1. Biomedical Conditions Among the Homeless
Care of the Medically Underserved, Domain 2: Biopsychosocial Care
1. Biomedical Conditions Among the Homeless
Knowledge Objectives:
Learners will be able to describe:
- Type and prevalence of conditions more common among homeless persons.
- Prevalence of tobacco use and substance abuse in the homeless population.
- Examples of biomedical complications of food scarcity and malnutrition.
- Common skin conditions of the homeless, and treatment options.
- Exposure-related conditions seen in cold conditions: frost bite, trench foot, and hypothermia.
- Challenges to chronic disease management imposed by homelessness, precarious housing, and food scarcity.
Objective 1: Type and prevalence of conditions more common among homeless persons.
Case 1A:
A 45 year old homeless man presents to your shelter clinic due to a troublesome cough. The cough has been present for at least 6 weeks, is productive of whitish sputum, and the sputum is occasionally streaked with blood. He does not know if he has any chronic lung problems. He smokes one pack of cigarettes a day and drinks up to 12 cans of beer daily. On direct questioning, he does think his pants are getting rather loose. He is afebrile with normal vital signs, and he is not cyanotic. Lungs show rhonchi in the upper more than lower lobes, with otherwise good air entry and no wheezing.
You are concerned that he may have TB. Which of the following is a correct statement?
1. Material incentives (e.g. cash, vouchers, tokens) have been consistently linked with improved adherence to TB diagnostic testing and treatment.
2. Shelters are required to annually assess and upgrade their ventilation systems to reduce TB transmission risk.
3. Excess alcohol use increases risk of TB transmission.
4. The overall rate of TB in the U.S. is rising.
Case 1A Answer
You are concerned that he may have TB. Which of the following is a correct statement?
1. Material incentives (e.g. cash, vouchers, tokens) have been consistently linked with improved adherence to TB diagnostic testing and treatment. Not correct. Material incentives have not been shown to improve adherence.
2. Shelters are required to annually assess and upgrade their ventilation systems to reduce TB transmission risk. Not correct. While desirable, ventilation upgrades are costly and cannot be performed annually
3. Excess alcohol use increases risk of TB transmission.
4. The overall rate of TB in the U.S. is rising. Not correct. The overall rate has been declining, but transmission among the homeless remains a persistent source of the disease.
The overall incidence of tuberculosis (TB) is declining in the U.S., but homeless persons remain a population at risk. Close shelter living quarters, poorly ventilated and under-resourced shelters, and excess alcohol use (such as in our case patient) all contribute to increased transmission. Homeless status is also an independent risk factor for being a member of a large cluster TB outbreak[1]. Once established, outbreaks among homeless persons and shelter communities are difficult to control, in part due to the difficulty of locating exposed contacts and in part due to the systems difficulties of providing therapy for latent TB infection (LTBI).[2]
Treatment of both TB and LTBI for sheltered persons requires close team collaboration of shelter staff to ensure completion of directly observed therapy. Case finding and disease transmission control measures instituted at some shelters includes pre-screening for active TB symptoms upon overnight admission, TB disease screening within the initial week of residential stay, and periodic repeat symptom and disease screening. Screening methods vary, with no clearly superior method. QuantiFERON-TB Gold testing can be used, but tuberculin skin testing (TST) remains popular because it can be readily implemented and interpreted by nursing staff and outreach workers.[3] Systematic chest radiography is pursued in other clinics. Even when screening programs are in place, diagnostic follow-up with completion of recommended therapy can be difficult to achieve when patients have unstable housing and contact information. Material incentives (cash, vouchers, and tokens) have not been shown to improve diagnostic test return rates or adherence to antituberculosis preventive therapy.[4] When homeless patients are tested, it can be helpful to provide them with a written record of their results on a portable card.
Shelters do not always have funds for environmental controls such as ventilation improvements or reduction of crowding, and provision of isolation housing during directly observed therapy places further financial strain on the support system. Due to these difficulties and costs associated with treatment, all staff caring for homeless persons must collaborate to maximize TB control and reduce outbreaks among vulnerable populations.
Key Points:
· While the overall incidence of TB in the U.S. has been declining, the homeless population remains at higher risk, and shelters may be sites of large outbreaks.
