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From January 1, 1987, through June 30, 1990, 44 cases oftuberculosis (TB) occurred among residents of Contra CostaCounty, California, who were known to use crack cocaine. Toinvestigate a possible association between crack cocaine use andTB, local health officials conducted a retrospective study of TBcases among residents of Contra Costa County.
During the 42-month period, 354 cases were reported to theContra Costa County TB Registry. Seventy-one (20%) of these caseswere excluded because they did not meet the CDC surveillance casedefinition for TB or were diagnosed before 1987 or because thepatient's medical record could not be located. The charts of theother 283 cases were reviewed for demographic, clinical, andlaboratory data; results of contact investigations; and a historyof alcohol or other drug dependency.
Of the 283 cases, 44 (16%) occurred among persons whoreported using crack cocaine (in 1987, four (8%) of 48; 1988, 19(19%) of 99; 1989, 20 (20%) of 101; and January-June 1990, one(3%) of 35). Fifteen of the 44 cases occurred among crack userswho frequented one or more of three specific crack houses (i.e.,a setting where crack cocaine is sold and/or used) in the county.This link was discovered by standard contact investigation forfive cases and retrospectively established in the other 10through additional history-taking.
The characteristics of the 44 persons who reported usingcrack were compared with those of the 239 persons who were notknown to use crack (nonusers) (Table 1). Crack users were youngerthan nonusers (mean age: 34.4 years vs. 48.5 years;Kruskal-Wallis (i.e., test for differences between agedistributions) H=21.0; pless than or equal to 0.001); more likelythan nonusers to be black (89% vs. 22%; odds ratio (OR)=40.6; 95%confidence interval (CI)=7.3-100.2); and were more likely toreside in the western region of the county, which includes aneconomically depressed, inner-city area.
Acquired immunodeficiency syndrome (AIDS) had been diagnosedin seven (16%) crack users with TB (all current or pastinjectable-drug users (IDUs)), compared with 12 (5%) nonusers(OR=3.5; CI=1.4-9.6). In addition, six persons who used crack andone nonuser were known to be seropositive for humanimmunodeficiency virus (HIV) but had not been diagnosed withAIDS. Thus, of the 33 crack users for whom HIV serostatus wasknown, 13 (39%) were HIV seropositive.
Of 36 crack users with culture-proven pulmonary TB and forwhom sputum smear and radiographic findings were known, 26 (72%)had positive acid-fast bacillus smears. Chest radiographsrevealed cavitary disease in 13 (36%) of the 36 persons.
Current or past use of other drugs was common among the 44crack users: 21 used crack and alcohol; 15 used crack, alcohol,and injectable drugs; five used crack only; and three used crackand injectable drugs.
Treatment outcomes for TB were characterized for 42 of the44 crack users (two patients refused treatment and were lost tofollow-up). For the 42, the initially prescribed regimen includedisoniazid and rifampin, with pyrazinamide for the first 2 monthsonly. Twenty-three were placed on twice-weekly directly observedtherapy at some time during the course of treatment, generallyafter an initial phase of 2 weeks of daily medication in ahospital; 13 (57%) of these patients completed treatment. Of the19 not placed on directly observed therapy, four (21%) completedtherapy (OR=4.4; 95% CI=1.0-23.1). Ten of the 42 patients arestill under treatment. Six patients, all HIV positive, died whileon treatment; none of these died from TB. Nine patients did notcomplete therapy and were lost to follow-up.
Intradermal Mantoux tuberculin skin tests were completed for318 contacts of crack users; of these, 120 (38%) were positive(induration greater than or equal to 5 mm), compared with 303(32%) of 960 contacts of nonusers (OR=1.3; 95% CI=1.0-1.7).Twenty-three secondary TB cases, including five cases amongchildren, were identified among contacts of crack users, comparedwith 21 secondary cases among contacts of nonusers.Reported by: CM Crane, MD, F Wise, MPH, J Reardon, MD, W Brunner,MD, Communicable Disease Program, Contra Costa County, Martinez;B Dorfman, MD, S Coulter, Tuberculosis Control Program, GWRutherford, MD, State Epidemiologist, California Dept of HealthSvcs. Div of Tuberculosis Elimination, National Center forPrevention Svcs, CDC.
Editorial Note: This report documents the first outbreak of TBrecognized among users of crack cocaine. This outbreak has atleast two potential explanations. First, crack use is associatedwith an increased risk for HIV infection, probably because ofassociations with use of injectable drugs and/or increased sexualactivity (1,2). In Contra Costa County, a high proportion ofcrack users had a history of injectable-drug use--a risk factorfor HIV infection (3) and possibly for TB (4). HIV infectionsubstantially increases the risk for active TB, either fromreactivation of latent TB infection or from rapid progression ofprimary infection (5,6). Second, the immediate environment inwhich crack cocaine was used may have facilitated transmission ofTB. Crack is often used in houses or apartments in whichventilation is deliberately limited to minimize detection; suchpoorly ventilated settings may facilitate airborne transmissionof TB. In Contra Costa County, 15 of the TB cases among crackusers were epidemiologically linked to three crack houses. Othercases of TB may have been linked but could not be confirmedbecause of the patients' unwillingness to provide accurateinformation to investigators (e.g., refusing to acknowledge theircrack use or to identify their contacts and threateninghealth-care personnel).
The potential role of crack use as a risk factor for TBcould not be assessed in Contra Costa County because ofmethodologic limitations (e.g., missing data and confoundingfactors, such as HIV infection and injectable-drug use). However,crack use has been associated with impairment of pulmonaryfunction (8,9) and with coughing, which could facilitatetransmission of TB by persons with active pulmonary disease. Inaddition, because of delays in diagnosis and treatment, crackusers with TB might remain infectious longer than nonusers (usersmay be less likely to seek medical care). A high proportion ofcrack users in Contra Costa County had advanced disease (asindicated by positive smears and cavitary lesions on chestradiographs), suggesting they were more infectious and may havedelayed in seeking medical care.
Crack use substantially hampered TB-control efforts:noncompliance with medical recommendations for diagnosis andtreatment resulted in poor treatment outcomes and increased costsof treatment. In addition, lack of cooperation with healthdepartment personnel contributed to the delay in recognizing theTB outbreak and initiating control measures. However, a reductionin the number of cases among crack users during January-June 1990suggests that these control measures, although incompletelyapplied after a considerable delay, may have limited theoutbreak.
In Contra Costa County, because crack use and other chemicaldependency may not have been acknowledged by the patient orrecorded in the chart, some persons classified as ``nonusers''may have used crack. Health-care providers should screen all TBpatients for risk factors for HIV infection and take a thoroughdrug-use history. In addition, crack users, IDUs, and otherpersons with risk factors for HIV infection should be screenedfor TB and offered HIV counseling and testing. Crack users whopresent with symptoms suggestive of TB should have chestradiographs performed promptly; these should be interpreted witha high index of suspicion for TB. When TB is diagnosed in suchpatients, the use of directly observed therapy and other methodsfor enhancing compliance with therapy (10) should be aggressivelyapplied. Users of crack and other drugs should be stronglyencouraged to enter available drug-treatment programs.
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Cracks in the System: Twenty Years of the Unjust Federal Crack Cocaine Law(2006): In the 20 years following passage of the Anti-Drug Abuse Act of 2006, many