AJPH RESEARCH

High Tuberculosis Strain Diversity Among New York

City Public Housing Residents
Patrick Dawson, MPH, Bianca R. Perri, MPH, and Shama D. Ahuja, PhD, MPH

Objectives. We sought to better understand tuberculosis (TB) epidemiology among 2. estimate TB incidence rates among
New York City Housing Authority (NYCHA) residents, after a recent TB investigation persons living in NYCHA developments;
identified patients who had the same TB strain. 3. compare demographic, clinical,
Methods. The study population included all New York City patients with TB confirmed and social characteristics of persons
with TB who are NYCHA and non-
during 2001 through 2009. Patient address at diagnosis determined NYCHA residence.
NYCHA residents;
We calculated TB incidence, reviewed TB strain data, and identified factors associated
4. describe the molecular epidemiology
with TB clustering.
of TB stratified by NYCHA residence;
Results. During 2001 to 2009, of 8953 individuals in New York City with TB, 512 (6%) and
had a NYCHA address. Among the US-born, TB incidence among NYCHA residents (6.0/ 5. identify patient factors associated
100 000 persons) was twice that among non-NYCHA residents (3.0/100 000 persons). with TB strain clustering among
Patients in NYCHA had high TB strain diversity. US birth, younger age, and substance use NYCHA and non-NYCHA residents.
were associated with TB clustering among NYCHA individuals with TB.
Conclusions. High TB strain diversity among residents of NYCHA with TB does not
suggest transmission among residents. These findings illustrate that NYCHA’s
METHODS
higher TB incidence is likely attributable to its higher concentration of individuals
The study population included all
with known TB risk factors. (Am J Public Health. 2016;106:563–568. doi:10.2105/
New York City patients with TB verified
AJPH.2015.302910) from January 1, 2001, through December
31, 2009. We obtained patient de-
mographic, clinical, and social history in-

A
lthough tuberculosis (TB) rates in the
United States have declined since the
TB epidemic peaked in 1992,1 TB continues
to disproportionately affect the poor,2,3 racial
and ethnic minorities,2,4 substance users,5 and
other marginalized populations.2,3,5,6 In New
York City, despite a sharp decline in TB
incidence since 1992 (1992 incidence = 51.1
cases per 100 000 population),1 the TB in-
cidence rate in 2013 was more than twice the
US average (8.0 vs 3.0 per 100 000 pop-
ulation)7,8 and disparities persist. In 2013, the
incidence rate of TB in New York City
among non-Hispanic Blacks was more than 5
times that among non-Hispanic Whites.7
Furthermore, area-based poverty indicators
revealed that 53% of individuals diagnosed
with TB in 2012 resided in high- or very-
high-poverty areas within New York City.9
During a TB epidemiological investigation,
New York City Department of Health and
Mental Hygiene (DOHMH) Bureau of
Tuberculosis Control staff identified individuals
with TB who lived in New York City public
housing developments and had the same strain
formation from the New York City TB
of TB. New York City Housing Authority
surveillance registry.
(NYCHA)isthelargestpublichousingauthority
We used patient address at TB diagnosis to
in North America, housing more than 400 000 identify NYCHA residence. We geocoded
low- to moderate-income New Yorkers.10 and assigned addresses building identification
Among NYCHA residents, 46% are non- numbers through the New York City
Hispanic Black, 45% are Hispanic, 5% are Asian, DOHMH Geographic Information Systems
and 4% are White; 79% of heads of households Center’s online geocoder. We matched in-
are US-born; and the average residency is 20 dividual patient building identification
years.11 The epidemiological investigation numbers to an array of NYCHA building
prompted the DOHMH to systematically in- identification numbers provided by NYCHA
vestigate the epidemiology of TB among New staff. Individuals whose address building
York City public housing residents. identification number matched a NYCHA
The study objectives were to building identification number were identi-
fied as having a NYCHA residence at di-
1. quantify the number of patients agnosis. We defined addresses that did not
with TB who reported a NYCHA match a NYCHA building identification
residence at time of TB diagnosis; number or that were unable to be geocoded
ABOUT THE AUTHORS
All authors are with the New York City Department of Health and Mental Hygiene Bureau of Tuberculosis Control, Queens,
NY. Patrick Dawson is also with Columbia University Mailman School of Public Health Department of Epidemiology,
New York, NY.
Correspondence should be sent to Patrick Dawson, MPH, 722 W 168th St, 7th Floor Desk 720.7, New York, NY 10032
(e-mail: ptd2103@cumc.columbia.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
This article was accepted September 5, 2015.
doi: 10.2105/AJPH.2015.302910

