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Open Access Research article

Tuberculosis and homelessness in Montreal: a retrospective cohort study

Jason Tan de Bibiana1, Carmine Rossi12, Paul Rivest34, Alice Zwerling12, Louise Thibert5, Fiona McIntosh6, Marcel A Behr678, Dick Menzies129 and Kevin Schwartzman19*

Author Affiliations

1 Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, Quebec, Canada

2 Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada

3 Direction de la Santé publique, Agence de la santé et des services sociaux, Montreal, Quebec, Canada

4 Département de médecine social et préventive, Université de Montréal, Montreal, Quebec, Canada

5 Laboratoire de Santé publique du Québec, Ste-Anne-de-Bellevue, Quebec, Canada

6 Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada

7 Division of Infectious Diseases and Medical Microbiology, McGill University, Montreal, Quebec, Canada

8 Department of Microbiology and Immunology, McGill University, Montreal, Quebec, Canada

9 Respiratory Division, McGill University, Montreal, Quebec, Canada

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BMC Public Health 2011, 11:833  doi:10.1186/1471-2458-11-833

Published: 28 October 2011

Abstract

Background

Montreal is Canada's second-largest city, where mean annual tuberculosis (TB) incidence from 1996 to 2007 was 8.9/100,000. The objectives of this study were to describe the epidemiology of TB among homeless persons in Montreal and assess patterns of transmission and sharing of key locations.

Methods

We reviewed demographic, clinical, and microbiologic data for all active TB cases reported in Montreal from 1996 to 2007 and identified persons who were homeless in the year prior to TB diagnosis. We genotyped all available Mycobacterium tuberculosis isolates by IS6110 restriction fragment length polymorphism (IS6110-RFLP) and spoligotyping, and used a geographic information system to identify potential locations for transmission between persons with matching isolates.

Results

There were 20 cases of TB in homeless persons, out of 1823 total reported from 1996-2007. 17/20 were Canadian-born, including 5 Aboriginals. Homeless persons were more likely than non-homeless persons to have pulmonary TB (20/20), smear-positive disease (17/20, odds ratio (OR) = 5.7, 95% confidence interval (CI): 1.7-20), HIV co-infection (12/20, OR = 14, 95%CI: 4.8-40), and a history of substance use. The median duration from symptom onset to diagnosis was 61 days for homeless persons vs. 28 days for non-homeless persons (P = 0.022). Eleven homeless persons with TB belonged to genotype-defined clusters (OR = 5.4, 95%CI: 2.2-13), and ten potential locations for transmission were identified, including health care facilities, homeless shelters/drop-in centres, and an Aboriginal community centre.

Conclusions

TB cases among homeless persons in Montreal raise concerns about delayed diagnosis and ongoing local transmission.