaneous anergy. JAAL4. 1992;268:504-509. Wolfe H, Marmor M, Moss AR, Des Jarlais D. Tuberculosis beliefs among New York City injecting drug users. Lancet. 1993;341:1658-1659. Letter. Benenson AS, ed. Control of Communicable Diseases in Man. 15th ed. Washington, DC: American Public Health Association; 1990. Barnhoom F, Adriaanse H. In search of factors responsible for noncompliance among tuberculosis patients in Wardha district, India. Soc Sci Med. 1992;34:291306. Alcabes P, Vossenas P, Cohen R, Braslow C, Michaels D, Zoloth S. Compliance with isoniazid prophylaxis in jail. Am Rev Respir Dis. 1989;140:1194-1197.

Unintentional Carbon Monoxide Poisoning in Colorado, 1986 through 1991 Magdalena Cook MS, PaulA. Simon, MD, MPH, and Richard E. Hoffman, MD, MPH

Introduction

to 19., " 81

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Carbon monoxide is an odorless, colorless, highly toxic gas produced by fire and by motor vehicles and appliances that use carbon-based fuels. Depending on a person's level of exposure, signs and symptoms of intoxication may range from mild headache, malaise, and subtle changes in mental status to coma and death.' While the rate of death from unintentional carbon monoxide poisoning appears to be decreasing, unintended exposure to this gas continues to cause more than 800 deaths each year in the United States.2 Public health surveillance data on the incidence of nonfatal carbon monoxide poisoning have not been reported, although two studies of persons evaluated for flulike symptoms in emergency room settings during cold weather months found that between 5% and 23% had laboratory evidence of carbon monoxide toxicity.3'4 In February 1985, to describe the epidemiology of unintentional carbon monoxide poisoning in the state and to help develop and target prevention strate-

gies, the Colorado Department of Health initiated population-based surveillance for carbon monoxide-related fatal and nonfatal poisonings. This report describes the results of that surveillance from 1986 through 1991.

Methods A case was defined as the unintentional carbon monoxide poisoning of a Colorado resident in Colorado, as identified from one or more of three sources: laboratory reports of carboxyhemoglobin levels above 12%, reports from hyperbaric chambers treating victims of carbon monMagdalena Cook and Richard E. Hoffman are with the Division of Disease Control and Environmental Epidemiology, the Colorado Department of Health, Denver. At the time of this study, Paul A. Simon was with the Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Ga. Requests for reprints should be sent to Magdalena Cook, MS, DCEED-IE-A3, Colorado Department of Health, 4300 Cherry Creek Dr S, Denver, CO 80222. This paper was accepted January 24, 1995. July 1995, Vol. 85, No. 7