March 2016, Vol 106, No. 3 AJPH Dawson et al. Peer Reviewed Research 563
AJPH RESEARCH
(n = 87; < 1% including addresses outside of
New York City) as non-NYCHA residences.
We used annual NYCHA population
counts for each year of the study period to
calculate TB incidence rates among persons
residing in NYCHA developments. We used
unchallenged US Census Bureau estimates of
New York City population totals for each
study year to calculate overall New York City
TB incidence by study year.12,13 To estimate
the TB incidence rate among US-born
NYCHA residents, we used the 2002, 2005,
and 2008 editions of the US Census Bureau
New York City Housing and Vacancy Survey
to approximate the proportion of US-born
New York City public housing heads of
households. For incidence calculations
among US-born NYCHA residents, we used
the proportion of US-born heads of house-
holds in 2002 (79%; obtained from the 2002
survey,14 the median value of the 3 surveys) to
estimate the proportion of NYCHA residents
that were US-born. We used the proportion
of US-born New York City residents from
the 2000 Census (64%) as a proxy for the
proportion of US-born non-NYCHA resi-
dents for each study year.
We used sociogeographic exposure indices
to adjust for individual-level exposures rele-
vant to TB epidemiology in our analyses, as
outlined by Acevedo-Garcia.2-3 Individual-
level exposures were not available; therefore,
we used census-tract exposures by race as
a surrogate. We calculated 5 sociogeographic
exposure indices by using 2000 Census data:
poverty (proportion of persons living below
the poverty line), residential racial segregation
(proportion of persons having the same race as
one’s own race in one’s neighborhood),
residential racial concentration (density of
persons having the same race as one’s own
race in one’s neighborhood), severe over-
crowding (proportion of units with mean
persons per room more than 1.5 in one’s
neighborhood), and local foreign-born
population (proportion of foreign-born
persons in one’s neighborhood). For each
exposure, we established thresholds to define
high or low exposure. We adopted the
thresholds from established literature for
poverty2,15-17 and residential racial segrega-
tion,2,18–20 and from census data for
residential racial concentration, severe over-
crowding, and local foreign-born population
(we set these 3 threshold values as one third
564 Research Peer Reviewed Dawson et al.
higher than the overall New York City
value). We coded values greater than the
threshold value as high exposure to the
corresponding sociogeographic exposure
index. Conversely, we defined values less
than or equal to the threshold value as low
exposure. Extreme exposure to these mea-
sures was a separate characteristic defined as
having high exposure in at least 4 of the 5
sociogeographic exposure indices.
We calculated values for each sociogeo-
graphic exposure index for 8 race categories in
each of the 176 New York City zip codes
(Appendix A, available as a supplement to the
online version of this article at http://www.
ajph.org). Race categorization was consistent
between US Census 2000 and New York City
TB surveillance data. We aggregated census
tract–level data into zip codes for calculations;
however, a small number of census tracts fell-
between 2 zip codes. We used ArcGIS version
10.0 (ESRI, Redlands, CA) to correct these rare
occurrences by matching the 2000 Census
tract to the zip code in which the majority of
