Tuberculosis and homelessness in the United States, 1994-2003

Context 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. Objectives To describe homeless persons with TB and to compare risk factors and disease characteristics between homeless and nonhomeless persons with TB. Design and Setting 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. Main Outcome Measures Number and proportion of TB cases associated with homelessness, demographic characteristics, risk factors, disease characteristics, treatment, and outcomes. Results Of 185870 cases of TB disease reported between 1994 and 2003, 11369 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. Conclusions 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.