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Perspective.inddPreventing and Controlling Emerging
and Reemerging Transmissible
Diseases in the Homeless
Sékéné Badiaga, Didier Raoult, and Philippe Brouqui
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Upon completion of this activity, participants will be able to:
Describe practices to reduce the burden of HIV and hepatitis infection among the homeless.
Identify how to screen for tuberculosis and treat tuberculosis in homeless settings.
Describe the problem of scabies and body louse infections among the homeless.
Specify the burden of illness associated with Bartonella quintana among the homeless and how to treat this infection.
Anne Mather, Technical Writer-Editor, Emerging Infectious Diseases. Disclosure: Anne Mather has disclosed no relevant fi nancial
Charles P. Vega, MD, Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine, California,
USA. Disclosure: Charles P. Vega, MD, has disclosed that he has served as an advisor or consultant to Novartis, Inc.
Disclosures: Sékéné Badiaga, MD; Didier Raoult, MD, PhD; and Philippe Brouqui, MD, PhD, have disclosed no relevant fi nancial
Homelessness is an increasing public health prob- infestation. Systematic vaccination against hepatitis B virus, lem. Because of poor living conditions and limited access hepatitis A virus, infl uenza, Streptococcus pneumoniae, and to healthcare systems, homeless persons are exposed to diphtheria is strongly recommended. National public health many communicable infections. We summarize the inter- programs specifi c to homeless populations are required.
vention measures reported to be effi cient for the control and the prevention of common transmissible infections among homeless populations. Evidence suggests that appropriate Homelessness is an increasing social and public health street- or shelter-based interventions for targeted popula- problem worldwide. According to the United Nations, tions are the most effi cient methods. Depending on the “absolute homelessness” describes the conditions of per-populations targeted, these interventions may include edu- sons without physical shelter. “Relative homelessness” de- cation, free condom distribution, syringe and needle pre- scribes the condition of those who have a physical shelter scription programs, chest radiography screening for tuber- but one that does not meet basic standards of health and culosis, directly observed therapy for tuberculosis treatment, safety, such as and access to safe water and sanitation, per- improvement of personal clothing and bedding hygiene, and sonal safety, and protection from the elements (1). An es- widespread use of ivermectin for scabies and body louse timated 100 million persons worldwide experience either absolute or relative homelessness (2). Homelessness is Author affi liations: Assistance Publique – Hôpitaux de Marseille, associated with numerous behavioral, social, and environ- Marseille, France (S. Badiaga, D. Raoult, P. Brouqui); and Univer- mental risks that expose persons to many communicable sité de la Méditerranée, Marseille, France (D. Raoult, P. Brouqui) infections, which may spread among the homeless and lead to outbreaks that can become serious public health concerns Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 9, September 2008 (3–8). Epidemiologic studies of homeless populations have multiple sexual partners; those who fi nd it more diffi cult reported the following prevalence rates for infectious dis- to use or obtain condoms (6,10); and those who use drugs eases: 6.2%–35% for HIV infection (6,9–13), 17%–30% in shooting galleries or who share syringes or other drug for hepatitis B virus (HBV) infection (9,10), 12%–30% paraphernalia (6). Controlling the spread of HIV among for hepatitis C virus (HCV) infection (9,10), 1.2%–6.8% the homeless requires interventions targeting high-risk for active tuberculosis (TB) (3,4), 3.8%–56% for scabies groups such as youth, female street sex workers, and IDUs (11,12), 7%–22% for body louse infestation (5,11,13,14), (16,19,20). For example, an intensive intervention program and 2%–30% for Bartonella quintana infection (5,15), targeting homeless youth achieved a signifi cant reduction which is the most common louse-borne disease in urban of unprotected sex acts over 12 months (p = 0.018) and homeless.