the census tract fell. Following calculation of
each sociogeographic exposure index, we
matched each value to a patient by his or her
race and zip code of residence at TB diagnosis.
As previously described, in 2001,
New York City began routinely genotyping
initial isolates of all patients with TB with
a positive culture for Mycobacterium tuberculosis
by using both spacer oligonucleotide typing
(spoligotyping) and IS6110-based restriction
fragment length polymorphism (RFLP)
techniques.21 For this analysis, we defined
a TB strain by a combination of spoligotype
and RFLP result. We considered a patient
with TB clustered if the patient’s isolate had
a matching spoligotype result and RFLP
pattern to another New York City–verified
patient’s isolate during the study period. We
used clustering of strains as a surrogate for
recent transmission and coded it as yes or no,
and only for those individuals having
culture-positive TB and a TB strain available.
We used SAS version 9.2 (SAS Institute,
Cary, NC) for statistical analysis, including
incidence calculations and univariate analysis
with the Pearson c2. In comparison testing of
categorical variables, we considered differences
among cell distributions significant when
P < .05. To further evaluate transmission epi-
demiology, we constructed 2 separate logistic
regression models fit with generalized
estimating equations to determine which
factors were associated with clustering.
RESULTS
During 2001 to 2009, there were 8953
individuals with TB confirmed in New York
City. Among these patients, 512 (6%) re-
ported a NYCHA residence at the time of TB
diagnosis. The average NYCHA population
(minus the number of NYCHA patients with
TB) and the average non-NYCHA pop-
ulation (minus the number of non-NYCHA
patients with TB) throughout the study were
413 131 and 7 767 332, respectively. In-
dividuals residing in NYCHA developments
were more likely to be a patient with TB
(P = .004). The New York City neighbor-
hoods with the highest number of patients
with TB residing in NYCHA developments
were also the neighborhoods with the
highest number of NYCHA residents in
2009 (Figure A available as a supplement to the
online version of this article at http://www.
ajph.org). The number of patients with TB
residing in NYCHA and non-NYCHA
housing declined from 2001 to 2009 (83 to 41
and 1150 to 716, respectively), and the per-
centage of overall patients with TB that were
NYCHA residents ranged from 4% to 7%.
Tuberculosis incidence rates among both
NYCHA and non-NYCHA residents de-
clined from 2001 to 2009 (Figure 1). Overall,
the incidence of TB among NYCHA resi-
dents was higher than among non-NYCHA
residents (19.7/100 000 population vs 15.1 in
2001 and 10.2 vs 9.0 in 2009). Among the
US-born, TB incidence rates declined among
both NYCHA and non-NYCHA residents
throughout the study period (Figure 2).
However, the TB incidence rate among
NYCHA residents was twice that in non-
NYCHA residents (16.5 vs 7.4 in 2001 and
6.0 vs 3.0 in 2009).
Residents of NYCHA with TB were more
likely to be older, female, non-Hispanic
Black, US-born, HIV-infected, part of a TB
cluster, recently unemployed, and have
substance use in the past year compared with
non-NYCHA residents with TB (all P < .05),
and were less likely to be non-Hispanic White
or Asian (P < .05). There were no significant
differences between NYCHA and non-
NYCHA residents with TB regarding
AJPH March 2016, Vol 106, No. 3
 AJPH RESEARCH

