Differences in invasive group A Streptococcus infection (iGAS) outcomes between people experiencing homelessness (PEH) and those not experiencing homelessness in the United States from 2016-2021 Open Access

Abstract

Background: Group A Streptococcus (GAS) can cause multiple types of infections that range in severity from mild to invasive GAS (iGAS) infections. While several million cases of GAS infections occur in the United States yearly, the U.S. Centers for Disease Control and Prevention (CDC) estimates that about 18,500-27,000 cases of iGAS infections occur every year. Although anyone can get infected with iGAS, people experiencing homelessness (PEH) are at an elevated risk for severe iGAS infection. PEH are also more likely to have risk factors associated with iGAS infection such as HIV infection.

Objective: This study examined the association between homelessness and two iGAS infection outcomes: death and length of hospital stay.

Methods: Data from the CDC’s Active Bacterial Core Surveillance system (ABCs) were used for the analysis. 14,022 iGAS infections were reported between 2016 and 2021, 13.7% of which occurred among PEH and 12,106 non-PEH (86.3%). Logistic and negative binomial regression models were used to evaluate whether the associations between housing status and the two outcomes of interest were modified by iGAS syndrome type, controlling for age, race and ethnicity, state of residence, insurance status, sex, comorbidity score, and year of initial iGAS culture.

Results: For most iGAS syndrome types, PEH were less likely to die compared to non-PEH. However, among those with septic shock/streptococcal toxic shock syndrome (STSS), PEH had 2.57 times the odds of dying compared to non-PEH (95% CI=1.01, 6.50, p=0.05). For all iGAS syndrome types, PEH had a longer length of hospital stay compared to non-PEH. Notably, among those who developed necrotizing fasciitis, PEH stayed 2.55 times longer in the hospital compared to than non-PEH (95% CI=2.22, 2.94, p<0.01).

Conclusions: The relationships between housing status and both mortality and length of hospital stay differed by iGAS syndrome type. Compared to non-PEH, PEH were more likely to die when they developed septic shock/STSS and had longer stays when they developed necrotizing fasciitis. Further research is needed to understand the drivers of the observed disparities in infection outcomes among PEH who develop certain iGAS syndromes and identify opportunities for eliminating these disparities.

Table of Contents

Table of Contents

Introduction .................................................................................................................................... 1

Methods........................................................................................................................................... 8

Results............................................................................................................................................. 16

Discussion........................................................................................................................................ 30

Conclusions...................................................................................................................................... 38

Appendix – Tables............................................................................................................................. 39

References........................................................................................................................................ 43

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	invasive group a streptococcus active bacterial core surveillance system people experiencing homelessness infectious diseases
Committee Chair / Thesis Advisor	Lauren Christiansen-Lindquist, PhD, MPH, Emory University
Committee Members	Rieza H. Soelaeman, PhD, MPH,

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