Influenzalike illness among homeless persons.To the Editor: We report rates of influenzalike illness (ILI) and influenza vaccination among homeless persons at 3 shelter clinics in New York City New York City: see New York, city. New York City City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. examined from 1997 through 2004. Little is understood regarding the prevalence and transmission of influenza among the homeless (1). Further inquiry on this topic is timely because of concern over a possible influenza pandemic, because of US goals to increase vaccination rates among high-risk groups (2), and because of the potential threat to persons who live and work in shelters. Homeless shelters are paradigmatic See paradigm. congregate settings and thus likely sites for transmission of airborne pathogens such as influenza viruses and tubercle tubercle (t  `bərkyl') [Lat.,=little swelling], small, usually solid, nodule or prominence. bacilli bacilli /ba·cil·li/ (bah-sil´i) plural of bacillus. bacilli see bacillus. , shown in part by numerous tuberculosis outbreaks among the homeless (3). Homeless persons experience high rates of pneumonia (4) and related death (5,6). This outcome indicates that the homeless also have high rates of influenza because pneumonia is a common complication of influenza. Depending upon patient's age and sex, death rates attributed to pneumonia or influenza among homeless adults ranged from 1.6 to 6.3 (95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. 0.4-24.1) in one study (7). The New York City Departments of Health and Mental Hygiene mental hygiene, the science of promoting mental health and preventing mental illness through the application of psychiatry and psychology. A more commonly used term today is mental health. and Homeless Services reported in December 2005 that 1% of hospitalizations and 3.4% of deaths of homeless adults in New York City from 2001 to 2003 were caused by influenza or pneumonia (8). We analyzed 4,319 medical charts of persons who received medical services in 3 New York City homeless shelter clinics during influenza seasons (i.e., October 1 through May 30) from 1997 through 2004. This study was approved by the St. Vincent's Hospital Hospital:
Sore throat, also called pharyngitis, is a painful inflammation of the mucous membranes lining the pharynx. It is a symptom of many conditions, but most often is associated with colds or influenza. , or both (Table). ILI is accepted as an indicator of influenza by the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. and others (9). The overall medical chart review also showed that less than one fourth of all persons examined and one third of those [greater than or equal to] 65 years of age had evidence of influenza vaccination noted in their charts. Vaccinations are available from many sources, but those given at shelter clinics accounted for a large percentage, and vaccination rates varied widely by homeless shelter clinic site. This study has some limitations. Because vaccinations are offered at numerous health centers, rates of vaccination based on the medical charts we studied may be underestimated. Moreover, since only those homeless persons at shelters who attended the medical clinic provided data, the findings cannot be used to make generalizations regarding ILI or influenza vaccination rates among the general population of the shelters. Nonetheless, these numbers can serve as a basis for more rigorous inquiry. The implementation of an appropriate public health response is critical in maintaining the health of homeless persons. Controlling influenza transmission within shelters may benefit the broader public in the same way that reducing the rates of tuberculosis among homeless persons is regarded as essential in preventing transmission to the general population. The decision to receive an influenza vaccination is influenced by many factors. These factors include concern with related side effects Side effects Effects of a proposed project on other parts of the firm. , belief that the vaccine is not required, previous bad reactions, dislike of injections, and doubts about vaccine efficacy (10). Understanding how these factors affect vaccination rates among the homeless would be valuable in planning healthcare interactions and