Abstract

Background: The homeless are at very high risk for both respiratory diseases and poor access to health care delivery systems. The aim of this study was to assess the contribution of a shelter-based survey to identify respiratory diseases in the homeless population in Marseilles, in order to further develop preventive interventions. Methods: A prevalence survey of respiratory diseases was conducted in two homeless shelters in Marseilles, in February 2005. A multidisciplinary team including infectious diseases specialists, lung specialists, residents, nurses, physiotherapists and X-ray technicians visited the two shelters. Interview, physical examination, sputum sampling for Mycobacterium tuberculosis detection, nasal swabs for virus detection and chest X-rays were performed in shelters. Chest X-rays were subsequently analysed by a pneumonologist and subjects found to have radiological abnormalities were hospitalized for further investigations. Results: Of the 221 homeless persons enrolled, 110/221 (50%) had at least one respiratory manifestations. Chest X-rays were abnormal in 14 persons. Active tuberculosis was diagnosed in two, influenza in two, respiratory syncytial virus infection in two, acute pneumonia in one, asthma in two, lung cancer in one, acute bronchitis in 23, chronic bronchitis in 42, and exacerbation of chronic obstructive pulmonary disease in 22 persons, respectively. Conclusion: Our shelter-based survey, including clinical evaluation and chest radiographic screening, shows that this approach can be useful to control and prevent respiratory diseases among the homeless. However, further studies are necessary to determine the magnitude of influenza in the homeless, the impact of influenza immunization and optimal frequency of interventions in shelters.

Introduction

Homelessness, defined as the absence of customary and regular access to a conventional dwelling or residence, represents an increasing social and public health problem worldwide.1,2 Homeless people have significant rates of active smoking, heavy alcoholism, drug addiction, poor nutritional status and HIV infection, all of which predispose to various diseases, and especially to respiratory diseases.1,3,4 This population often sleeps in overcrowded shelters providing the ideal setting for the spread of respiratory communicable infections such as tuberculosis.4 They face many barriers which impede their access to health care delivery systems, leading to increased severity of illness as well as to an increased spread of transmission of infections among this population.1,5 Respiratory diseases represent one of the conditions most frequently associated with deaths among homeless adults.6 Thus, it is important to identify interventions that could improve detection, control and prevention of respiratory diseases in this high-risk population.

It has been reported that targeted interventions focused in places where homeless people are usually coming are the most efficient for providing care to the homeless.5,7,8 In Marseilles, France, the number of homeless is estimated to be about 1500 and about 600 of them sleep in two shelters. Since 1993, we have provided health care to this population through systematic physical examination and studies on louse-borne diseases.9,10 Since 2000, we sent a large medical team to perform targeted interventions once a year in these two shelters. This strategy allowed us to appreciate the magnitude of skin diseases and louse-borne diseases in this population as well as to implement appropriate preventive and curative interventions.11–13

In 2005, we added the determination of the prevalence of respiratory diseases as one of the goals of our annual survey thanks to the participation of pneumonologists and X-ray technologists using a mobile X-ray machine. We report here the result of a prevalence survey of respiratory diseases among sheltered homeless in Marseilles.

Patients and methods

The study protocol was reviewed and approved by the Institutional Review Board and Ethics Committee of Marseilles (CCPPCRB99/76). On February 1, 2005 and February 3, 2005, a prevalence survey was conducted in two shelters in Marseilles by a medical team composed of 40 persons including nurses, physiotherapists, infectious diseases specialists, residents or fellows, pneumonologists and X-ray technicians. Each shelter provides beds, showers, clothes and food to ∼300 homeless persons. About 30% of this population are long stay residents sleeping in these shelters for more than 2 years and the remaining are mobile persons with a median duration of staying in shelters of 62 days (ranges: 7 days to 24 months). A general practitioner and a registered nurse are available daily in each shelter to provide medical care.