25 45%; P < .001), residential racial concentra-

NYCHA tion (13% vs 18%; P = .005), and local
TB Incidence/100 000 Population

19.7
Non-NYCHA foreign-born population (4% vs 37%,
20 NYC overall P < .001). There was no difference in likeli-
hood of having high exposure to residential
racial segregation (33% vs 31%; P = .119).
15
US-born NYCHA residents with TB
15.1
were more likely than US-born non-
10.2 NYCHA residents with TB to be female and
10
non-Hispanic Black (all P < .05), and less
9.0 likely to have a history of homelessness
5 (P < .05; Table 1). There were no significant
differences between the US-born NYCHA
and US-born non-NYCHA TB populations
0 regarding age group, recent unemployment,
recent substance use, and being part of a TB
01

02

03

04

05

06

07

08

09
20

20

20

20

20

20

20

20

20
cluster.
Year Among all US-born and foreign-born
Note. NYC = New York City; TB = tuberculosis.
culture-positive patients with TB living in
NYCHA developments (n = 379), 364 (96%)
FIGURE 1—Incidence of Tuberculosis Among the New York City Housing Authority (NYCHA) had a TB strain result available (data not
Population vs the Non-NYCHA New York City Population by Year, and the Overall New York shown). There were 225 patients living in
City Tuberculosis Incidence by Year: 2001–2009 NYCHA developments with a TB strain that
was part of a known New York City cluster
(62%). In total, 120 distinct TB clusters and
drug-resistant strains, history of homelessness, more likely than non-NYCHA residents with 139 unique noncluster TB strains comprised
and having a TB strain available. TB to have high exposure to poverty (84% vs 259 TB strains among patients living in
Among the sociogeographic exposure 52%; P < .001) and less likely to have high NYCHA developments. Of the New York
indices, NYCHA residents with TB were exposure to severe overcrowding (31% vs City TB clusters having at least 1 NYCHA
resident, the median cluster size was 4 patients
(range = 2–183 patients). The median num-
25 ber of patients with TB residing in NYCHA
NYCHA who were part of a distinct cluster having at
TB Incidence/100 000 Population

Non-NYCHA least 1 NYCHA resident was 1 patient

20 NYC overall (range = 1–21 patients). Among the 6417
16.5 non-NYCHA culture-positive patients with
TB, 6057 (94%) had a TB strain result
15
available. There were 2723 patients with TB
not living in NYCHA developments having
a TB strain that was part of a known
10
New York City cluster (45%). In total, 744
6.0 distinct TB clusters and 3334 unique
7.4
5 noncluster strains comprised 4078 TB strains
among patients not living in NYCHA
3.0 developments. Of the New York City TB
0 clusters having at least 1 non-NYCHA resi-
dent, the median cluster size was 2 patients
01

02

03

04

05

06

07

08

09
20

20

20

20

20

20

20

20

20

(range = 2–183 patients). The median

Year number of patients with TB not residing in
Note. NYC = New York City; TB = tuberculosis. US-born populations were estimated as a percentage of the total
NYCHA who were part of a distinct cluster
population. having at least 1 non-NYCHA resident was
2 patients (range = 1–162 patients).
FIGURE 2—Incidence of Tuberculosis Among the US-Born New York City Housing Authority Among NYCHA residents who had a TB
(NYCHA) Population vs the US-Born Non-NYCHA New York City Population by Year, and the isolate with strain results, factors associated
Overall US-Born New York City Tuberculosis Incidence by Year: 2001–2009
with clustering were US birth (odds ratio

March 2016, Vol 106, No. 3 AJPH Dawson et al. Peer Reviewed Research 565
AJPH RESEARCH