drug use over 12 months (p = 0.019) among female partici- The prevalence of these transmissible diseases among pants as well as a strong reduction in marijuana use over the homeless varies greatly according to living conditions. 12 months (p = 0.082) in male participants (16). The pro-Homeless persons who sleep outdoors in vehicles, aban- gram involved training shelter staff and residents in small doned buildings, or other places not intended for human groups, providing access to health resources, and making habitation are mainly street youth, female street sex work- condoms available easily and at no cost. An interven- ers, and persons with mental health problems (1). These tion program targeting homeless and crack-using African persons are frequently injection drug users (IDUs), and they American women provided them with psychoeducational often engage in risky sexual behavior, which exposes them information and skills training on how to reduce HIV risk to both blood-borne and sexually transmitted infections and drug use; the program signifi cantly (p = 0.03) reduced such as HIV, HCV, and HBV (6,9,10). Homeless persons the number of unprotected sex acts among participants, sleeping in shelters are mainly single men, but they also compared with control participants, at 6 months after the include single women, families with children, and mentally program was started (19). In Rhode Island, a prescription ill persons (1). The primary health concerns for this popu- program to deliver syringes to high-risk underserved and lation are the overcrowded living conditions that expose diverse populations was conducted within the context of them to airborne infections, especially TB (7), and the lack comprehensive drug treatment. The program recruited 327 of personal hygiene and clothing changes that expose them persons and found that 86% saw a physician for syringe to scabies, infestation with body lice, and louse-borne dis- prescription at least 1 time, 46% at least twice, and 32% eases (5). Homeless persons using single-room hotels or >3 times; this program demonstrated the feasibility and ac-living with friends and family show a high prevalence of ceptability of such a program for and by its target popula-illicit drug use and risky sexual behavior that increases the tion, and it reduced the number of injection drug–related risk for infections transmitted by blood and/or sex (6), and risky behavior traits (20).
they also frequently live in overcrowded conditions that ex- Factors predisposing to infections with HBV and HCV are much the same as those for HIV, with HBV a greater risk Homeless people face many barriers to accessing with of unprotected sex and HCV a greater risk with injec- healthcare systems; these factors contribute to increasing tion drug–related behavior (9,10). Therefore, intervention the spread of infections (1). Implementing effi cient strat- measures to prevent the spread of HCV among the home- egies to survey and prevent the spread of communicable less are the same as those noted above for HIV prevention infections among the homeless is a public health prior- (16,19,20). As for HBV infection, some evidence suggests ity. Strategies reported to be effi cient for controlling or that HBV immunizations for the homeless are feasible and preventing communicable infections in the homeless are effective. A study in New Haven, Connecticut, recruited targeted interventions that focus on areas where homeless 212 IDUs at syringe-exchange sites to undergo HBV vac-people are more likely to reside and are conducted with a cination. Most (63%) were vaccine eligible, including 23% mobile team that includes outreach workers (8,16–19). In of homeless persons; of the vaccine-eligible IDUs, 77% this review, which concentrates on the primary communi- completed 2 vaccinations and 66% completed all 3 vac- cable infections commonly associated with homelessness, cinations (21). Homeless IDUs were more likely than other we summarize the main intervention measures reported to IDUs to complete the vaccination schedule, probably be-be effi cient in controlling and preventing these infections.
cause the vaccination program and the syringe-exchange sites are areas where the homeless tend to congregate, pro- Interventions for Homeless at
viding more opportunities for them to access these services. Risk for HIV and Hepatitis
An accelerated HBV vaccination schedule should be the re- The risk for HIV infection is higher in the following gime of choice for homeless people, especially those with a populations of homeless people: those engaged in sexual past history of drug use. This recommendation is supported behavior such as sex work, receptive anal sex, and having by a study in the United Kingdom that compared comple- Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 9, September 2008 tion rates for a conventional HBV vaccine schedule (im- TB transmission among the homeless, as demonstrated by munization at 0, 1, and 6 months) conducted among home- the reduction of genotype clustering in DNA fi ngerprinting less in 1999 with the rates for an accelerated immunization analyses (17) (Table 1).
