Keywords
COVID-19
TB–COVID coinfection
Narrative review
Observational evidence
Data Availability Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.
How to Cite
Abstract
Background: Tuberculosis (TB) remains a significant global public health problem, disproportionately affecting people experiencing homelessness (PEH). During the COVID-19 pandemic, healthcare resources were redirected, potentially disrupting TB monitoring and care for this already vulnerable population.
Methods: This review of primary observational studies was conducted using PubMed, LILACS, SciELO, Cochrane Library, CAPES Periódicos, and ScienceDirect. Searches used the terms [(Tuberculosis) AND (homeless people) AND (COVID)] and [(Tuberculosis) AND (unhoused) AND (COVID)], covering publications from 2020 to November 2025. Secondary reviews identified during the search were excluded from the primary evidence set and used solely for background contextualization.
Results: The studies documented high rates of unfavorable TB outcomes among PEH — including treatment discontinuation, prolonged hospitalization, and elevated mortality — across multiple settings and healthcare contexts. Each study employed a distinct operational definition of homelessness, limiting direct cross-study comparisons. Where PEH-specific denominators were available, outcomes were substantially worse than general population comparators. Evidence on TB–COVID coinfection specifically within PEH remains scarce; most relevant estimates come from broader vulnerable or mixed populations and are considered indirect evidence.
Conclusion: Structural vulnerabilities — including inadequate housing, barriers to healthcare access, and high comorbidity burden — are the primary drivers of poor TB outcomes in PEH. Pandemic-era care disruptions were associated with worsened TB indicators in the general population; among PEH, outcomes remained persistently high across periods, suggesting a pre-existing ceiling of vulnerability. The descriptive nature of the available primary evidence constrains causal attribution.
References
1. Saúde Md. Manual de recomendações para o controle da tuberculose no Brasil Brasília: Ministério da Saúde; 2019; 2:[Available from: http://bvsms.saude.gov.br/bvs/publicacoes/manual_recomendacoes_controle_tuberculose_brasil_2_ed.pdf.
2. Savacool JW. Philadelphia and the White Plague. Trans Stud Coll Physicians Phila. 1986: 147 [PMID: 3532445,
3. Prevention CfDCa. Tuberculosis (TB): Basic TB Facts Atlanta: Centers for Disease Control and Prevention; 2019. Available from: https://www.cdc.gov/tb/topic/basics/default.htm.
4. Saúde Md. Boletim Epidemiológico de Tuberculose - número especial Brasília: Ministério da Saúde; 2024. Available from: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/boletins/epidemiologicos/especiais/2024/boletim-epidemiologico-de-tuberculose-numero-especial-mar-2024.pdf.
5. Nascimento CPA, Silva SYBe, Ferreira AGL, Silva SBd, Lira ALBdC, Érika Simone Galvão P. Vulnerabilidade De Pessoas Em SituaÇÃo De Rua Que Vivem Com Tuberculose: AnÁlise De Conceito. Revista Enfermagem Atual In Derme. 2023: https://doi.org/10.31011/reaid-2023-v.97-n.3-art.1908]
6. Silva DR, Mello FCQ, D'Ambrosio L, Centis R, Dalcolmo MP, Migliori GB. Tuberculosis and COVID-19, the new cursed duet: what differs between Brazil and Europe? J Bras Pneumol. 2021: e20210044 [PMID: 33950095, https://doi.org/10.36416/1806-3756/e20210044]
7. Maia CMF, Martelli DRB, Silveira D, Oliveira EA, Martelli Junior H. Tuberculosis in Brazil: the impact of the COVID-19 pandemic. J Bras Pneumol. 2022: e20220082 [PMID: 35475872, https://doi.org/10.36416/1806-3756/e20220082]
8. Organization PAH. Histórico da pandemia de COVID-19 Washington: Pan American Health Organization. Available from: https://www.paho.org/pt/covid19/historico-da-pandemia-covid-19.
