Sara Hemming

High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population

Introduction Urban homeless populations in the UK have been shown to have high rates of active tuberculosis, but less is known about the prevalence of latent tuberculosis infection (LTBI). This study aimed to estimate the prevalence of LTBI among individuals using homeless hostels in London. Methods We performed a cross-sectional survey with outcome follow-up in homeless hostels in London. Our primary outcome was prevalence of LTBI. Recruitment for the study took place between May 2011 and June 2013. To estimate an LTBI prevalence of 10% with 95% CIs between 8% and 13%, we required 500 participants. Results 491/804 (61.1%) individuals agreed to be screened. The prevalence of LTBI was 16.5% (81/491; 95% CI 13.2 to 19.8). In UK-born individuals, a history of incarceration was associated with increased risk of LTBI (OR 3.49; 95% CI 1.10 to 11.04; P=0.018) after adjusting for age, length of time spent homeless and illicit drug use. Of the three subjects who met English treatment guidelines for LTBI at the time of the study, none engaged with services after referral for treatment. Prevalence of past hepatitis B infection was 10.4% (51/489; 95% CI 7.7 to 13.1), and 59.5% (291/489; 95% CI 55.1 to 63.9) of individuals were non-immune. Prevalence of current hepatitis C infection was 10.4% (51/489; 95% CI 7.8 to 13.1). Conclusions This study demonstrates the high prevalence of LTBI in homeless people in London and the associated poor engagement with care. There is a large unmet need for LTBI and hepatitis C infection treatment, and hepatitis B vaccination, in this group.

Effectiveness of peer educators on the uptake of mobile X-ray tuberculosis screening at homeless hostels: a cluster randomised controlled trial

Trial design Cluster randomised controlled trial. Objective To compare current practice for encouraging homeless people to be screened for tuberculosis on a mobile digital X-ray unit in London, UK, with the additional use of volunteer peer educators who have direct experience of tuberculosis, homelessness or both. Participants 46 hostels took part in the study, with a total of 2342 residents eligible for screening. The study took place between February 2012 and October 2013 at homeless hostels in London, UK. Intervention At intervention sites, volunteer peer educators agreed to a work plan that involved moving around the hostel in conjunction with the hostel staff, and speaking to residents in order to encourage them to attend the screening. Randomisation Cluster randomisation (by hostel) was performed using an internet-based service to ensure allocation concealment, with minimisation by hostel size and historical screening uptake. Blinding Only the study statistician was blinded to the allocation of intervention or control arms. Primary outcome The primary outcome was the number of eligible clients at a hostel venue screened for active pulmonary tuberculosis by the mobile X-ray unit. Results A total of 59 hostels were considered for eligibility and 46 were randomised. Control sites had a total of 1192 residents, with a median uptake of 45% (IQR 33–55). Intervention sites had 1150 eligible residents with a median uptake of 40% (IQR 25–61). Using Poisson regression to account for the clustered study design, hostel size and historical screening levels, there was no evidence that peer educators increased uptake (adjusted risk ratio 0.98; 95% CIs 0.80 to 1.20). The study team noted no adverse events. Conclusions This study found no evidence that volunteer peer educators increased client uptake of mobile X-ray unit screening for tuberculosis. Further qualitative work should be undertaken to explore the possible ancillary benefits to peer volunteers. Trial registration number ISRCTN17270334.

P160 Treating TB patients with no entitlement to social support—welcome to the social jungle