schedule (immunization at 0, 7, and 21 days) in 2000. The No consensus has been reached regarding the most completion rates for the accelerated vaccination regimen effective diagnostic tools for screening for TB among the were almost 7 times higher than rates for the conventional homeless. Logistically, TST is likely to be the simplest one (22). A hepatitis A (HAV) outbreak has been reported method to use because it requires only nurses and outreach among homeless persons and IDUs in Bristol (UK), possi- workers (17). It was used successfully to identify TB infec- bly transmitted parenterally (8). The same city is the site of tion in several intervention programs (17,24,25). However, a successful HAV vaccination program for homeless per- TST lacks specifi city, especially in areas where Mycobac- sons and drug users to control HAV outbreaks and prevent terium bovis BCG vaccination is common. Spot sputum transmission to the wider population (8). In June 2000, this screening is also logistically easy, feasible, and effi cient program immunized 136 homeless persons and IDUs and for identifying unsuspected TB cases in persons in shelters, 9 members of staff in shelters, hostels, drug services, and and it can permit rapid detection of patients with smears drop-in centers. The result was a signifi cant (p<0.001) drop that are acid-fast positive (24,25). However, 50% of TB in HAV cases in the Bristol population (including home- patients’ smears are negative, and the patients may be dif- less persons) from 90 cases (January–June) to 33 (July– fi cult to locate after culture results are known because the homeless tend to be very mobile. Screening by chest radi-ography either periodically in all residents or specifi cally in Interventions for Homeless at Risk
symptomatic persons (e.g., chronic coughers) is likely to be for TB and Airborne Diseases
the most cost-effective approach, as was demonstrated in a TB incidence is higher in homeless populations than in jail setting (26). This strategy detected 42 cases of TB in the general population, as reported in San Francisco (270 9,877 homeless persons in Los Angeles (7), and 2 cases of cases/105 persons/year vs. 39.5 cases/105 persons/year) active pulmonary TB among 221 persons during a 1-night (23). Molecular epidemiology studies, using DNA fi nger- “snapshot” shelter-based survey (see “Snapshot Interven- printing, demonstrated that most TB cases occurring in the tions,” below) in Marseille, France (27).
homeless are primary infections (7,23). The spread of TB Screening the contacts made by TB-infected homeless among the homeless is related to recent person-to-person persons is more effective when it focuses on possible sites transmission, which produces outbreaks with large clusters of transmission such as homeless shelters rather than when in which >50% of persons are infected (7). Genotyping it investigates contacts of specifi c persons. By contrast, also identifi ed homeless shelters as major sites of transmis- shelters and housing records are excellent sources of infor- sion (7,23). For example, in Los Angeles, California, from mation for location-based investigation of contacts (7,23). March 1994 through May 1999, 3 homeless shelters were The benefi ts for screening are clear: a 10% in increase in sites of TB transmission for 55 (70%) of 79 homeless per- the number of chronically homeless persons with active TB sons. Thirty-six of these 55 persons were infected in 1 large who access treatment each year produced a 12.5% decline in shelter in which 595 occupants shared 3 sleeping rooms. future TB cases in this population after 10 years compared (7). Common individual risk factors for TB among home- with the number expected without this intervention (28). less persons include alcohol abuse, poor nutrition, and HIV The conditions for effectively treating TB in homeless per-infection (4,23). Addiction to injection or inhaled drugs has sons include directly observed therapy (DOT) throughout also been reported as associated with TB in the homeless the treatment course to ensure patient compliance and free (4), but this association remains debated (7,23).
medical care, including extended hospitalization and stays Interventions to control the spread of TB among home- in convalescent-care institutions (3,4). Housing-based pro- less persons require early detection of cases and outbreaks grams involving DOT have higher completion rates than in shelters, screening of those persons with whom the in- programs in acute-care hospital settings.
fectious person has had contact, and effective treatment of In addition to TB, infl uenza, pneumococcal pneumo- TB patients. According to a shelter-based screening pro- nia, and diphtheria have been reported in the homeless gram that used symptom evaluation, chest radiography, and (29,30). Although no reports on interventions to prevent in some cases sputum culture and tuberculin skin testing these infections in the homeless have been published, it has (TST), a TB infection rate of 1%–3% has been detected been suggested that immunization against these diseases among sheltered homeless populations (24,25). Imple- should be planned and delivered easily and at no cost to menting mandatory shelter-based screening in several homeless people since this population is at high risk for homeless shelters in the United States led to reduction of outbreaks and severe illness (29,30).
