Active Tuberculosis among Homeless Persons, Toronto | CDC EID

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Volume 17, Number 3–March 2011
Research
Active Tuberculosis among Homeless Persons, Toronto, Ontario, Canada, 1998–2007
Kamran Khan, Elizabeth Rea, Cameron McDermaid, Rebecca Stuart, Catharine Chambers, Jun Wang, Angie Chan, Michael Gardam, Frances Jamieson, Jae Yang, and Stephen W. Hwang

Author affiliations: St. Michael's Hospital, Toronto, Ontario, Canada (K. Khan, C. Chambers, J. Wang, A. Chan, J. Yang, S.W. Hwang); University of Toronto, Toronto (K. Khan, E. Rea, M. Gardam, F. Jamieson, S.W. Hwang); Toronto Public Health, Toronto (E. Rea, R. Stuart); City of Ottawa, Ottawa, Ontario, Canada (C. McDermaid); University Health Network, Toronto (M. Gardam); and Ontario Agency for Health Promotion and Protection, Toronto (F. Jamieson)

Suggested citation for this article

Abstract
While tuberculosis (TB) in Canadian cities is increasingly affecting foreign-born persons, homeless persons remain at high risk. To assess trends in TB, we studied all homeless persons in Toronto who had a diagnosis of active TB during 1998–2007. We compared Canada-born and foreign-born homeless persons and assessed changes over time. We identified 91 homeless persons with active TB; they typically had highly contagious, advanced disease, and 19% died within 12 months of diagnosis. The proportion of homeless persons who were foreign-born increased from 24% in 1998–2002 to 39% in 2003–2007. Among foreign-born homeless persons with TB, 56% of infections were caused by strains not known to circulate among homeless persons in Toronto. Only 2% of infections were resistant to first-line TB medications. The rise in foreign-born homeless persons with TB strains likely acquired overseas suggests that the risk for drug-resistant strains entering the homeless shelter system may be escalating.

In Canada's major cities, tuberculosis (TB) is increasingly becoming a disease of persons born outside Canada (foreign-born). In 2009 in the city of Toronto in Ontario, 94% of all persons with active TB were foreign-born (1). Although homeless and marginally housed persons represent a smaller proportion of TB case-patients, they remain a persistent high-risk population. Recent TB outbreaks and disease clusters among homeless persons have been reported in many cities in the United States (2–5) and have been associated with transmission at shelters, single-room–occupancy hotels, and rooming houses (which provide inexpensive rooms with shared bathrooms), prisons, and bars (6–10).

Toronto is the largest city in Canada; among its population of 2.5 million persons, ≈50% were born outside Canada (11). Each year in Toronto, ≈29,000 persons use emergency shelters, and on any given night ≈5,000 are without homes (12). During 2001–2002, a large shelter-based TB outbreak occurred among homeless persons in Toronto. A coroner's inquest into the death of a homeless man in whom pulmonary TB developed during the course of this outbreak revealed the many challenges of diagnosing and managing TB in homeless populations (13). In response to the inquest and resulting jury recommendations, major changes to the management of homeless TB cases occurred in the public health and shelter systems, and local TB clinic capacity expanded. This case resulted in the creation of a public health team dedicated to case management, contact follow-up, advocacy, education, health promotion, and active case finding among the city's homeless and underhoused population.

A comprehensive review of the population and molecular epidemiology, clinical features, management and health outcomes of homeless persons with TB in Canada is needed but lacking. To better understand and address the extent of disease in this vulnerable population, we studied TB among Toronto's homeless persons over a 10-year period.

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Active Tuberculosis among Homeless Persons, Toronto | CDC EID


Suggested Citation for this Article
Khan K, Rea E, McDermaid C, Stuart R, Chambers C, Wang J, et al. Active tuberculosis among homeless persons, Toronto, Ontario, Canada, 1998–2007. Emerg Infect Dis [serial on the Internet]. 2011 Mar [date cited]. http://www.cdc.gov/EID/content/17/3/357.htm


DOI: 10.3201/eid1703.100833


Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:

Kamran Khan, St. Michael's Hospital, 30 Bond St, Toronto, ON M5B 1W8, Canada; email: khank@smh.ca