Tuberculosis among Shanghai's homeless: a retrospective cohort study highlighting critical care gaps

China ranks third among high tuberculosis (TB) burden countries, yet people experiencing homelessness remain overlooked in TB control. We aim to explore this population.

We conducted a retrospective cohort study of 36 homeless inpatients with pulmonary TB and 72 non-homeless controls in Shanghai.

Homeless patients were younger (31.5 vs 51.5 yrs), all male (100% vs 70.8%), less often married (22.2% vs 80.6%), and had lower education (primary school or lower, 66.7% vs 36.1%) and BMI (17.5 vs 20.8). They had longer diagnostic delays (30 vs 3 days), more severe anemia (hemoglobin 99.7 vs 112 g/L), worse nutrition (albumin 23.6 vs 36.8 g/L; prealbumin 54.6 vs 169.0 mg/L), more electrolyte imbalance (84.4% vs 15.5%), higher CRP (71.2 vs 22.5 mg/L), and heavier mycobacterial burden (smear-positive 90.0% vs 64.9%; culture-positive 96.2% vs 68.6%). Homeless patients had higher in-hospital mortality (22.2% vs 1.4%), longer hospital stays (34.5 vs 14 days), over fourfold higher costs (9253.6 vs 1982.7 USD), and poorer post-discharge adherence (33.3% vs 100%; all P<0.05).

Despite significant healthcare investment, homeless pulmonary TB patients in Shanghai have advanced disease and poor outcomes, underscoring an urgent need for integrated medical-social support strategies.