Background In the UK, TB medication is free but access to additional resources necessary for treatment completion is conditional. Patients with no recourse to public funds (NRPF), including undocumented and some European Economic Area migrants, have no rights to benefits, public housing or social care. The International Union Against Tuberculosis and Lung Disease (IUATLD) recommends that undocumented migrants with tuberculosis (TB) should receive free treatment and not be deported until completion of treatment. We used case reviews to explore how this guidance translates into current practice in London. Methods We reviewed clinical, social circumstances and treatment outcomes for 32 NRPF patients with active TB referred from September 2007 to June 2010 to Find and Treat, a pan-London multi-disciplinary project developed to strengthen TB control in hard-to-reach groups. Results The case reviews demonstrated that, while TB medication is free, lack of access to public funds severely compromises treatment access, completion and cure. Patients are unable to pay for transport to attend clinic appointments, buy food or access accommodation. Many (7/32) in fact were sleeping rough. More than a third (10/32) had resistant forms of TB, including 3 to a single drug (Isoniazid) and 7 with Multi Drug resistance (MDR). Despite close working relationships with Border Control Agencies, threat of deportation is a reality. Nine patients (28%) were lost to follow-up care, of which almost half (4/9) have never been found. Consequences included unsupervised medication, street homelessness, hospital admission (including for malnutrition) and treatment interruption and default. Conclusion Though ensuring access to free treatment, current guidance does not address the wider determinants of health in tuberculosis. This results in severe inequity of care, and poor treatment outcomes with potentially serious public health implications. Political commitment to provide for basic social needs as well as free medication for all patients is required to effectively control TB.

Hepatitis C among vulnerable populations: A seroprevalence study of homeless, people who inject drugs and prisoners in London

Injecting drugs substantially increases the risk of hepatitis C virus (HCV) infection and is common in the homeless and prisoners. Capturing accurate data on disease prevalence within these groups is challenging but is essential to inform strategies to reduce HCV transmission. The aim of this study was to estimate the prevalence of HCV in these populations. We conducted a cross‐sectional study between May 2011 and June 2013 in London and, using convenience sampling, recruited participants from hostels for the homeless, drug treatment services and a prison. A questionnaire was administered and blood samples were tested for hepatitis C. We recruited 491 individuals who were homeless (40.7%), 205 drug users (17%) and 511 prisoners (42.3%). Eight per cent of patients (98/1207, 95% CI: 6.7%‐9.8%) had active HCV infection and 3% (38/1207, 95% CI: 2.3%‐4.3%) past HCV infection. Overall, one quarter (51/205) of people recruited in drug treatment services, 13% (65/491) of people from homeless residential sites and 4% (20/511) prisoners in this study were anti‐HCV positive. Seventy‐seven of the 136 (56.6%, 95% CI: 47.9%‐65%) of HCV infected participants identified had a history of all three risk factors (homelessness, imprisonment and drug use), 27.3% (95% CI: 20.1%‐35.6%) had 2 overlapping risk factors, and 15.4% (95% CI: 10.6%‐23.7%) one risk factor. Drug treatment services, prisons and homelessness services provide good opportunities for identifying hepatitis C‐infected individuals. Effective models need to be developed to ensure case identification in these settings that can lead to an effective treatment and an efficient HCV prevention.

S29 A randomised controlled trial comparing smartphone enabled remote video observation with direct observation of treatment for tuberculosis

Background Directly observed treatment (DOT) has been the standard of care for tuberculosis since the early 1990s. In England DOT is targeted at those considered to be at high risk of poor adherence and clinically complex patients. We report the first randomised controlled trial of smartphone-enabled video observation of treatment (VOT) for active tuberculosis compared to DOT. Methods Tuberculosis patients eligible for selective DOT in England were randomised to an offer of asynchronous VOT (daily remote observation using a smartphone app) or DOT (3 or 5 times weekly observation in community or clinic settings). Results 58% of 226 randomised patients had a history of homelessness, drug use, imprisonment, alcohol or mental health problems. Of the 112 patients randomised to an offer of VOT, 70% had over 80% of scheduled observations completed over two months (the primary outcome measure) compared to 31% of 114 patients randomised to an offer of DOT (p<0.001). The effect was, in part, due to 51% of those randomised to DOT having less than one week of observation (compared to 10% of those randomised to VOT), and so not starting treatment with their allocated regimen. VOT patients sustained high observation levels throughout treatment, whereas this declined rapidly in DOT patients. We estimate that observation of a six month course of treatment with daily VOT cost £1645 per patient compared to £5700 for five times per week DOT. Conclusions VOT is a more effective and cheaper approach to observation of tuberculosis treatment than clinic or community based DOT.