· Shelters have routine procedures for detection and treatment of TB and LTBI. Procedures vary based on staffing and other resources.
· Shelter fund insufficiencies often limit implementation of environmental controls such as ventilation improvement, reduction of crowding, and provision of isolation housing.
· Provide patients with written portable documentation of TB screening results.
Case 1B:
A 22-year-old homeless man presents to your clinic desiring treatment of the flu. About 2 weeks ago he developed a feverish sensation accompanied by malaise, headache, and aches in his legs. The symptoms lasted for about 5 days then improved, but 3 days ago the symptoms returned. He does not know his HIV status. Other than a recent case of body lice, his shelter record shows no medical problems. He does not use IV drugs. His temperature is 102.30F. Heart rate is 100 and regular, and he otherwise has normal vital signs.
Which of the following is a correct statement?
1. Persons with primary HIV infection from recent viral exposure are less infectious than those with established chronic infection.
2. In patients with Trench Fever, lymphadenopathy and hepatomegaly are usually present
3. The prevalence of hepatitis C in the homeless population is double that of the background population.
4. Bartonella quintana causes endocarditis in immunocompetent individuals
Case 1B Answer
Which of the following is a correct statement?
1. Persons with primary HIV infection from recent viral exposure are less infectious than those with established chronic infection. Not correct. Primary HIV infection results in a highly infectious level of acute viremia in genital secretions and blood.
2. In patients with Trench Fever, lymphadenopathy and hepatomegaly are usually present. Not Correct. Only a small minority of contemporary cases of trench fever include lymphadenopathy or splenomegaly. B. quintana does not cause hepatomegaly.
3. The prevalence of hepatitis C in the homeless population is double that of the background population. Not Correct. Hepatitis C is at least 10 times more prevalent in the homeless population than in the general population.
4. Bartonella quintana causes endocarditis in immunocompetent individuals
Communicable infectious diseases are disproportionately represented in homeless populations, with one out of every five having an infectious or other communicable disease.[5] Respiratory infections, hepatitis, HIV, sexually transmitted diseases, skin diseases, and other infestations are common in crowded shelters and in street dwelling populations. Some of these infections, such as trench fever, are relatively isolated to the homeless and underserved population, while other infections may easily cross into the general population.
Classic trench fever was named for its effects on over a million World War I soldiers. It is also known as “quintan fever” due to the classic presentation of recurrent febrile episodes lasting 4 or 5 days followed by asymptomatic periods of the same duration. Trench fever is caused by Bartonella quintana, which is carried by lice and transmitted in louse feces. Along with a quintan fever, patients develop malaise, headache, and bone aches. Some cases include splenomegaly or lymphadenopathy. Other B. quintana presentations include endocarditis or a single prolonged febrile illness. A high index of suspicion is warranted in the homeless population, particularly in those with known lice infection. In a study of homeless populations in San Francisco, one third of body-lice infected persons and ¼ of head-lice infected persons had lice pools that were infected with B. quintana.[6] Our case patient presents with classic quintan cyclic fever and a recent history of body lice, highly suggestive of trench fever. Definitive diagnosis is made by isolation of the organism from blood or infected body tissue. Because the organism is fastidious, blood cultures should be incubated in isolator tubes or obtained in EDTA blood tubes. Diagnosis may also be made using serology or polymerase chain reaction. Treatment requires a combination of oral doxycycline and IV gentamicin.
In homeless patients, sexually transmitted infections (STIs) are more common than in the housed population. STIs with high prevalence among homeless persons include chlamydia, gonorrhea, syphilis, HIV, hepatitis B, hepatitis C, trichomonas, and bacterial vaginosis. Sexual assault and risky sexual behavior, including transaction sex (sex for money, drugs, or survival needs), increase risk for sexually transmitted infections. Sexual abuse is particularly prevalent among homeless, both as a cause and as a result of homelessness. Difficulty obtaining or using condoms further increases the risk. Homeless women are at particularly high risk, with up to 90% reporting a history of physical or sexual abuse.[7] Gay, lesbian, and transgender homeless individuals are also at particularly high risk of both assault and STIs. Clinicians should therefore remain vigilant for STIs and screen for interpersonal violence in the homeless population. When possible and appropriate, offer abused persons the option of being examined by someone of preferred gender.