On the day of the survey, upon arrival at the shelter between 5 pm and 10 pm, homeless persons were informed of the purpose of the medical team's visit and were asked to read and sign an informed consent form. Persons who accepted to participate in the study were interviewed by using a standardized questionnaire and examined by a medical doctor. Sputum samples and nasal swabs were collected. Three consecutive measurements of peak expiratory flow (PEF) were taken by physiotherapists; the best value was recorded and linked to age and height. A PEF value <70% of the predicted value according to age and height was considered as abnormal. Chest X-rays were performed by technicians in a mobile X-ray converted truck. Sputum smears were stained with Ziehl-Neelsen stain and culture was performed after decontamination in Bactec® lytic bottle (Becton–Dickinson, Sparks, MD). Detection and identification of viruses from nasal swabs were performed by the real-time reverse transcriptase PCR for influenza A and B viruses as well as for respiratory syncytial virus (RSV), as previously described.14,15

Chest X-rays were subsequently analysed by a pneumonologist who sent the results to the medical team within 48 h following the shelter investigation. If a radiological abnormality was observed, the shelter's staff was immediately informed so that those homeless persons could be sent to the Emergency Department of the University Hospital (Hôpital Nord, Marseilles) for further investigation and care. Hospital evaluation included collection of sputum or gastric aspirate specimens for microscopic detection of acid-fast bacilli by the Ziehl-Neelsen stain, culture in Bactec® bottles, and detection and identification by PCR, as previously described.16 Other microbiological investigations in hospitalized patients included the collection of three set of blood cultures, a urinary antigen assay for the detection of Legionella pneumonia, and serological testing for Mycoplasma pneumoniae (ELISA), L. pneumophila (IFA), Chlamydophila pneumoniae (IFA) and Coxiella burnetii (IFA). Computed tomography, bronchoscopy with bronchoalveolar lavage and biopsy were performed if necessary.

Statistical analysis

Data were analysed using statistical software (Entry Builder 3.0, and SPSS version 10.0, 2003, SPSS Inc. Chicago, IL). Two-tailed tests were used for all comparisons. Differences in proportion were tested using Chi-square test or Fisher's exact test as appropriate. Continuous variables were tested using Student's t-test and Levene test as appropriate. Statistical significance was defined as P < 0.05.

Results

Demographic characteristics of the studied population

Five hundred and forty homeless persons were present in the shelters on the day of the study, 221 (41%) of them—corresponding to 15% of estimated homeless population in Marseille—agreed to participate in the study and were subsequently enrolled. The remaining 319 persons refused to participate in the study. Table 1 summarizes the main demographic characteristics of the participants. The mean age (ranges) was 41 years (7–76 years). There were 208 (94%) male, 169 (78%) current smokers and 77 (35%) alcohol abusers. A history of asthma was reported by 15 persons (7%), HIV infection by 2 (1%) and a past history of pulmonary tuberculosis by 11 (5%).

Table 1

Characteristics of the study population

Characteristics n/N (%) 
Mean age (ranges): 41 years (7–76 years)  
Distribution of cases by age group (years)  
    ≤ 20 13/221 (6) 
    21–40 102/221 (46) 
    41–60 84/221 (38) 
    > 60 22/221 (10) 
Sex  
    Men 208/221 (94) 
    Women 13/221 (6) 
Pace of birth  
    North Africa 84/220 (38) 
    France 81/220 (37) 
    East Europa 31/220 (14) 
    Sub-Saharan Africa 12/220 (5) 
    West Europa 6/220 (3) 
    Other 6/220 (3) 
Duration in homelessness  
    ≤ 6 months 91/212 (43) 
    7–12 months 26/212 (12) 
    13–24 months 18/212 (9) 
    > 24 months 77/212 (36) 
Addiction  
    Current smoker 169/218 (78) 
    Alcohol abuser 77/219 (35) 
    Marijuana use 45/213 (21) 
    Injection drug use 4/213 (2) 
Underlying diseases  
    Asthma 15/221 (7) 
    Cirrhosis 4/197 (2) 
    HIV infection 2/190 (1) 
History of previous pulmonary tuberculosis 11/221 (5) 
Characteristics n/N (%) 
Mean age (ranges): 41 years (7–76 years)  
Distribution of cases by age group (years)  
    ≤ 20 13/221 (6) 
    21–40 102/221 (46) 
    41–60 84/221 (38) 
    > 60 22/221 (10) 
Sex  
    Men 208/221 (94) 
    Women 13/221 (6) 
Pace of birth  
    North Africa 84/220 (38) 
    France 81/220 (37) 
    East Europa 31/220 (14) 
    Sub-Saharan Africa 12/220 (5) 
    West Europa 6/220 (3) 
    Other 6/220 (3) 
Duration in homelessness  
    ≤ 6 months 91/212 (43) 
    7–12 months 26/212 (12) 
    13–24 months 18/212 (9) 
    > 24 months 77/212 (36) 
Addiction  
    Current smoker 169/218 (78) 
    Alcohol abuser 77/219 (35) 
    Marijuana use 45/213 (21) 
    Injection drug use 4/213 (2) 
Underlying diseases  
    Asthma 15/221 (7) 
    Cirrhosis 4/197 (2) 
    HIV infection 2/190 (1) 
History of previous pulmonary tuberculosis 11/221 (5) 

