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Tuberculosis in London: the importance of homelessness, problem drug use and prison
  1. A Story1,
  2. S Murad2,
  3. W Roberts3,
  4. M Verheyen4,
  5. A C Hayward2,
  6. for the London Tuberculosis Nurses Network
  1. 1Tuberculosis Section, Respiratory Diseases Department, Centre for Infections, Health Protection Agency, UK
  2. 2UCL Centre for Infectious Disease Epidemiology, Department of Primary Care and Population Sciences, University College London/Camden Primary Care Trust, London, UK
  3. 3North East London TB Network, London, UK
  4. 4Research Centre for Health Studies, Buckinghamshire Chilterns University College, Buckinghamshire, UK
  1. Correspondence to:
    Mr Alistair Story
    Tuberculosis Section, Respiratory Diseases Department, Health Protection Agency Centre for Infections, 61 Colindale Avenue, London NW9 5EQ, UK; alistair.story{at}


Background: The control of tuberculosis (TB) is founded on early case detection and complete treatment of disease. In the UK, TB is concentrated in subgroups of the population in large urban centres. The impact of homelessness, imprisonment and problem drug use on TB control in London is reviewed.

Methods: A cohort study was undertaken of all patients with TB in Greater London to determine the point prevalence of disease in different groups and to 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 TB was 27 per 100 000. An extremely high prevalence of TB was seen in homeless people (788/100 000), problem drug users (354/100 000) and prisoners (208/100 000). Multivariate analysis showed that problem drug use was associated with smear positive disease (OR 2.2, p<0.001), being part of a known outbreak of drug resistant TB (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 infectious TB (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 compliant 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 TB is not effectively controlled among homeless people, prisoners and problem drug users in London.

  • DOT, directly observed therapy
  • TB, tuberculosis

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  • Published Online First 8 February 2007

  • Funding: Department of Health and the Health Protection Agency.

  • Competing interests: None.

  • Ethics approval: London Metropolitan Multi-centre Research Ethics Committee

    Statement of independence of researchers from funders: Alistair Story is currently employed by the Health Protection Agency