Respiratory Syncytial Virus Infection in Homeless Populations, Washington, USA

Jim Boonyaratanakornkit; Seda Ekici; Amalia Magaret; Kathryn Gustafson; Emily Scott; Micaela Haglund; Jane Kuypers; Ronald Pergamit; John Lynch; Helen Y. Chu


Emerging Infectious Diseases. 2019;25(7):1408-1411. 

In This Article


In this study of adults hospitalized during 5 years in an urban hospital, 32% of patients given a diagnosis of RSV infection were homeless, compared with 6.5% of all patients hospitalized. Patients hospitalized with RSV infection were more likely to be older, homeless, drug users, or have COPD/asthma compared with persons with influenza. Homelessness has reached a national public health crisis, and many homeless persons seek acute care in emergency departments.[9] The city of Seattle has the largest concentration of homelessness per capita in the country.[10] Outbreaks of infections with respiratory viruses have been described in homeless shelters, in which transmission might be facilitated by crowding, poor sanitation, and the ability of RSV to spread through fomites.[6,11] Our findings for RSV in this homeless population might be generalizable to other urban public hospitals.

Several outcome measures were worse in patients hospitalized for RSV infection than for influenza, including 30-day readmission, admission to the ICU, and receipt of antimicrobial drugs. A previous study similarly reported higher rates of ICU admission among patients with RSV infection than for those with influenza.[12] More severe disease might have led clinicians to preferentially use antimicrobial drugs for patients hospitalized with RSV infection compared with influenza. The higher number of patients with RSV infection than influenza admitted to the ICU supports this interpretation. These results suggest that patients hospitalized with RSV infection might benefit from closer monitoring, follow-up, and antimicrobial drug stewardship to prevent readmission and overuse of antimicrobial drugs.

Homelessness and having RSV infection were independent risk factors for hospital readmission, demonstrating that the higher risk for poor outcomes in homeless persons was not simply explained by the disproportionately higher number of diagnosis of RSV infection in this group. All-cause readmission within 30 days is a major quality metric used by the Centers for Medicare and Medicaid Services and Hospital Quality Alliance ( Other studies have found an association between lower education and unemployment with rehospitalization and that most rehospitalizations were related to concurrent conditions.[13]

Limitations of this study include the retrospective study design, limiting analysis to only hospitalized patients with RSV infection or influenza. The overall number of hospitalizations annually for RSV infection and influenza increased during 2012–2017 and was likely caused by transition to on-site rapid testing, which might increase provider uptake.[14] In addition, without hospitalized and community controls who do not have influenza or RSV infection and who are not homeless, we cannot definitively conclude that homelessness is associated with a greater risk for hospitalization for RSV infection compared with influenza. The association might have 3 possible interpretations: risk factors are associated with more severe disease caused by RSV than influenza; risk factors are associated with a higher risk for infection with RSV compared with influenza; or risk factors are associated with greater susceptibility to RSV infection and disease compared with influenza. In addition, this study was limited to a single site, although it is representative of public, safety-net hospitals. Additional limitations include clinician-initiated testing triggered by influenza-like symptoms rather than for detection of RSV infection, which is less likely to manifest with fever.[15] Therefore, the true burden of RSV infection is likely higher than identified in this study.

In conclusion, homeless persons might represent a previously unrecognized population at increased risk for poor outcomes caused by infection with RSV. An effective vaccine or therapeutic in adults could benefit this medically underserved population. Further data on the impact of homelessness on respiratory virus infection severity and outcomes are needed to guide public health strategies and implementation.