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Respiratory infections in the homeless - FEATURE


Respiratory infections in the homeless 
Olga Wrezel (Meds 2009) 
Faculty Reviewer: Dr. Jamie Harris 

Many people are affected by homelessness worldwide, in Canada and the U.S. Homelessness is associated
with an increased risk of health problems due to overcrowding in shelters and host factors such as substance
abuse, HIV co-infection, poor nutrition and hygiene, mental illness and trauma. Respiratory infections are
among the most common problems that the homeless may present with and are associated with high
morbidity and mortality. Certain respiratory infections are more common among homeless individuals and
may be associated with complications unique to this population. Most of the literature in the field focuses
on tuberculosis in the homeless or on specific outbreaks of respiratory infections. This article discusses the
prevalence, risk factors, complications, treatment and prevention of tuberculous and non-tuberculous
respiratory infections such as influenza and pneumonia caused by S pneumoniae, S aureus, H influenzae b,
and anaerobes.

Introduction                                              the homeless.3,8,9 The mortality due to respiratory
                                                          illness is about seven times greater than expected
Homelessness is an alarming social problem that           in the homeless.9,10 This is compounded by the
affects up to 100 million people worldwide.1 The          increased rate of chronic respiratory illness such
2001 Canadian census counted 14,145 individuals           as bronchitis (11.4%), asthma (8.6%) and COPD
living in shelters, however, this largely                 (5%). Several factors specifically predispose this
underestimates the number as many homeless                population to respiratory infections including
may not stay in shelters.2 Homelessness is also a         crowding, increased exposure to pathogens,
significant health problem. Crowded shelters are          smoking, alcohol and drug abuse, HIV
favorable environments for infection and host             seropositivity and chronic lung disease.3,6,9 This
factors such as poor nutrition, obesity, sedentary        article will examine both tuberculous and non-
lifestyle, poor hygiene, alcoholism, drug use,            tuberculous respiratory infections such as
smoking, mental illness, abuse, trauma, or HIV            pneumonia and influenza in the homeless as they
co-infection increase susceptibility to illness and       are not only more common but are associated
may diminish immune systems.3,4,5,6 These                 with      greater   morbidity,    mortality     and
factors, combined with decreased financial and            complications.
personal resources, make the seeking out of
medical help and compliance with treatment less           Tuberculosis
likely. As a result, homeless people are more
likely to suffer from respiratory infections, skin        Tuberculosis is the most common respiratory
and foot infections, hepatitis, HIV, STI’s, and           infection among the homeless that is discussed in
chronic disease.5                                         the literature. The estimated annual pulmonary
                                                          TB rate for Canada and the U.S. is 2 per
       Respiratory infections are among the most          100,000.11 The urban homeless comprise a
common medical issue that homeless individuals            disproportionate burden of tuberculosis. The
seek help for and shelters can be sources of              prevalence of active tuberculosis among the
outbreaks of tuberculosis and pneumonia.7                 homeless in the U.S. is 1.6% to 6.8% and 18% to
Respiratory infections account for 33-42% of              51% for latent disease.8
presenting complaints and 20% of total deaths in