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 9, September 2008 Table 1. Communicable infections associated with homelessness* homosexuality/bisexuality, multiple sexual partners, crack and/or cocaine use, street sex work Drug risk behavioral traits: sharing syringe, needle, Overcrowding in shelters, alcohol abuse, drug Overcrowding in shelters, lack of personal hygiene, High prevalence of body louse infestation epidemic typhus *STIs, sexually transmitted infections. Interventions for Scabies, Body Louse
ministration of ivermectin as recommended, and education Infestations, and Louse-borne Diseases
of shelter staff to change and treat the bedding frequently Scabies is transmitted by person-to-person contact or (5). Despite these efforts, no signifi cant decrease in the by contaminated fomites (e.g., clothes, bedding). It is more prevalence of scabies and body louse infestation was ob-prevalent in the homeless than in the general population served during the study (5). In this population, a reduction (11). The reported prevalence of scabies varies from 3.8% in the prevalence of body lice infestation was seen after 3 in shelter-based investigations (11) to 56.5% among hos- doses of oral ivermectin were administered at 7-day inter- pitalized homeless persons (12). Human infestations with vals, but the effect was transient and disappeared by day body lice occur when clothes are not changed or washed 45 (18). In addition, a randomized, double-blind, placebo-regularly, and close body-to-body contacts in crowded en- controlled trial was conducted in Marseilles to evaluate vironments increase person-to-person transmission of body the effect of a single dose of oral ivermectin on reducing lice (31). In sheltered homeless populations, prevalence the ectoparasite-based pruritus in the sheltered homeless rates of body lice vary from 7% to 22% (5,11,13,14). In population. This study showed that a single dose of oral very poor hygienic conditions, an infection prevalence of ivermectin transiently reduces pruritus (S. Badiaga, unpub. 80% (18) and a single infected person carrying up to 600 data). These observations suggest that multiple repeated lice have been reported (14,18). Scabies and body lice in- treatments of ectoparasite-based pruritus with ivermectin festation generate severe pruritus, which leads to scratch- are an effi cient and practical complement to classic thera- ing, which may result in bacterial superinfections (11). In peutic measures like frequent, complete changes of cloth-addition, the body louse is an effi cient vector for Bartonella ing and bedding to reduce scabies and body lice infestation quintana, Rickettsia prowazekii, and Borrelia recurrentis in the homeless.
(3,5,15,32). Acinetobacter baumanii has also been isolated The most common louse-borne disease reported in the urban homeless is Bartonella quintana infection (5). B. Controlling scabies, body louse infestation, and their quintana is a pathogen restricted to humans and was fi rst effects on the homeless is a challenge. Classic therapeutic described as the agent of trench fever during World War I measures for scabies are based on bathing, followed by ap- (34). Emergence of B. quintana among the homeless was plication over the entire skin of topical scabicides such as recognized in the early 1990s by simultaneous reports of permethrin, lindane, benzyl benzoate, and crotamiton (33). B. quintana endocarditis in 3 homeless persons in France Treatment with 200 μg/kg ivermectin, 2 doses administered (35) and B. quintana bacteremia in 10 homeless persons in 2 weeks apart, has been reported to be as effective as a sin- Seattle, Washington, USA (36). Subsequent epidemiologic gle dose of a topical scabicide (33). Treatment of all close studies showed B. quintana seroprevalence rates of 2%–contacts and housemates is recommended, as well as care- 11% among nonhospitalized homeless (5,14,15) and 30% ful washing of clothing and bedding (33). The therapeutic in hospitalized homeless persons (15). B. quintana bacter-modality recommended for body lice is frequent changing emia rates of 5.4% in 930 nonhospitalized homeless per-and cleaning of clothing, including underwear and socks, as sons (5) and 14% in 71 hospitalized homeless persons (15) well as frequent treatment of bedding with insecticides or have been reported from Marseilles. B. quintana DNA has by boiling the sheets (3,34). In Marseilles, during a 4-year been identifi ed in 101 (14.9%) of 678 lice collected from study of arthropod-borne infections among homeless peo- the sheltered homeless population in Marseille (5), as well ple, we tried to treat, immediately and systematically, all as in lice collected from homeless persons in Japan (14).