Hepatitis C virus infection in vulnerable populations: a seroprevalence study of homeless, people who inject drugs and prisoners in London, UK

Abstract Background Injecting drugs substantially increases the risk of hepatitis C virus (HCV) infection and is common in homeless people and prisoners. Capturing accurate data on disease prevalence within these groups is challenging, and this problem hinders efforts to develop targeted strategies to reduce HCV transmission. The aim of this study was to estimate the prevalence of HCV in these vulnerable populations. Methods We conducted a cross-sectional study between May 1, 2011, and June 30, 2013, in London, UK. Using the National Health Service Find and Treat service, we recruited participants from 39 hostels for the homeless, 20 drug treatment services, and a prison. Inclusion criteria were age over 18 years, capacity to consent, and being identified as homeless (living in a homeless hotel), having a history of drug use (using services at drug treatment centres), or being a prisoner at the time of the study. A questionnaire was administered and blood samples were collected to be tested for HCV. Findings We recruited 1207 individuals, of whom 491 were homeless (40·7%), 205 were drug users (17·0%), and 511 were prisoners (42·3%). 98 (8·1%) of the 1207 participants had active HCV infection and 38 (3·1%) had a previous HCV infection. Among HCV-positive individuals, 77 (56·6%) had a history all three risk factors (homelessness, imprisonment, and drug use), 37 (27·3%) had two risk factors, and 22 (15·4%) had one risk factor. Multivariate logistic regression identified three factors associated with increased risk of HCV infection: duration of injecting (odds ratio for Interpretation Homeless services, drug treatment services, and prisons provide good opportunities for identifying HCV-positive individuals. More than half of HCV-infected individuals had the three intersecting risk factors, highlighting the vulnerability of these patients. Reducing the burden of HCV among these vulnerable groups is fundamental to lessen HCV transmission. Funding National Institute for Health Research (NIHR) under the Programme Grants for Applied Research programme (reference number RP-PG-0407-10340). RWA is funded by a Wellcome Trust research training fellowship (097980/Z/11/Z). DNA is funded by an Indonesia Presidential Scholarship.

S1 High Levels of Latent TB Infection, Blood Borne Viruses and Unmet Need Among Hard to Reach Groups in London: The TB Reach Study

Background Urban homeless people have high levels of disease and often present late for healthcare. Despite high rates of active TB in London’s large homeless population, limited data are available regarding the prevalence of latent TB infection (LTBI) and blood borne viruses (BBV) - HIV, Hepatitis B & C. We have undertaken a TB/BBV screening programme to assess the prevalence of LTBI, infection with BBV and co-infection within hard to reach groups (homeless people and substance misusers) in homeless hostels and residential drug services in London. Method Residents screened for TB on a mobile chest x-ray unit were approached and with consent, blood was drawn for TB IGRA (Quantiferon In-Tube) and BBV. Results were fed back to participants with onward referral as necessary. Results Of 413 eligible participants, 390 (94%) reported a history of homelessness. Of these 390 participants, 89% were male, 68% were 16–49 years of age and 66% UK born. 17% were IGRA positive, 1% HIV positive (all previously known), and 10% had current and 4% past Hepatitis C. 1% of those screened had current Hepatitis B infection, 10% past infection, 18% had vaccine induced protective levels of immunity and 71% had insufficient or no Hepatitis B immunity. 29% of subjects with Hepatitis C were LTBI co-infected. Multivariate analysis identified increasing age e.g. 30–49 age group (odd ratio [OR], 2.15; 95% confidence interval [CI95], 0.84–5.49) compared to the under 30, foreign birth (OR, 6.59; CI95, 3.50–12.39), smoking hard drugs (OR, 2.19; CI95, 1.02–4.64), and injecting hard drug (OR, 2.36; CI95, 1.08–5.16) such as heroin, crack or cocaine (although 95% of injectors also smoked hard drugs) as risk factors for LTBI. Injecting drug use was the only factor associated with increased risk for Hepatitis C infection (OR, 19.62; CI95, 8.23–46). Conclusion Extremely high rates of LTBI, Hepatitis C and co-infection are present in our urban study population. Despite targeted Hepatitis B vaccination programmes, a high proportion of participants appear unvaccinated. These levels of unmet need have major implications for public and personal healthcare planning and should be recognised through appropriate targeted health and social policy.