Tuberculosis and Homelessness in the United States, 1994–2003

Surveillance, Epidemiology, and Outbreak Investigations Branch, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Ga 30333, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 07/2005; 293(22):2762-6. DOI: 10.1001/jama.293.22.2762
Source: PubMed


Tuberculosis (TB) rates among US homeless persons cannot be calculated because they are not included in the US Census. However, homelessness is often associated with TB.
To describe homeless persons with TB and to compare risk factors and disease characteristics between homeless and nonhomeless persons with TB.
Cross-sectional analysis of all verified TB cases reported into the National TB Surveillance System from the 50 states and the District of Columbia from 1994 through 2003.
Number and proportion of TB cases associated with homelessness, demographic characteristics, risk factors, disease characteristics, treatment, and outcomes.
Of 185,870 cases of TB disease reported between 1994 and 2003, 11,369 were among persons classified as homeless during the 12 months before diagnosis. The annual proportion of cases associated with homelessness was stable (6.1%-6.7%). Regional differences occurred with a higher proportion of TB cases associated with homelessness in western and some southern states. Most homeless persons with TB were male (87%) and aged 30 to 59 years. Black individuals represented the highest proportion of TB cases among the homeless and nonhomeless. The proportion of homeless persons with TB who were born outside the United States (18%) was lower than that for nonhomeless persons with TB (44%). At the time of TB diagnosis, 9% of homeless persons were incarcerated, usually in a local jail; 3% of nonhomeless persons with TB were incarcerated. Compared with nonhomeless persons, homeless persons with TB had a higher prevalence of substance use (54% alcohol abuse, 29.5% noninjected drug use, and 14% injected drug use), and 34% of those tested had coinfection with human immunodeficiency virus. Compared with nonhomeless persons, TB disease in homeless persons was more likely to be infectious but not more likely to be drug resistant. Health departments managed 81% of TB cases in homeless persons. Directly observed therapy, used for 86% of homeless patients, was associated with timely completion of therapy. A similar proportion in both groups (9%) died from any cause during therapy.
Individual TB risk factors often overlap with risk factors for homelessness, and the social contexts in which TB occurs are often complex and important to consider in planning TB treatment. Nevertheless, given good case management, homeless persons with TB can achieve excellent treatment outcomes.

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    • "Epidemiological studies of homeless populations have reported the prevalence rate of 1.2%–6.8% for active TB [9, 10]. No data about the incidence of TB in homeless people are to date available in Rome. "
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    ABSTRACT: The authors show the results of an integrated model for risk management of tuberculosis in a sample of sheltered homeless in Rome. Tuberculin skin test (TST) was used for evaluating the prevalence of latent infection (LTBI). In TST positives, expectorate was collected and chest X-ray was achieved. Multiple logistic regression analysis was performed to investigate determinants of infection. Out of 288 recruited subjects, 259 returned for the TST reading; 45.56% were positive and referred to a specialized center; 70 accessed the health facility and completed the clinical pathway. The risk factors associated to LTBI were male gender (OR = 3.72), age over 60 years (OR = 3.59), immigrant status (OR = 3.73), and obesity (OR = 2.19). This approach, based on an integrated social network, guarantees high adherence to screening (89.93%), allowing patients testing positive for latent tuberculosis infection to be diagnosed and rapidly referred to a specialized center.
    The Scientific World Journal 02/2012; 2012:396302. DOI:10.1100/2012/396302 · 1.73 Impact Factor
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    • "In our small group of homeless persons with TB, most were successfully treated. The authors of a national survey of homelessness and tuberculosis in the United States reviewing 10 years of surveillance data concluded that despite risk factors for both the development of TB and for poorer outcomes (substance abuse, past incarceration, HIV co-infection), treatment was usually successful for homeless persons with TB[24]. Success was enhanced by effective case management and appropriate drug regimen. "
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    ABSTRACT: Montreal is Canada's second-largest city, where mean annual tuberculosis (TB) incidence from 1996 to 2007 was 8.9/100,000. The objectives of this study were to describe the epidemiology of TB among homeless persons in Montreal and assess patterns of transmission and sharing of key locations. We reviewed demographic, clinical, and microbiologic data for all active TB cases reported in Montreal from 1996 to 2007 and identified persons who were homeless in the year prior to TB diagnosis. We genotyped all available Mycobacterium tuberculosis isolates by IS6110 restriction fragment length polymorphism (IS6110-RFLP) and spoligotyping, and used a geographic information system to identify potential locations for transmission between persons with matching isolates. There were 20 cases of TB in homeless persons, out of 1823 total reported from 1996-2007. 17/20 were Canadian-born, including 5 Aboriginals. Homeless persons were more likely than non-homeless persons to have pulmonary TB (20/20), smear-positive disease (17/20, odds ratio (OR) = 5.7, 95% confidence interval (CI): 1.7-20), HIV co-infection (12/20, OR = 14, 95%CI: 4.8-40), and a history of substance use. The median duration from symptom onset to diagnosis was 61 days for homeless persons vs. 28 days for non-homeless persons (P = 0.022). Eleven homeless persons with TB belonged to genotype-defined clusters (OR = 5.4, 95%CI: 2.2-13), and ten potential locations for transmission were identified, including health care facilities, homeless shelters/drop-in centres, and an Aboriginal community centre. TB cases among homeless persons in Montreal raise concerns about delayed diagnosis and ongoing local transmission.
    BMC Public Health 10/2011; 11:833. DOI:10.1186/1471-2458-11-833 · 2.26 Impact Factor
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    • "When contact investigations are incomplete, a pool of latent TB infection remains, threatening to generate additional cases and cause ongoing transmission (10,15,24). Compounding these risks, persons who report substance abuse are more likely to be poor, homeless, and have an incarceration history—all documented TB risk factors (5,11,13–15,28,37,38). When contact investigations involve a hard-to-reach population, conventional methods of contact tracing may need to be expanded to include other approaches (2,5,10,13–15,27,39). "
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    ABSTRACT: To understand circumstances of tuberculosis transmission that strain public health resources, we systematically reviewed Centers for Disease Control and Prevention (CDC) staff reports of US outbreaks in which CDC participated during 2002-2008 that involved ≥3 culture-confirmed tuberculosis cases linked by genotype and epidemiology. Twenty-seven outbreaks, representing 398 patients, were reviewed. Twenty-four of the 27 outbreaks involved primarily US-born patients; substance abuse was another predominant feature of outbreaks. Prolonged infectiousness because of provider- and patient-related factors was common. In 17 outbreaks, a drug house was a notable contributing factor. The most frequently documented intervention to control the outbreak was prioritizing contacts according to risk for infection and disease progression to ensure that the highest risk contacts were completely evaluated. US-born persons with reported substance abuse most strongly characterized the tuberculosis outbreaks in this review. Substance abuse remains one of the greatest challenges to controlling tuberculosis transmission in the United States.
    Emerging Infectious Diseases 03/2011; 17(3):425-31. DOI:10.3201/eid1703.101550 · 6.75 Impact Factor
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