TABLE 1—Demographic, Clinical, and Social History Characteristics of US-Born New York City
95% CI = 2.29, 3.46); being aged 0 to 18 years
Patients With Tuberculosis by New York City Housing Authority Residence: 2001–2009 (OR = 3.09; 95% CI = 2.20, 4.35), 19 to
44 years (OR = 2.47; 95% CI = 2.07, 2.94),
US-Born NYC Patients With TB and 45 to 64 years (OR = 2.10; 95% CI = 1.75,
Characteristic NYCHA Residents, No. (%) Non-NYCHA Residents, No. (%) P
2.53) versus being aged 65 years and older;
male gender (OR = 1.20; 95% CI = 1.08,
Total 371 (14) 2280 (86)
1.34); Hispanic or non-Hispanic Black race
Age group, y .06 (OR = 1.89; 95% CI = 1.47, 2.42; and
0–18 28 (8) 279 (12) OR = 1.85; 95% CI = 1.45, 2.37; respectively);
19–44 141 (38) 812 (36) substance use in the past year (OR = 1.35;
45–64 138 (37) 787 (35) 95% CI = 1.20, 1.53); extreme exposure to
‡ 65 64 (17) 402 (18) the sociogeographic measures (OR = 1.31;
Male gender 186 (50) 1405 (62) < .001 95% CI = 1.12, 1.54); and history of home-
Race/ethnicity < .001 lessness (OR = 1.30; 95% CI = 1.03, 1.66).
Non-Hispanic White 10 (3) 355 (16)
Non-Hispanic Black 266 (72) 1241 (54)
Asian 0 (0) 61 (3) DISCUSSION
Hispanic 94 (25) 619 (27) We identified disparities in TB rates be-
Other 1 (< 1) 4 (< 1) tween NYCHA and non-NYCHA residents
History of previous TB 20 (5) 95 (4) .28
in New York City. Despite NYCHA resi-
dents comprising 5% of the New York City
History of homelessness 28 (8) 272 (12) .01
population during the study period,10
HIV status .02 NYCHA residents made up 6% of New York
Infected 89 (24) 675 (30) City’s patients with TB population. Because
Not infected 198 (53) 1042 (46) more than two thirds of New York City
Refused, not done, not offered, or unknown 84 (23) 563 (25) patients with TB were foreign-born and
History of substance use in past year 126 (35) 788 (36) .69 NYCHA residents were predominately
Recent unemployment (in past 24 mo) 283 (76) 1701 (75) .49 US-born, US-born NYCHA residents
compared with US-born non-NYCHA
History of mental illness 30 (8) 230 (10) .24
residents was a more appropriate comparison.
Site of disease .93
When we compared the TB incidence among
Pulmonary TB only 249 (67) 1553 (68)
US-born residents, the disparity increased as
Extrapulmonary TB only 81 (22) 483 (21)
NYCHA residents had twice the TB in-
Both pulmonary and extrapulmonary TB 41 (11) 244 (11)
cidence than that of non-NYCHA residents.
Acid-fast bacilli sputum smear–positive TBa 157 (54) 847 (47) .001 The 2 US-born groups were similar with
a
Cavities on chest radiograph 63 (22) 319 (18) .1 regard to demographic, clinical, and social
Culture-positive TB 275 (74) 1616 (71) .2 characteristics. The overall differences between
NYCHA and non-NYCHA residents could
Strain availableb 265 (96) 1526 (94) .19
c
be attributed to the higher number of
Clustered TB strain 178 (67) 1004 (66) .66
foreign-born individuals among non-
Note. NYC = New York City; NYCHA = New York City Housing Authority; TB = tuberculosis. NYCHA residents. Therefore, the disparity
a
Calculated as a percentage of pulmonary cases, which includes pulmonary and both pulmonary and identified may be because the US-born
extrapulmonary cases. NYCHA residents have a higher concentration
b
A TB specimen with IS6110-based restriction fragment length polymorphism and spacer oligonucleotide
of individuals with risk factors for TB than the
type results, as a percentage of those with culture-positive TB.
c
Those with a TB strain genotype that is part of a known NYC TB cluster, as a percentage of those with
general US-born non-NYCHA population.
restriction fragment length polymorphism and spacer oligonucleotide type results. We conducted an analysis of the strain
diversity in the NYCHA TB population to
[OR] = 2.31; 95% confidence interval 95% CI = 1.16, 23.91; Table 2). Asian race assess whether TB transmission was occurring
[CI] = 1.25, 4.29), being aged 0 to 18 years (OR = 0.15; 95% CI = 0.03, 0.72) and high between residents. Low strain diversity
(OR = 7.59; 95% CI = 4.11, 14.02) and 19 to exposure to severe overcrowding among NYCHA residents, indicated by
44 years (OR = 2.71; 95% CI = 1.65, 4.43) (OR = 0.50; 95% CI = 0.35, 0.72) were a large proportion of patients having a TB
versus being aged 65 years and older, sub- negatively associated with clustering. Among strain matching 1 of a small number of TB
stance use in the past year (OR = 2.93; non-NYCHA residents who had a TB isolate strain clusters, would have suggested trans-
95% CI = 1.78, 4.81), and extreme exposure with strain results, factors associated with mission among NYCHA residents. Con-
to the sociogeographic measures (OR = 5.26; clustering were US birth (OR = 2.81; versely, high strain diversity among NYCHA