Prevalence of clinical, biological and radiographic abnormalities

Table 2 presents the self reported symptoms, physical findings, and results of investigations made during shelter interventions. A total of 110 persons (50%) had at least one respiratory symptom or physical finding. Chronic cough (41%) and sputum production (33%) were the most frequent respiratory manifestations. Among the homeless tested, 37% had a decreased peak flow. Ninety-five persons (43%) agreed to have nasal swabbing performed enabling to detect influenza virus in two persons (2%) and RSV in two other persons (2%). Chest radiograph was found to be abnormal in 14 persons (6%), four were lost to follow up and 10 were hospitalized for further evaluation. In five hospitalized patients no diagnosis was established and radiographic abnormalities were attributed to sequels of past pulmonary tuberculosis. Four of these five persons reported a past history of TB.

Table 2

Prevalence of clinical, laboratory and radiographic abnormalities observed in 221 homeless persons at time of a snapshot intervention in two shelters in Marseilles

Variables n/N (%) 
Reported symptoms and physical findings  
    Chronic cough 87/210 (41) 
    Dyspnea 33/208 (16) 
    Sputum production 68/206 (33) 
    Hemoptysis 2/207 (1) 
    Rhonchi 24/221 (11) 
    Crackles on auscultation 3/221 (1) 
    Wheeze 27/204 (13) 
    At least one respiratory manifestation 110/221 (50) 
Investigations performed in shelters  
    Decreased peak expiratory flow 68/184 (37) 
    Chest radiograph abnormalities 14/219 (6) 
    Detection of viruses in nasal swabs 4/95 (4) 
    Detection of Mycobacterium spp in sputum 0/95 (0) 
Variables n/N (%) 
Reported symptoms and physical findings  
    Chronic cough 87/210 (41) 
    Dyspnea 33/208 (16) 
    Sputum production 68/206 (33) 
    Hemoptysis 2/207 (1) 
    Rhonchi 24/221 (11) 
    Crackles on auscultation 3/221 (1) 
    Wheeze 27/204 (13) 
    At least one respiratory manifestation 110/221 (50) 
Investigations performed in shelters  
    Decreased peak expiratory flow 68/184 (37) 
    Chest radiograph abnormalities 14/219 (6) 
    Detection of viruses in nasal swabs 4/95 (4) 
    Detection of Mycobacterium spp in sputum 0/95 (0) 

Respiratory diseases observed by the survey

In five hospitalized patients with X-ray abnormalities, the discharge diagnoses were active TB in 2 (1%), pneumonia in 1 (0.5%), lung cancer in 1 (0.5%) and emphysema in 1 (0.5%) (table 3). In patients diagnosed with TB, M. tuberculosis was detected in one patient by culture of sputum, and in the second patient by PCR of the sputum.

