TUBERCULOSIS IN HOMELESS PATIENTS - POTENTIAL FOR CASE-FINDING IN PUBLIC EMERGENCY DEPARTMENTS

Study objectives: Previous studies have had difficulty evaluating the optimal clinical site for screening homeless patients for active tuber culosis (TB). We hypothesized that homeless patients with TB would not frequently reside in shelters at the time of their diagnosis and woul d be more likely than other patients with TB to seek care in public ho spitals, thus presenting an opportunity for screening radiography. Met hods: This registry-based survey included 743 consecutive patients wit h confirmed active TB in Los Angeles County. No therapeutic interventi on was involved. Results: When compared with patients with TB who were not homeless, homeless patients with TB were more likely to be male ( 93% versus 63%, P < .001), black (44% versus 15%, P < .001), living in the inner city (55% versus 7%, P < .001), and born in the United Stat es (67% versus 32%, P < .001). They were more infectious than other pa tients with TB as evidenced by a trend toward more cavitary radiograph ic lesions (24% versus 16%, P = .11) and significantly more positive s putum smears (56% versus 41%, P = .009). Less than a third lived in co ngregate facilities such as shelters at the time of their diagnosis. I nstead, their disease was diagnosed more often at county hospitals (54 % versus 23%, P < .001) than patients with TB who were not homeless. C onclusion: Widespread screening for TB in shelters may miss most homel ess patients with TB. Because most county-hospital homeless patients w ith TB initially present to emergency departments and many do not live in shelters, future cost-effectiveness studies should evaluate chest radiograph screening for all homeless ED patients.