Background Tuberculosis control is founded on early case detection and complete treatment of disease. In the UK tuberculosis is concentrated in subgroups of the population in large urban centres. We sought to describe the impact of homelessness, imprisonment and problem drug use on tuberculosis control in London.
Methods We conducted a cohort study of all tuberculosis patients in Greater London to determine the point prevalence of disease in different groups and examine risk factors for smear positivity, drug resistance, treatment adherence, loss to follow-up and use of directly observed therapy (DOT).
Results Data were collected on 97% (1941/1995) of eligible patients. The overall prevalence of tuberculosis was 27 per 100,000. Extremely high prevalence of tuberculosis was seen in homeless people living on the streets or in hostels (788/100,000), problem drug users (354/100,000), and prisoners (208/100,000). On multivariate analysis problem drug use was associated with smear positive disease (OR 2.2, p<0.001), being part of a known outbreak of drug resistant tuberculosis (OR 3.5, p=0.001) and loss to follow-up (OR 2.7, p<0.001). Imprisonment was associated with being part of the outbreak (OR 10.3, p<0.001) and poor adherence (OR 3.9, p<0.001). Homelessness was associated with smear positive tuberculosis (OR 1.6, p=0.05), multidrug resistance (OR 2.1, p=0.03), poor adherence (OR 2.5, p<0.001) and loss to follow-up (OR 3.8, p<0.001). In London homeless people, prisoners and problem drug users collectively comprise 17% of TB cases, 44% of smear positive drug resistant cases, 38% of poorly adherent cases and 44% of cases lost to follow-up. 15% of these patients start treatment on DOT but 46% end up on DOT.
Conclusions High levels of infectious and drug resistant disease, poor adherence and loss to follow up care indicate that tuberculosis is not effectively controlled among homeless people, prisoners and problem drug users in London.
- Homeless persons
- Patient non-adherence
- Substance abuse