Adinarayanan, Srividya

Dolla, Chandrakumar

Kavitha, D

Muniyandi, M

Padmapriyadarsini, C

Pradeep Menon, A

Sekar, Gomathi

Swaminathan, Soumya

Tripathy, Srikanth Prasad

NIRT Institutional Repository

SHORTCOMMUNICATIONTrans R Soc Trop Med Hyg 2017; 111: 479–481doi:10.1093/trstmh/trx081 Advance Access publication 16 January 2018Tuberculosis among the homeless in Chennai city, South IndiaChandrakumar Dollaa,*, C. Padmapriyadarsinia, A. Pradeep Menona, M. Muniyandia, Srividya Adinarayananb,Gomathi Sekara, D. Kavithaa, Srikanth Prasad Tripathya and Soumya SwaminathancaNational Institute for Research in Tuberculosis, Indian Council of Medical Research, Chennai; bVector Control Research Centre, IndianCouncil of Medical Research, Puducherry; cSecretary, Department of Health Research & Director General, Indian Council of MedicalResearch, New Delhi, India*Corresponding author: Department of Epidemiology, National Institute for Research in Tuberculosis, Indian Council of Medical Research, No. 1 MayorSathyamoorthy Road, Chetput, Chennai 600 031 Tamilnadu, India. Tel: +91 9884783385; E-mail: ckdolla@gmail.comReceived 5 July 2017; revised 1 December 2017; editorial decision 13 December 2017; accepted 20 December 2017Background: In India from a national perspective, the incidence/prevalence of active tuberculosis (TB) amongthe homeless are unknown.Methods: Homeless individuals, aged 15 years and above, were screened for TB by radiography and smearexamination in Chennai city.Results: 301 individuals were enrolled and screened for TB; 8% (24/301) had chest symptoms; 5.6% (17/301)found X-ray abnormalities. The overall prevalence of TB was 1661/100 000; prevalence of culture-positive TBwas 997/100 000 and smear-positive TB was 664/100 000 population.Conclusion: There is a need to address TB control among homeless populations. The current pilot studyshowed that the prevalence of TB was disproportionately high and there is a need for a larger study with anadequately powered sample size.Keywords: Tuberculosis, Prevalence, Homeless, India, Epidemiology, Active case findingBackgroundIndustrialization and rapid urbanization in India has resulted inmassive migration of people from rural to urban areas, is one ofthe reason leading to a huge homeless population. According toIndia’s 2011 Census, five metros—Mumbai, Kolkata, Bangalore,Delhi and Chennai have a major contribution of 26% of coun-tries homeless population.1 The health status of the homelesspopulation is affected by poor living conditions, such as thehazards of street life, lack of nutritious food, and lack of facilitiesto maintain personal hygiene.2 Homelessness leads to the spreadof infectious diseases through overcrowding in shelters for thehomeless, negligence towards disease and enforced lifestyle.Tuberculosis (TB) is not exceptional in this population since theassociation between TB and poverty is mediated by overcrowd-ing, malnutrition, smoking, stress, social deprivation, and poorsocial capital. It was reported that, in many industrialized coun-tries, TB rates among the homeless was up to 20 times higherthan the general population.3TB was recognized as a disease associated with homeless-ness as early as 1914.4 In this context, in India, from a nationalperspective, the overall incidence or prevalence of active TBamong the homeless are unknown. The National Institute ofResearch in Tuberculosis of Indian Council of Medical Researchin Chennai conducted a pilot study to estimate the prevalenceof TB among the homeless people in Chennai metro city in theyear 2013–14.MethodsStudy areaThis study was conducted in Broadway, MUC ground, Egmore,Walltax Road, and the Flower bazaar in Chennai city, wherehomeless persons are living nearby central railway station fromMay to December 2013.Study populationAll individuals, both male and female, aged 15 years and above,living in the selected areas, formed the study population.© The Author(s) 2018. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.479Downloaded from https://academic.oup.com/trstmh/article/111/10/479/4811852 by Bangalore University user on 27 July 2022TB screening strategyAll individuals in the selected area were registered by subjectsaged 15 years and above were questioned about chest symp-toms suggestive of TB disease, such as having a cough for morethan 2 weeks, and having chest pain, fever, and haemoptysis.Mass miniature radiography (MMR) was done for all individualsand the radiograph was read independently by two readers. Incases of disagreement, the radiograph was read by a third reader.For those with an abnormal chest radiograph or chest symptoms,two sputum samples were collected (the first on the spot and thesecond early in the morning the next day). The samples weretransported to the NIRT laboratory on the same day and exam-ined by trained laboratory technician. The results were gradedas per Revised National Tuberculosis Control Programme (RNTCP)guidelines. The number of AFB were recorded as 3+, 2+, 1+,scanty, or negative. It was based on more than 10 AFB per oil-immersion field graded as positive 3+; 1–10 AFB per oil-immersionfield graded as positive 2+; 10–99 AFB per 100 oil-immersion fieldsgraded as positive 1+; 1–9 AFB per 100 oil-immersion fields gradedas positive scanty; and no AFB per 100 oil-immersion fields gradedas negative.5Those