Homelessness and unstable housing are strongly associated with HIV risk, and risk is particularly high for homeless persons engaging in transaction sex or using intravenous drugs. Acute (primary) HIV infection should be considered in any at-risk person presenting with a non-specific febrile illness, such as the case patient. Acute HIV may present like heterophile-negative mononucleosis with fever, lymphadenopathy, sore throat and a maculopapular rash, or as aseptic meningitis with fever and headache. Acute HIV symptoms generally resolve in 1 to 4 weeks. Both HIV viral load and HIV antibody testing are recommended for diagnosis of acute HIV; standard HIV antibody seroconversion requires weeks to detect in routine assays, so the diagnosis of acute HIV infection is made when there is a detectable HIV viral load in the presence of an equivocal or negative HIV antibody test. This two-test strategy also aids case finding for previously undetected chronic (antibody positive) HIV infection.
The prevalence of HIV infection has slowly risen as each year approximately 50,000 additional persons become infected.[8] Approximately 20% of persons infected with HIV are not aware of their infection, and the percentage is higher in subpopulations at greatest risk.[9] The Center for Disease Control therefore recommends annual HIV testing and prevention counseling for high risk populations.[10] In practice, about 1/3 of people who undergo standard tests for HIV do not learn their results because of difficulties with lab result follow up. Rapid point-of-care HIV tests mitigate this problem and are now available. These rapid tests can be performed on a finger stick blood droplet. Rapid tests assess for antibody presence, so false negatives are possible after recent (<3 months) infection. Positive rapid tests are considered preliminary, and should be followed with confirmatory testing (Western blot or immunofluorescence assay.) Further information on rapid HIV testing is available through the CDC at: http://www.cdc.gov/hiv/topics/testing/rapid/index.htm
Once infected with HIV, homeless and precariously housed persons are less likely to see a physician regularly or to use pneumocystis prophylaxis.[11] Establishment of stable housing has been associated with reduction in high risk behaviors, and provision of rental assistance has been shown to be cost-effective per quality-adjusted-life-year saved.[12]
Crowding, poor sanitary conditions, illegal drug use, and high risk sexual activity all contribute to an increased risk for transmission of hepatitis viruses among the homeless. Hepatitis A and B vaccines should be considered for all high risk homeless persons. Hepatitis C is particularly prevalent in the homeless community. In studies of homeless populations, hepatitis C prevalence has ranged from 19% to 69% for the general homeless community and 41% to 44% for homeless veterans.[13] These estimated rates are at least 10 times greater than the background population prevalence. Clinicians caring for homeless patients should therefore have a high index of suspicion for hepatitis C infection, and offer testing as appropriate.
Pneumococcal infections and influenza are highly contagious and can spread easily in overcrowded shelter settings, particularly for patients with predisposing conditions: alcoholism, smoking, chronic bronchitis, congestive heart failure, and HIV/AIDS. Homeless persons may have missed recommended vaccinations, and outbreaks of pneumococcal pneumonia occur even in settings where pneumococcal polyvalent vaccine is administered.[14] Whenever possible, standard immunizations should be provided for influenza, pneumococcus, and Td/Tdap. In high-risk homeless populations with febrile illness, careful review of the pulmonary history is required.
Once diagnosed with a community-acquired pneumonia, treatment may be complicated by social support needs. To improve adherence, providers should prescribe the simplest appropriate regimen. Consider expense, dose frequency, storage requirements, and administration requirements. Preferred regimens are once daily, nonrefrigerated, inexpensive, and can be taken without food. Patient’s who do not otherwise meet severity criteria for hospital admission may find it difficult to adhere with more complex antibiotic regimens and may have need of daytime respite care or directly observed therapy; consideration of daybed treatment or respite admission for hospital care may be necessary.
Key Points:
· Communicable infectious diseases are disproportionately represented in homeless populations
· Trench fever is caused by Bartonella quintana, which is transmitted in louse feces. The classic presentation includes quintan fever, malaise, headache, bone aches, and may also include splenomegaly, lymphadenopathy or endocarditis.
· Sexual abuse, transaction sex, and lack of access to condoms all contribute to increased risk for STIs in the homeless population.
· Clinicians should be sensitive to the likelihood of sexual and/or physical abuse history in their homeless patients.