Table 3

Final diagnoses observed among 221 homeless persons and relevant diagnostic tools used during intervention in shelters

Diagnoses Cases n(%) Relevant diagnostic tool 
Active pulmonary tuberculosis 2 (1) Chest radiography 
Emphysema 1 (0.5) Chest radiography 
Lung cancer 1 (0.5) Chest radiography 
Pneumonia 1 (0.5) Chest radiography 
Influenza 2 (1) Nasal swabbing 
Respiratory syncitial virus 2 (1) Nasal swabbing 
Asthma 2 (1) Clinical evaluation 
Acute bronchitis 23 (10) Clinical evaluation 
Chronic bronchitis 42 (19) Clinical evaluation 
Exacerbation of COPD 22 (10) Clinical evaluation 
Total 98 (44) – 
Diagnoses Cases n(%) Relevant diagnostic tool 
Active pulmonary tuberculosis 2 (1) Chest radiography 
Emphysema 1 (0.5) Chest radiography 
Lung cancer 1 (0.5) Chest radiography 
Pneumonia 1 (0.5) Chest radiography 
Influenza 2 (1) Nasal swabbing 
Respiratory syncitial virus 2 (1) Nasal swabbing 
Asthma 2 (1) Clinical evaluation 
Acute bronchitis 23 (10) Clinical evaluation 
Chronic bronchitis 42 (19) Clinical evaluation 
Exacerbation of COPD 22 (10) Clinical evaluation 
Total 98 (44) – 

Among the homeless persons with normal chest radiography, two persons (1%) presented asthma crisis, 23 (10%) an acute bronchitis, 42 (19%) a chronic bronchitis, and 22 (10%) an exacerbation of chronic obstructive lung diseases (COPD) based on observation of increased chronic cough, increased volume and/or purulence of sputum, and dyspnea or wheezing (table 3). Appropriate care was immediately provided for them in shelters.

None of the persons diagnosed with respiratory diseases had previously sought medical care for their symptoms.

A statistical analysis was made to determine whether clinical and radiographic findings vary according to the characteristics of the population such as age, place of birth, duration of homelessness, history of pulmonary tuberculosis, history of addiction and existing underlying diseases. Persons older than 40 years presented more frequently rhonchi (P = 0.002), decreased PEF (P < 0.001) and exacerbation of COPD (P < 0.001). Duration of homelessness >24 months was associated with decreased PEF (P = 0.01); history of previous pulmonary tuberculosis was associated with radiographic abnormalities (P = 0.03); current smoking was associated with abnormal PEF (P = 0.03), exacerbation of COPD (P < 0.001) and radiographic abnormalities (P = 0.043). No other statistically significant association was found.

Discussion

This shelter-based investigation, performed with a large mobile team including infectious diseases specialists, pneumonologists, nurses and X-ray technologists using a mobile X-ray machine, found that 50% of the examined population had at least one respiratory manifestation, 98 (44%) were diagnosed with a respiratory disease including communicable infections such as tuberculosis (two persons) and influenza (two patients), RSV infection (two patients) as well as life-threatening diseases such as asthma (two persons) and lung cancer (one person). The fact that none of the persons diagnosed with these diseases had previously sought medical care for their symptoms is consistent with the poor access of homeless population to health care delivery systems.1,5 Our survey identified early a number of respiratory diseases that would have worsened and, in the case of transmissible infection such as tuberculosis, could have spread among shelter residents.

In the current study, 1% of homeless persons who underwent chest radiographic screening were diagnosed with active tuberculosis. This prevalence rate is in accordance with what was found in similar studies reporting active documented TB prevalence rates ranging from 1.1% to 1.4% among the homeless.5,17–20 Epidemiological studies have shown that TB incidence is higher in the homeless population than in the general population,4,7 and molecular epidemiologic studies identified many unsuspected outbreaks of TB in homeless shelters due to person-to-person transmission.5,7,21,22 Shelter-based interventions using symptom evaluation, sputum culture, tuberculin skin test, and/or chest radiograph have been performed in previous studies and detected 1–3% of TB among sheltered homeless populations. 5,7,17–20 The strategy that seems to be the most effective includes screening chest radiography for active tuberculosis either at shelter admission and periodically in all residents or in symptomatic persons, as it was demonstrated in jails setting,23 in homeless shelters in Los Angeles, USA21 as well as in drug users and in homeless persons in Rotterdam, Netherlands.7 However, further studies based on economic evaluation are necessary to confirm the cost effectiveness of this option.

Identification of influenza among our sheltered homeless population is consistent with a recent study which reports identification of 59 cases of influenza among 4319 medical charts in three homeless shelters clinics in New York City.24 This finding represents a great concern since our homeless population included a high proportion of persons at high risk for developing influenza-related complications. To reduce the likelihood of influenza transmission in homeless shelters, in homeless people and staff, influenza vaccination should be given before the winter months. This may be done by annual shelter-based intervention including systematic immunization of shelter population against influenza.