individuals who were not available for examination onthe day of the visit were revisited a maximum of three times.The individuals with positive smears or cultures were revisited withthe reports and referred to the nearest RNTCP, Directly ObservedTreatment Short-course (DOTS) centre.Data collectionData related to demographics (e.g. age, sex), occupation, self-reported past history of TB treatment, alcohol consumption andtobacco smoking were collected using a pre-coded interviewschedule.Definition of homeless populationThe ‘houseless population’ is defined as ‘persons who are not liv-ing in “census houses”, but are live in buildings or live in the openon roadsides, pavements, in hume pipes, under flyovers and stair-cases, or in the open in places of worship, railway platforms, etc’.6Data managementTo ensure accuracy, two independent data-entry operators keyedall records twice. Data were checked for errors and analysed usingthe SPSS 14.0 software (SPSS Inc., Chicago, IL). The prevalence ofTB among the homeless was estimated per 100 000 population,and univariate analysis by age, sex, occupation, smoking, alcoholconsumption stratification was done. Due to the small numberswe did not used any statistical tools to test the significance.Ethical issuesThe trained field investigators approached eligible individuals andexplained the procedures, risks and benefits of the study in the locallanguage. Written informed consent was obtained from all indivi-duals willing to participate. For participants between 15–18 years,assent was obtained from the individuals and written informedconsent was obtained from parents/guardians. Children below 15years were not included in the study. All patients found positivefor TB were referred to RNTCP, followed through their treatmentand free counselling was provided to encourage completion ofthe full course of treatment. This study was approved by theScientific Advisory Committee and Institutional Ethics Committeeof National Institute for Research in Tuberculosis (NIRT), IndianCouncil of Medical Research (ICMR), Chennai.Results and discussionThere were 332 individuals approached, of whom 301 were will-ing to participate and were enrolled and screened for TB. Thecoverage of the total subjects who were seen was 90%. Despiteour three visits, 10% of individual could not be included in thisstudy due to their non-availability. In addition 16 (4.8%) werenot willing to participate. Table 1 shows the demographic, life-style characteristics and symptomatic profile of study subjects.All the TB cases were males aged over 35 years. The prevalenceof smoking and alcohol consumption was 11% (33/301) and 17%(51/301), respectively. The corresponding figures was less amongfemales that compared with males. Two were diagnosed as hav-ing TB, among asymptomatic individuals with abnormal X-ray.Out of all the subjects screened 8% (24/301) reported chestsymptoms suggestive of TB; 5.6% (17/301) were found to haveX-ray abnormalities suggestive of TB and 2% (6/301) had previ-ous history of TB. Of these, 6.3% (19/301) were able to providesputum for examination, two sputum samples were collectedfrom these individuals. Smear and culture tests were done onall these samples for TB. The estimated overall prevalence of TBamong this population was 5/301 (1661/100 000 population).The remaining 14 were negative for TB and were treated withTable 1. Profile of TB patients among homeless in Chennai cityCase Age Sex Smear Culture Category HIV status Treatment outcome1 62 M 1+ Negative I Negative Not able to trace2 53 M 1+ 1+ I Negative Not able to trace3 38 M 2+ 3+ I Negative Not able to trace4 48 M 1+ 2+ II Positive Died5 57 M 1+ Negative I Negative CompletedC. Dolla et al.480Downloaded from https://academic.oup.com/trstmh/article/111/10/479/4811852 by Bangalore University user on 27 July 2022antibiotics. The prevalence of culture positive for TB was 3/301(997/100 000 population) and smear positive for TB was 2/301(664/100 000 population).Although the number of TB cases among this group is small,the estimated prevalence was disproportionately high (almostfive times) compared with the general population in Chennai city(349/100 000).7 This empirically supports the perception thathomeless individuals had a considerably high burden of active pul-monary tuberculosis (PTB). The similar findings were reported fromcities from other countries such as South Korea,8 London,9 Atlanta,Jacksonville, Los Angels and Seattle, USA.10,11 With the small num-ber of cases in this current study, the difference may not be static-ally significant. There is a need for a large-scale survey to estimatethe prevalence of PTB among this population in India. AddressingTB control among this key population are our greatest challengesand opportunities for achieving a Global End TB Strategy.All TB cases confirmed were refered for treatment to the RNTCPDOTS centre for treatment and all started treatment as per RNTCPguidelines. The treatment outcome was that one person completedtreatment; one person co-infected with HIV and died during treat-ment; and three were moved to other places and were not trac-able. Due to the vulnerable conditions, this population have higherrisk of not achieving treatment success. There is a need to developinterventions to improve treatment outcomes among this popula-tion. It