quality improvements. Similarly, since the New York City Departments of Health and Mental Hygiene and Homeless Services recommend that influenza immunizations be provided to all sheltered homeless adults and shelter staff (8), further inquiry would help determine the risk-benefit balance of such an approach. This study was supported, in part, by the Tuberculosis Ultraviolet Shelter Study (TUSS TUSS A clinical trial–Tuberculosis Ultraviolet Shelter Study ). References (1.) Rogers MA, Wright JG, Levy BD. Influenza. In: O'Connell JJ, Swain SE, Daniels CL, Allen JS, editors. The health care of homeless persons: a manual of communicable diseases and common problems in shelters and on the streets. Boston: Boston Healthcare for the Homeless Program, 2004. p. 67-71. (2.) US Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS . Healthy people 2010. 2nd ed. With understanding and improving health and objectives for improving health. Washington: US Government Printing Office; 2000 [cited 2006 Apr 26]. Available from http://www.healthypeople.gov/ (3.) Haddad MB, Wilson TW, Ijaz K, Marks SM, Moore M. Tuberculosis M. tuberculosis, n the bacterium responsible for tuberculosis, generally a respiratory infection in man; nonrespiratory tuberculosis is considered an indicator disease for AIDS. See also tuberculosis. and homelessness in the United States, 1994-2003. JAMA JAMA abbr. Journal of the American Medical Association . 2005;293:2762-6. (4.) Shariatzadeh MR, Huang JQ, Tyrrell GJ, Johnson MM, Marrie TJ. Bacteremic bac·te·re·mi·a n. The presence of bacteria in the blood. bac  te·re pneumococcal pneumonia Pneumococcal Pneumonia DefinitionPneumococcal pneumonia is a common but serious infection and inflammation of the lungs. It is caused by the bacterium Streptococcus pneumoniae. : a prospective study in Edmonton and neighboring municipalities. Medicine (Baltimore). 2005;84: 147-61. (5.) Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA. 2000;283:2152-7. (6.) Hibbs JR, Benner L, Klugman L, Spencer R, Macchia I, Mellinger A, et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med. 1994;331: 304-9. (7.) Hwang SW, Orav EJ, O'Connell JJ, Lebow JM, Brennan TA. Causes of death in homeless adults in Boston. Ann Intern Med. 1997; 126:625-8. (8.) Kerker B, Bainbridge J, Li W, Kennedy J, Bennani Y, Agerton T, et al. The health of homeless adults in New York City: a report from the New York City Departments of Health and Mental Hygiene and Homeless Services. New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : Departments of Health and Mental Hygiene and Homeless Services; 2005 (9.) Centers for Disease Control and Prevention. Fact sheet: influenza (flu) [monograph on the internet]. Atlanta: The Centers; 2001 [cited 2006 Jan 25]. Available from http://www.cdc.gov/flu/ weekly/pdf/flu-surveillance-overview.pdf (10.) Allsup SJ, Gosney MA. Difficulties of recruitment for a randomized controlled trial A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. involving influenza vaccination in healthy older people. Gerontology gerontology: see geriatrics. . 2002;48:170-3. Scott J. Bucher,* Philip W. Brickner,* and Richard L. Vincent* * St. Vincent's Hospital-Manhattan, New York, New York, USA Address for correspondence: Philip W. Brickner, Department of Community Medicine, St. Vincent's Hospital-Manhattan, 41-51 East 11th St, 9th Floor, New York, NY 10003, USA; email: drpwb@aol.com
Table. Cases of influenzalike illness (ILI) among homeless persons
by influenza season, New York City, 1997-2004
Shelter 1 Shelter 2
Season % %
No. patients No. patients
No. patients seen No. patients seen
cases seen with ILI cases seen with ILI
1997-98 5 284 1.8 3 221 1.4
1998-99 4 363 1.1 5 197 2.5
1999-00 2 170 1.2 1 186 0.5
2000-01 1 198 0.5 2 206 1.0
2001-02 2 202 1.0 2 122 1.6
2002-03 2 196 1.0 1 136 0.7
2003-04 6 152 3.9 1 157 0.6
Total 22 1,565 1.4 15 1,225 1.2
Shelter 3 Total
Season % %
No. patients No. patients
No. patients seen No. patients seen
cases seen with ILI cases seen with ILI
1997-98 3 202 1.5 11 707 1.6
1998-99 5 240 2.1 14 800 1.8
1999-00 4 248 1.6 7 604 1.2
2000-01 4 227 1.8 7 631 1.1
2001-02 1 258 0.4 5 582 0.9
2002-03 1 218 0.5 4 550 0.7
2003-04 4 235 1.7 11 544 2.0
Total 22 1,628 1.4 59 4,418 1.3
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