9. Organization WH. Origin of SARS-CoV-2. Geneva: World Health Organization, 2020.
10. Fan H, Wu F, Liu J, Zeng W, Zheng S, Tian H, Li H, Yang H, Wang Z, Deng Z, Peng J, Zheng Y, Xiao S, Hu G, Zhou Y, Ran P. Pulmonary tuberculosis as a risk factor for chronic obstructive pulmonary disease: a systematic review and meta-analysis. Ann Transl Med. 2021: 390 [PMID: 33842611, https://doi.org/10.21037/atm-20-4576]
11. Aggarwal AN, Agarwal R, Dhooria S, Prasad KT, Sehgal IS, Muthu V. Active pulmonary tuberculosis and coronavirus disease 2019: A systematic review and meta-analysis. PLoS One. 2021: e0259006 [PMID: 34673822, https://doi.org/10.1371/journal.pone.0259006]
12. Baratella E, Crivelli P, Marrocchio C, Bozzato AM, Vito A, Madeddu G, Saderi L, Confalonieri M, Tenaglia L, Cova MA. Severity of lung involvement on chest X-rays in SARS-coronavirus-2 infected patients as a possible tool to predict clinical progression: an observational retrospective analysis of the relationship between radiological, clinical, and laboratory data. J Bras Pneumol. 2020: e20200226 [PMID: 32965310, https://doi.org/10.36416/1806-3756/e20200226]
13. McQuaid CF, Vassall A, Cohen T, Fiekert K, White RG. The impact of COVID-19 on TB: a review of the data. Int J Tuberc Lung Dis. 2021: 436 [PMID: 34049605, https://doi.org/10.5588/ijtld.21.0148]
14. Ortiz-Martínez Y, Rodríguez-Morales AJ, Henao-Martínez AF. Decreased notification of TB cases during the COVID-19 pandemic. Int J Tuberc Lung Dis. 2022: 177 [PMID: 35086633, https://doi.org/10.5588/ijtld.21.0651]
15. Fukunaga R, Glaziou P, Harris JB, Date A, Floyd K, Kasaeva T. Epidemiology of Tuberculosis and Progress Toward Meeting Global Targets - Worldwide, 2019. MMWR Morb Mortal Wkly Rep. 2021: 427 [PMID: 33764960, https://doi.org/10.15585/mmwr.mm7012a4]
16. Fei H, Yinyin X, Hui C, Ni W, Xin D, Wei C, Tao L, Shitong H, Miaomiao S, Mingting C, Keshavjee S, Yanlin Z, Chin DP, Jianjun L. The impact of the COVID-19 epidemic on tuberculosis control in China. Lancet Reg Health West Pac. 2020: 100032 [PMID: 34173601, https://doi.org/10.1016/j.lanwpc.2020.100032]
17. Sousa IV, Brasil CCP, Silva RMD, Vasconcelos DPE, Silva KA, Bezerra IN, Finan TJ. Participatory diagnosis to identify health problems in a socially vulnerable community. Cien Saude Colet. 2017: 3945 [PMID: 29267711, https://doi.org/10.1590/1413-812320172212.25012017]
18. Brito C, Silva L, Xavier C, Antunes V, Costa M, Filgueiras S. The way of life of the unhoused people as an enhance for COVID-19 care. Revista Brasileira de Enfermagem. 2021: https://doi.org/10.1590/0034-7167-2020-0832]
19. Laycock KM, Enane LA, Steenhoff AP. Tuberculosis in Adolescents and Young Adults: Emerging Data on TB Transmission and Prevention among Vulnerable Young People. Trop Med Infect Dis. 2021: [PMID: 34449722, https://doi.org/10.3390/tropicalmed6030148]
20. Zhu A, Bruketa E, Svoboda T, Patel J, Elmi N, El-Khechen Richandi G, Baral S, Orkin AM. Respiratory infectious disease outbreaks among people experiencing homelessness: a systematic review of prevention and mitigation strategies. Ann Epidemiol. 2023: 127 [PMID: 35342013, https://doi.org/10.1016/j.annepidem.2022.03.004]
21. Alsaïdi I, De Sousa Santos F, Plard B, Janvier E, Tinland A, Hafni A, Mosnier E. Factors associated with SARS-CoV2 infection and care pathways among the most vulnerable populations living in Marseille: a case control study. BMC Public Health. 2021: 1704 [PMID: 34538240, https://doi.org/10.1186/s12889-021-11716-6]
22. Di Gennaro F, Lattanzio R, Guido G, Ricciardi A, Novara R, Patti G, Cotugno S, De Vita E, Brindicci G, Mariano MF, Ronga L, Santoro CR, Romanelli F, Stolfa S, Papagni R, Bavaro DF, De Iaco G, Saracino A. Predictors for Pulmonary Tuberculosis Outcome and Adverse Events in an Italian Referral Hospital: A Nine-Year Retrospective Study (2013-2021). Ann Glob Health. 2022: 26 [PMID: 35582409, https://doi.org/10.5334/aogh.3677]
23. Gabdullina M, Maes EF, Horth RZ, Dzhazybekova P, Amanova GN, Zikriyarova S, Nabirova DA. COVID-19 pandemic and other factors associated with unfavorable tuberculosis treatment outcomes-Almaty, Kazakhstan, 2018-2021. Front Public Health. 2023: 1247661 [PMID: 37808989, https://doi.org/10.3389/fpubh.2023.1247661]
24. da Silva Campana P, da Silva ATC, Klautau GB, Rujula MJP, Salles MJ, de Castro MC. Impact of the COVID-19 pandemic on unfavorable tuberculosis outcomes: a comparative analysis of unhoused and general populations. BMC Public Health. 2025: 2260 [PMID: 40604738, https://doi.org/10.1186/s12889-025-23491-9]
25. Vidal AA, Coelho KSC, Merhy EE. [The street as a space for care production: the singular therapeutic project and tuberculosis management in people experiencing homelessness during the Covid-19 pandemic in the city of Rio de Janeiro]. Salud Colect. 2024: e4774 [PMID: 38457779, https://doi.org/10.18294/sc.2024.4774]
26. Medeiros MMd, Dias ALM, Figueira PB. Analysis of the proportion of homeless individuals diagnosed with pulmonary tuberculosis among the total cases, by Brazilian region, in the period from 2019 to 2021. Atena Editora; 2023.