The observed prevalence rates of chronic bronchitis symptoms (19%) and exacerbation of COPD (10%) among our population are consistent with the results of a prior study showing a 15% prevalence of spirometry-confirmed COPD among homeless adults.25 The association we found between duration of the homelessness and decreased PEF may be attributed to an accumulation of cigarettes smoking favoured by age and homelessness. In addition, prevalence of smoking was much higher in our population (78%) than in the French male population in 2005 (30%).26

The prevention of COPD and lung cancer should be based on smoking cessation; however, the implementation of this measure remains a challenge and seems difficult or even impossible to achieve among the homeless. Therefore, early diagnosis of these diseases should be a priority. The survey we performed is one way to achieve such an objective. Its efficacy could be improved by intensive and repeated follow up performed by general practitioners and registered nurses available daily in the shelters. These health professionals may perform a systematic medical check at first admission of homeless person in shelters and send symptomatic persons or current smokers as well as in symptomatic long stay residents in emergency departments or community dispensary for chest radiograph screening.

Some potential limitations of this study must be considered. These limitations include the small proportion of homeless covered by the survey (only 41% and 15% of homeless persons in the two shelters and in Marseille, respectively) and the absence of comparison with the general population, especially for influenza prevalence. The high proportion (70%) of highly mobile persons with a median duration of staying in shelters of 62 days is another potential limitation for intensive and repeated follow up.

Despite these limitations, this study confirms that sheltered homeless persons are at high risk of developing respiratory diseases, including transmissible diseases, such as tuberculosis and influenza.8–15 However, further studies are necessary to investigate the prevalence and the impact of influenza among a large sample of homeless persons. Strategies aimed at either preventing or shortening the delay in obtaining the diagnosis in order to improve prognosis and avoid spread of diseases in the population are necessary. Since primary prevention is difficult to implement in such a population, efforts should be focused on secondary and tertiary preventions that require intensive survey in homeless shelters. Further studies are necessary to determine the optimal method to survey this population that includes mainly highly mobile individuals, resulting in important turn over.

Acknowledgements

We acknowledge for the financial supports in the original data collection, the Conseil Général 13 (Bouches du Rhône) and the Œuvre Antituberculeuse des Bouches du Rhône. For their cooperation, we thank the medical students, interns and fellows, the pulmonologists (Dr M. Bellenfant, Dr C. Frenay, Dr B. Hayoun, Dr M. Saadjian), and the infectious diseases specialists (Prof. A. Stein, Prof. B. La Scola, Dr Hervé Tissot Dupont, Dr Cédric Foucault, Dr V. Roux, Dr P.E. Fournier, Dr Clarisse Rovery, Dr B. Doudier, Dr P. Parola, Dr A. Menard, Dr P. Berger, Dr J.P. Casalta), infectious disease residents (S. Rebaudet, E. Botelho-Nevers, S. Ben Soltana, A. Bienaimé), Dr H. Gadelius who actively participated in the study; the nurses from the Centre de Formation et de Recherche en Médecine et Santé Tropicale (Prof. J. Delmont) and from the infectious disease service (Prof. A Stein); the nurses and the physiotherapists from the centre de lutte anti-tuberculeuse, Conseil Général 13, Marseille who participated in the epidemiologic investigation in shelters; the directors, the general practitioner, the nurses and the personal of the two shelters; M. Coantic and E. Blisson from Oeuvre antituberculeuse. We also thank A.G. Kasmar, MD MSc (Brigham and Women's Hospital, Harvard Medical School and Moody Lab—Smith, Boston, USA) for English review and judicial suggestions.

Conflicts of interest: None declared.

Key points

  • Homeless people are at high risk of respiratory diseases.

  • Homeless persons are limited access to health care systems.

  • This survey detected life-threatening diseases including: tuberculosis, asthma and lung cancer among a sheltered homeless population.

  • Shelter-based intervention may contribute to avoid the spread of contagious diseases and to improve prognosis of non infectious respiratory diseases among the homeless.

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