566 Research Peer Reviewed Dawson et al. AJPH March 2016, Vol 106, No. 3
 AJPH RESEARCH

TABLE 2—Factors Associated With Being Part of a Tuberculosis Cluster Among New York City
NYCHA residents was rare. Furthermore,
Housing Authority Patients With Tuberculosis vs Non–New York City Housing Authority New few clusters had more than 1 NYCHA resi-
York City Patients With Tuberculosis: 2001–2009 dent having TB, implying that any trans-
mission associated with NYCHA residency
Patients Living in NYCHA Patients Living Outside of was limited. Although there was 1 cluster
Covariatea (n = 362), AOR (95% CI) NYCHA (n = 6035), AOR (95% CI) including 21 patients with TB with
Birth in the United States (includes all US territories) a NYCHA residence, the strain associated
Yes 2.31 (1.25, 4.29) 2.81 (2.29, 3.46) with that cluster is endemic to New York
No (Ref) 1 1 City, the cluster had 162 patients not having
Age group, y a NYCHA residence, and the 21 patients
0–18 7.59 (4.11, 14.02) 3.09 (2.20, 4.35) having a NYCHA address were distributed
19–44 2.71 (1.65, 4.43) 2.47 (2.07, 2.94) among 17 different NYCHA addresses. If TB
45–64 1.23 (0.73, 2.05) 2.10 (1.75, 2.53) transmission were happening in NYCHA, we
‡ 65 (Ref) 1 1 would expect to have seen a small number of
clusters with many NYCHA residents with
Gender
TB; however, we did not see this. This
Male 0.84 (0.58, 1.21) 1.20 (1.08, 1.34)
suggests that transmission was not necessarily
Female (Ref) 1 1
occurring among NYCHA residents.
Race Among NYCHA and non-NYCHA
Non-Hispanic Black 0.31 (0.09, 1.08) 1.85 (1.45, 2.37) residents in the study population, similar
Hispanic 0.33 (0.09, 1.13) 1.89 (1.47, 2.42) factors were associated with TB clustering. In
Asian 0.15 (0.03, 0.72) 0.86 (0.65, 1.15) both populations, US birth, younger age,
Other 0.15 (0.01, 1.52) 0.79 (0.42, 1.49) recent substance use, and high exposure to 4
Non-Hispanic White (Ref) 1 1 or more sociogeographic measures (poverty,
History of substance use in past year severe overcrowding, residential racial seg-
Yes 2.93 (1.78, 4.81) 1.35 (1.20, 1.53) regation, residential racial concentration, or
No (Ref) 1 1 local foreign-born population) were posi-
High exposure to ‡ 4 sociogeographic measures tively associated with clustering. The overlap
Yes 5.26 (1.16, 23.91) 1.31 (1.12, 1.54) in some of the risk factors in this study
No (Ref) 1 1 demonstrates that higher TB incidence in
High exposure to overcrowding NYCHA is more likely the result of its
Yes 0.50 (0.35, 0.72) NA higher concentration of individuals
No (Ref) 1 NA with known TB risk factors rather than some
aspect of housing quality or resident
History of mental illnessb
interaction.
Yes NA 1.35 (0.97, 1.88)
There were limitations to the study. First,
No (Ref) NA 1
individual-level data of NYCHA residents
History of homelessness were not available for certain measures.
Yes NA 1.30 (1.03, 1.66) Therefore, we used head-of-household
No (Ref) NA 1 characteristics as a surrogate measure for
Note. AOR = adjusted odds ratio; CI = confidence interval; NA = not applicable; NYC = New York City; variables, such as the proportion of NYCHA
NYCHA = New York City Housing Authority; TB = tuberculosis. residents that were US-born. Second, we
a
Both models always included US birth, age, gender, and race. Other a priori covariates were tested, based denominator data on officially reported
including any substance use in past year, HIV status, borough of residence, recent unemployment, history
of mental illness, history of homelessness, high exposure to poverty, high exposure to severe over-
figures, which may not include unreported
crowding, high exposure to residential racial segregation, high exposure to residential racial concentration, additional tenants within residences. Third,
high exposure to local foreign-born population, and high exposure in ‡ 4 of the aforementioned socio- data on the length of individuals’ residence in
geographic indices.
b NYCHA developments were not available,
History of mental illness, despite being nonsignificant by our criterion, was retained in the final model for
patients living outside of NYCHA because it provided significant predictive value during model though the average residency was known to
construction. be 20 years. Fourth, social history variables
such as substance use may have been subject to
residents, consisting of many different TB There were 259 unique strains among the reporting bias. Fifth, use of surrogate measures
strains among patients and a small proportion 364 NYCHA persons with TB, indicating to estimate the population at risk naturally
of clustering, would have suggested high strain diversity in this population. High yielded imprecise incidence measures, and
that transmission happened through other strain diversity among NYCHA persons should be considered best estimates rather
means. with TB suggests that transmission between than true incidence.