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        As with other respiratory infections,         chest radiography, TST and sputum culture upon
poverty, malnutrition and overcrowding are all        shelter admission before access to free meal
risk factors for tuberculosis. Larger, more           services.17
crowded shelters with increased people sharing
the same breathing space increases transmission               Lack of treatment compliance is a
and poor ventilation or recirculation of air          common problem among the homeless. A 48%
compounds this risk.8 HIV co-infection and            non-compliance rate was reported in New York in
alcoholism commonly complicate the course of          1991 leading to increased length of treatment
infection. HIV is the single-most important risk      (560 versus 324 days) and decreased completion
factor for latent disease progressing to active       of treatment. Directly observed therapy (DOT)
disease and it is recommended that all individuals    and supervised housing programs are both
with TB be tested for HIV.5,8 Some studies link       effective       methods     used    to     increase
multi-drug resistance to homelessness, although       compliance.          Other novel solutions include
contradictory data disputes this.5,12 Homelessness    financial or food incentives, transportation
is associated with poor adherence, loss to follow-    assistance and education using a peer health
up and is an independent risk factor for no           advisor.5,8,19 More dramatically, incarceration has
contacts.12,13 Contact tracing is accomplished by     also been evaluated as a method for treating
mass screening in shelters as opposed to              patients refusing treatment.8,20
searching for named contacts.3
        Screening and detection in the homeless is
important for preventing TB resurgence.14 The         Pneumonia affects over 1 million Americans
CDC recommends that the detection of                  annually and is the 6th leading cause of death with
tuberculosis be given first priority as opposed to    a 14% mortality rate among hospitalized
screening asymptomatic individuals.8 City-wide        patients.21 This burden is disproportionally shared
symptom screening programs have been                  by the homeless. An Edmonton-based study from
implemented in Philadelphia shelters on intake to     2000-2002 showed a pneumococcal infection rate
ensure that symptoms such as prolonged cough,         among the homeless of 266.7 per 100,000
night sweats, fever, and weight loss are further      contrasted with 9.7 per 100,000 in the general
investigated.15 Mass screening in shelters has also   population.       Outbreaks    of    pneumococcal
been widely used with resulting decreases in          pneumonia more commonly occur in crowded
tuberculosis transmission. No consensus has been      shelters with high pneumococcal carriage rates of
reached about the most effective screening tool.1     up to 60%. Shelter outbreaks in Chicago, Boston,
Tuberculin skin testing (TST) is likely the           Paris and the UK as well as in several provinces
simplest and least expensive to administer, but       of Western Canada have been described in the
lacks specificity and results in many false           literature. 20,22
negatives in the immunocompromised.1,16
Mandatory skin test screening in one U.S. study              In addition to homelessness, risk factors
resulted in a decreased incidence of TB from 510      for pneumonia include smoking, drug or alcohol
to 121 cases per 100,000 per year.1 Spot sputum       use, HIV, asthma and COPD; all frequent
is also a fairly rapid screening technique but 50%    comorbidities in the homeless. It is estimated that
of smears are negative and subsequent tracing of      78% of homeless individuals are smokers and
patients is difficult.1,8 Studies in incarcerated     60% abuse alcohol.3,9,22,23 In two shelter
individuals show that chest radiography is likely     outbreaks in Boston and Paris, the majority of
to be the most cost-effective method. Annual          those infected were alcoholics, smokers or had
snapshot screening for tuberculosis in shelters       chronic bronchitis.9,24 Outbreaks of Hib
using combinations of these methods has been          pneumonia are also mostly found among
undertaken in Los Angeles and Marseille with          alcoholic homeless patients.3,9
great effectiveness.1 Certain shelters, as in
Barcelona, imposed mandatory screening with
Page | 62 
       The most common organisms responsible         Influenza
for community acquired pneumonia in the
homeless are Streptococcus pneumoniae,               Influenza affects millions of Americans per year
Staphylococcus aureus, and H influenzae b.           and results in 100,000 hospitalizations and 36,000
Aspiration pneumonia is also frequent and            deaths annually. Influenza can result in secondary
organisms          include   anaerobes      like     pneumonia and exacerbations of COPD or
peptostreptococcus, Fusobacterium nucleatum,         asthma.26 Despite the large morbidity and
Prevotella and bacteroides species. Pneumocystis     mortality associated with the virus, influenza
carinii can be found in HIV positive                 among the homeless is very poorly studied. A
individuals.20,21,22                                 New York-based study of 3 shelters evaluated
                                                     4,319 charts for influenza-like illness with 59
        Vaccination     against    pneumococcal      recorded cases, less than one fourth of which had
pneumonia is one method of reducing invasive         been vaccinated. Vaccination against influenza
pneumococcal disease in shelters.25 The Canadian     has been advocated for in those at increased risk
National Advisory Committee on Immunization          of influenza and pneumonia including the
(NACI) recommends the use of 23-valent               homeless, HIV-infected and those with COPD.27
pneumococcal polysaccharide vaccine (PPV-23)         Influenza vaccination remains underutilized and
in the homeless, those who use illicit drugs, HIV    organized efforts concentrated over a day or week
infected individuals and those with other chronic    to vaccinate all shelter residents and staff is
conditions    such     as   COPD        that   are   suggested.26 Various strategies for improving
disproportionately higher in the homeless.           vaccination rates include educational campaigns,
Vaccination of hard to reach populations like the    improving        patient-provider      interactions,
homeless can be challenging and a 1999               broadening the provider base, adoption of
vaccination campaign in Edmonton addressed this      standing orders for immunization administration,
issue by targeting as many sites as possible         and promoting wider availability and access to
including single room occupancy hotels, soup         vaccine at the structural level.28
kitchens, community agencies, needle exchanges,
pubs, parks and alleys. The year following the       Conclusion
campaign, there was a decrease in the amount of
emergency department visits for pneumonia (863       Homeless individuals are at increased risk of
compared to 646), and a decrease in admissions       respiratory infections such as tuberculosis,
for pneumonia.22 Vaccination is also the best way    influenza and pneumonia due to S pneumoniae, S
to prevent Hib pneumonia in at-risk persons who      aureus, H influenzae b and anaerobes. Risk
are not immune.23                                    factors include overcrowding, increased pathogen
                                                     exposure and host factors such as alcoholism,
       Special considerations for pneumonia in       smoking, drug abuse, HIV co-infection and
the homeless include keeping a high index of         chronic lung disease. Morbidity, mortality and
suspicion for aspiration in those who abuse drugs    complications are greater in these specific
and alcohol. One must also consider the difficulty   populations and outbreaks are common.
of completing antibiotic regimens especially those   Diagnosis and treatment non-compliance are
with frequent dosing. Furthermore, there is often    serious challenges. It is important to remember
no safe storage for medications or a place to        that respiratory infections and their complications
convalesce with closures of shelters during the      in the homeless are largely influenced by social
day. Hospitalization or admission in a medical       factors. Mindfulness of the unique risks and
respite unit is worthwhile to ensure proper          challenges associated with this population is
treatment.21 Smoking cessation is another            important. It is only through comprehensive
important arm of prevention although it is often     programs that involve initiatives like screening,
overlooked in the homeless due to falsely            immunization, low threshold for hospitalization,
assumed lack of motivation.6                         smoking cessation, and incentives or education to
                                                     increase compliance, that effective prevention and

UWO Medical Journal, Vol 78, Issue 2                                                          Page | 63 
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can be attained.                                             Dis. 2003 Dec;7(12 Suppl 3):S397-404.
                                                       14.   de Vries G, van Hest RA, Richardus JH. Impact
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