27. Zuim RCB, Almeida JRd, Soeiro I. Casos de tuberculose, cura e interrupção de tratamento na População em Situação de Rua, no estado do Rio de Janeiro, de 2016 a 2021: um estudo descritivo com base nos dados de vigilância. REPIS (Revista Educação, Pesquisa e Informação em Saúde). 2025: https://doi.org/10.71209/repis.2025.3.e.0356]
28. Mohsenpour A, Bozorgmehr K, Rohleder S, Stratil J, Costa D. SARS-Cov-2 prevalence, transmission, health-related outcomes and control strategies in homeless shelters: Systematic review and meta-analysis. EClinicalMedicine. 2021: 101032 [PMID: 34316550, https://doi.org/10.1016/j.eclinm.2021.101032]
29. Pavinati G, Lima LV, Ferreira MRL, Zanatta STP, Magnabosco GT. Trends and clusters of tuberculosis treatment interruption among people experiencing homelessness in Brazil: influence of individual, social and programmatic factors. Rev Bras Epidemiol. 2025: e250041 [PMID: 40802343, https://doi.org/10.1590/1980-549720250041]
30. Santos A, Brunfentrinker C, Pena LDS, Saraiva SDS, Boing AF. Analysis and comparison of tuberculosis treatment outcomes in the homeless population and in the general population of Brazil. J Bras Pneumol. 2021: e20200178 [PMID: 33656159, https://doi.org/10.36416/1806-3756/e20200178]
31. Gioseffi JR, Batista R, Brignol SM. Tuberculosis, vulnerabilities, and HIV in homeless persons: a systematic review. Rev Saude Publica. 2022: 43 [PMID: 35649090, https://doi.org/10.11606/s1518-8787.2022056003964]
32. Berra TZ, Ramos ACV, Alves YM, Tavares RBV, Tartaro AF, Nascimento MCD, Moura HSD, Delpino FM, de Almeida Soares D, Silva R, Gomes D, Monroe AA, Arcencio RA. Impact of COVID-19 on Tuberculosis Indicators in Brazil: A Time Series and Spatial Analysis Study. Trop Med Infect Dis. 2022: [PMID: 36136658, https://doi.org/10.3390/tropicalmed7090247]
33. Irfani TH, Siburian R, Nabila R, Umar TP. Tuberculosis and Coronavirus Disease 2019 (COVID-19) from A Clinical Perspective: A Systematic Review. Medeni Med J. 2020: 338 [PMID: 33717627, https://doi.org/10.5222/MMJ.2020.36775]
34. Gao Y, Liu M, Chen Y, Shi S, Geng J, Tian J. Association between tuberculosis and COVID-19 severity and mortality: A rapid systematic review and meta-analysis. J Med Virol. 2021: 194 [PMID: 32687228, https://doi.org/10.1002/jmv.26311]
35. Wang Q, Guo S, Wei X, Dong Q, Xu N, Li H, Zhao J, Sun Q. Global prevalence, treatment and outcome of tuberculosis and COVID-19 coinfection: a systematic review and meta-analysis (from November 2019 to March 2021). BMJ Open. 2022: e059396 [PMID: 35725250, https://doi.org/10.1136/bmjopen-2021-059396]
36. Flores-Lovon K, Ortiz-Saavedra B, Cueva-Chicana LA, Aperrigue-Lira S, Montes-Madariaga ES, Soriano-Moreno DR, Bell B, Macedo R. Immune responses in COVID-19 and tuberculosis coinfection: A scoping review. Front Immunol. 2022: 992743 [PMID: 36090983, https://doi.org/10.3389/fimmu.2022.992743]
37. Aoki L, de Carvalho Rodrigues J, Bertollini Lamy I, da Veiga GL, Alves BdCA, Pereira EC, Sousa LVdA, Fonseca FLA. Impact of COVID-19 on Social, Economic, and Health
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