was proved that, in Russia, the food incentives improved theTB treatment outcome among homeless patients with TB.12 In thiscurrent series, only one individual completed treatment out of fivepatients diagnosed as PTB. This finding was corroborated with thefindings from other studies in Sao Paulo, Brazil and London.13 Interms of the incidence of TB in a large cohort of homeless popula-tion in San Francisco reported was 270/100 000 per year.14We are interpreting this findings with certain limitations. Thecurrent evidence on prevalence of TB among homeless are fromonly Chennai city, Tamilnadu, south India. This may vary in otherareas, and the findings may not, therefore, be generalizable. Theother limitation was that the present study was based on a verysmall sample; therefore, there is a need for a large sample-basedsurvey to estimate the national average to draw implications forthe programme. Further information on relevant secondary out-comes such as co-morbidities also be included for the betterunderstanding of risk factors for TB among this population.ConclusionThe current study findings highlighted the high prevalence of TBamong the homeless and that treating this population is a bigchallenge. This poor people’s priority is searching for food, ratherthan for TB treatment. There is a need to develop newer strat-egies to diagnose and treat this special population. The pro-blems between homelessness and the health system has notbeen studied in India. Thus, there is a need to provide scientificevidence from India, and also a need to learn from the experi-ences of other countries and implement it in India.Authors’ contributions: CD, SA, SS conceived the study and designed thestudy protocol; CD, PM, SA, GS supervised the data collection andassessment; PC, CD, PM were read the X-ray; GS carried out the labora-tory work; MM, SA, KD carried out analysis and interpretation of thesedata; CD, MM, SA, KD wrote the manuscript; SP, SS had overall supervision.All authors contributed to revising the draft, and read and approved thefinal manuscript. CD is guarantor of the paper.Acknowledgements: The authors would like to thank the field staff ofthe Epidemiology Unit for their efforts in data collection; the staff of theElectronic Data Processing Division for data entry and data manage-ment; the support given by the government of Tamil Nadu and districtofficials in carrying out the surveys and service delivery in the area; andthe respondents who participated in this study. The authors would alsolike to thank Mr A. J. Hariharan, Founder Secretary, Indian CommunityWelfare Organization, Chennai, for his support in carrying out survey.Funding: No financial support from any external agencies was received.This work was done with the intramural support of the Indian Council ofMedical Research.Competing interests: None declared.Ethical approval: Not required.References1 Kumuda D. Homeless population in India: a study. Glob J Res 2014;3(8):54–5.2 Patra S, Anand K. Homelessness: a hidden public health problem.Indian J Public Health 2008;52(3):164–70.3 Kong PM, Tapy J, Calixto P et al. Skin-test screening and tuberculosistransmission among the homeless. Emerg Infect Dis 2002;8:1280–4.4 Knopf SA. Tuberculosis as a cause and result of poverty. JAMA 1914;63:1720–5.5 Rajpal S, Dhingra VK, Aggarwal JK. Sputum grading as predictor oftreatment outcome in pulmonary tuberculosis. Indian J Tuberc2002;49:139–41.6 Chennai corporation. Sheller for Homeless initiative. Chennai Corporation.http://www.chennaicorporation.gov.in/images/SHELTER.pdf7 Dhanaraj B, Papanna MK, Adinarayanan S et al. Prevalence and riskfactors for adult pulmonary tuberculosis in a metropolitan city ofsouth India. PLoS One 2015;10(4):e0124260.8 Lee CH, Jeong YJ, Heo EY et al. Active pulmonary tuberculosis andlatent tuberculosis infection among homeless people in Seoul, SouthKorea: a cross-sectional study. BMC Public Health 2013;13:720.9 Story A, Murad S, Roberts W et al. Tuberculosis in London: theimportance of homelessness, problem drug use and prison. Thorax2007;62:667–71.10 Gupta V, Sugg N, Butners M et al. Tuberculosis among the homeless—preventing another outbreak through community action. N Engl JMed 2015;372(16):1483–5.11 Bamrah S, Yelk Woodruff RS, Powell K et al. Tuberculosis among thehomeless, United States, 1994–2010. Int J Tuberc Lung Dis 2013;17(11):1414–9.12 Garden B, Samarina A, Stavchanskaya I et al. Food incentivesimprove adherence to tuberculosis drug treatment among homelesspatients in Russia. Scand J Caring Sci 2013; 27(1):117–22.13 Otavio TR, Carlos RRC, Eliseu AW et al. The impact of being homeless onthe unsuccessful outcome of treatment of pulmonary TB in São PauloState, Brazil. BMC Med 2016. http://download.springer.com/static/pdf14 Andrew RM, Judith AH, Jacqueline PT et al. Tuberculosis in the home-less: a prospective study. Am J Respir Crit Care Med 2000;162:460–4.Transactions of the Royal Society of Tropical Medicine and Hygiene481Downloaded from https://academic.oup.com/trstmh/article/111/10/479/4811852 by Bangalore University user on 27 July 2022

Tuberculosis among the homeless in Chennai city, South India

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Tuberculosis among the homeless in Chennai city, South India

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