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Evidence in brief

Infectious diseases among homeless populations

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Incidence of a range of infectious diseases is higher in homeless people than in the general population. Local studies are needed to inform service planning and provision

Citation: Thomason C (2013) Infectious diseases among homeless populations. Nursing Times; 109: 24, 18. 

Author: Carmel Thomason is senior publishing manager, evidence resources, National Institute for Health and Care Excellence.


Nationally in England, the number of people sleeping rough is estimated to have risen by 23%, on average, between autumn 2010 and autumn 2011 (Crisis, 2012).

People who are homeless die 30 years before reaching the national average life expectancy (Crisis, 2011) and, compared with the general population, they also have a higher prevalence of infectious diseases, associated with malnutrition, long periods of homelessness and high use of medical services.

HIV, hepatitis C and tuberculosis are the most heavily studied infectious diseases among homeless populations. However, high rates of other infectious diseases - such as hepatitis A, hepatitis B, diphtheria, foot problems and skin infections - have also been reported.

New evidence

A systematic review and meta-analysis of 43 studies (four of which are from the UK), involving 59,736 homeless people, assessed the prevalence of TB, hepatitis C virus and HIV in this population between 1984 and 2012 (Beijer et al, 2012). Results showed that homeless people have a much higher likelihood of having one of these three diseases than the general population, although there was considerable variation between the studies.

In the United States, the prevalence of TB was at least 46 times greater in the homeless population than in the general population, and the prevalence of hepatitis C viral infection was increased approximately four-fold. In the UK, the prevalence of TB was at least 34 times greater in homeless people than in the general population, and the prevalence of hepatitis C viral infection was approximately 50 times greater.

HIV prevalence was typically 1-20 times higher in homeless people in the US than in the general population, but no studies were found in the UK. However, there was considerable heterogeneity between studies, suggesting the need for locally based studies to inform service planning and public health measures.

Of the 17 studies of TB included in the review, 15 reported TB prevalence being higher than 0.25%, suggesting that universal screening of homeless populations could be considered. The prevalence of TB was higher in studies in which chest radiography was used for diagnosis than in those in which other diagnostic methods were used. The reviewers suggested that screening programmes should not be restricted to people presenting to health services with symptoms, which happens less and later in marginalised groups than in general populations.

The prevalence of TB in homeless people was positively associated with prevalence in the general population, but this relation did not hold for hepatitis C virus and HIV. The reviewers highlighted this result as potentially important from a public health perspective because it suggests

that general population measures to reduce rates of hepatitis C virus and HIV infections might not equate to lower prevalence in homeless people. They suggested that more effective treatment and management should be considered including syringe and needle-exchange programmes, first-aid centres in large cities and annual snapshot interventions for homeless populations.

Box 1. Commentary

“The evidence provided by this paper supports current NICE guidance. It is recognised and accepted as standard practice to screen homeless populations for hepatitis, HIV and tuberculosis. Screening for TB is more problematic in primary care, where Mantoux tests are not routinely carried out and blood tests not, as yet, routine. However, a low threshold for referral for chest X-ray, as well as referral to secondary care, is accepted. Screening with a mobile chest X-ray unit in London at sites where homeless people are found has proved effective in case finding and follow up.”

Philip Reid is a GP at Great Chapel Street Medical Centre for Homeless People, Soho, London

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