March 2016, Vol 106, No. 3 AJPH Dawson et al. Peer Reviewed Research 567
AJPH RESEARCH
Strengths of this study include the large
study population size, high completeness of
patient address data used to assign NYCHA
residence, high capture of TB cases in New
York City, and availability of TB strain results
for nearly all individuals with TB. With al-
most 9000 individuals having TB over the
9-year study period, there was adequate
power to detect meaningful differences be-
tween the demographic, clinical, and social
history characteristics. With the long obser-
vation period of 9 years and the availability of
genotyping data, our study was able to pro-
vide a better understanding of TB trans-
mission over a longer time frame than many
previous studies, perhaps better reflecting the
natural course of TB transmission and
pathogenesis.
As a disease that increasingly affects hard-
to-reach populations, TB presents challenges
for TB-control programs whose primary
mission is to prevent and cure TB.22 Identi-
fying populations at high risk for developing
TB to engage them in prevention activities is
critical to the success of TB control programs
in both global and local contexts. The
NYCHA is the largest public housing au-
thority in North America, with more than
400 000 residents living in more than 350
developments in all 5 boroughs of New York
City. The health of public housing residents
has been shown to be poorer than that of their
neighbors in various studies,23,24 but this has
been shown to be the result of public hous-
ing’s role as a social safety net rather than
a result of housing quality.25
Although this study has shown that TB
transmission between NYCHA residents is
not a primary mode of transmission, and thus
New York City DOHMH does not need to
intervene on such a pathway, the overall
NYCHA population still has a relatively high
burden of TB. Because the NYCHA pop-
ulation is well-defined both demographically
and geographically and has a relatively static
population with an average residency of
20 years, this population is accessible to public
health authorities and can be engaged in
ongoing TB prevention activities. However,
because public housing residents tend to have
more health challenges than non–public
housing residents,23,24 efforts to reduce the
burden of TB among them should not be
enacted in isolation of other health pro-
motion activities. A comprehensive approach
568 Research Peer Reviewed Dawson et al.
that targets a multitude of this population’s
unique health needs is warranted. In light of
the rising prevalence of type 2 diabetes and
other obesity-related conditions, more work
is needed to address the role of comorbidities
in TB reactivation among New Yorkers.
New York City DOHMH, through district
public health offices, is working to address the
primary health concerns of the population in
its catchment area,26 and should continue to
be supported. Tuberculosis control program
staff plan to work collaboratively with district
public health offices and NYCHA adminis-
trators to better target the NYCHA pop-
ulation for TB screening and treatment of TB
infection.
CONTRIBUTORS
P. Dawson contributed to originating the study meth-
odologies, conducted the statistical analyses, and wrote the
article. B. R. Perri and S. D. Ahuja conceptualized the
project, assisted with analysis, and provided revisions to
the article.
ACKNOWLEDGMENTS
This work was presented at the American Thoracic Society
International Conference, May 2012.
The authors thank the New York City Housing Au-
thority, especially Anne-Marie Flatley, as well as Bureau of
Tuberculosis Control staff and the Epi Scholars Program in
Health Disparities, New York City Department of Health
and Mental Hygiene. The authors also wish to thank our
genotyping laboratory partners, the New York City Public
Health Laboratory (New York, NY), Public Health
Research Institute at Rutgers University (Newark, NJ),
New York State Department of Health Wadsworth
Center (Albany, NY), and the Centers for Disease Control
and Prevention (Atlanta, GA).
HUMAN PARTICIPANT PROTECTION
This study was approved by the New York City De-
partment of Health and Mental Hygiene institutional
review board and conducted with the support of
New York City Housing Authority.
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AJPH March 2016, Vol 106, No. 3
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