persons in shelters who had scabies or body lice through B. quintana causes trench fever, chronic bacteremia complete clothing change, application of insecticide, ad- that may last up to 78 weeks, endocarditis in alcoholic per- Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 9, September 2008 sons without previous valvulopathy, and bacillary angiom- prowazekii antibodies (0.75% vs. 0% in blood donors, p = atosis in HIV-infected persons (34). Chronic bacteremia 0.05) and of B. recurrentis (1.61% vs. 0% of blood donors, may be identifi ed by blood cultures in homeless persons p = 0.005) (5). In a massive outbreak of epidemic typhus seen in emergency departments, as reported in a study from observed in Burundi, doxycycline was effi cient in control-Marseilles (15). The phenomenon of chronic bacteremia ling the outbreak among jail inmates, causing a decrease in suggests that humans are the natural reservoir of B. quin- the death rate from 15% to 0.5% after administration of a tana, as demonstrated by identifi cation of the bacterium in erythrocytes from homeless persons with B. quintana bac-
teremia (37). In addition to delousing, which is the best way Snapshot Interventions
to prevent louse-borne diseases, antimicrobial drug therapy
Yearly snapshot interventions in shelters, performed against bacterial agents may be important for eradicating by large multidisciplinary teams, have been reported to be reservoirs and preventing complications such as endocardi- effi cient for controlling or preventing infections among the tis in cases of B. quintana infection. A randomized, open, homeless (5,11). These investigations can reach a category placebo-controlled trial demonstrated signifi cant effi cacy of homeless who do not usually seek healthcare. In Mar-of doxycycline (200 mg orally once a day for 28 days) in seilles, since 2000, a large mobile team is sent once a year combination with gentamycin (3 mg/kg intravenously once to perform these snapshot interventions in order to survey a day for 14 days) in homeless persons with B. quintana louse-borne disease in the 2 shelters designated for accom-chronic bacteremia (38). A regimen of gentamycin for 14 modating the homeless (5). This team comprises 30–40 per-days and doxycycline for 28 days is recommended for pa- sons, including physicians, residents, or fellows; nurses; and tients with endocarditis (34).
outreach workers. During interventions, homeless persons Epidemic typhus caused by R. prowazekii and relaps- who choose to participate are interviewed and physically ing fever due to Borrelia recurrentis are 2 other louse-borne examined. Clothes are carefully screened for body lice, and diseases that tend to affect the urban homeless. Outbreaks specifi c treatment is given when appropriate. Nurses also of epidemic typhus occur when body louse infestations are collect blood and other microbiologic samples for serologic more prevalent in the population, as observed in Burundi tests for louse-, fl ea-, and tick-borne diseases, as well as (31). To date, no outbreak of epidemic typhus or relapsing hepatitis, HIV; and syphilis. Arthropods are collected and fever has been observed in the urban homeless, nor has evi- PCR-screened for pathogens such as Bartonella, the epi- dence of R. prowazekii or B. recurrentis been found in lice demic typhus rickettsia, and Borrelia recurrentis. Depend-collected from this population. Nevertheless, during a 4-year ing on the epidemiologic situation, other surveys such as for study of louse-borne diseases among sheltered homeless the prevalence of TB and other respiratory diseases can be persons in Marseille, we detected a sporadic acute autoch- organized (27). In such cases, a pneumologist and radiogra- thonous case of epidemic typhus in a sheltered homeless phy technologists using a mobile x-ray machine are added person (39) and signifi cantly higher seroprevalences of R. to the intervention team. These snapshot interventions led Table 2. Interventions to control and prevent the spread of infections in the homeless* HIV, HCV, HBV infections Tailored education of targeted population on reducing infection risk with provision of free condoms Syringe prescription program and needle exchange programs HBV, HAV infections HBV accelerated immunization Tuberculosis Shelter based-intervention with chest radiograph screening, sputum culture, tuberculin skin testing Contact investigation through homeless shelters Influenza, diphtheria, Streptococcus pneumoniae infections Systematic Scabies, body louse infestation Providing facilities for bathing and laundry; insecticide application to bedding in shelters Ivermectin for scabies, body louse, and ectoparasite-based pruritus Louse-borne diseases Doxycycline and gentamicin for persons with chronic Bartonella quintana bacteremia Doxycycline for persons with epidemic typhus *HCV, hepatitis C virus; HBV, hepatitis B virus; HAV, hepatitis A virus. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 9, September 2008 to successively identifying a high prevalence of louse in- bedding hygiene; use of ivermectin to treat pruritus most festation, louse-borne diseases such as B. quintana infec- often caused by scabies or body louse infestation; and im- tion, and skin infections among this homeless population munizations against HBV, HAV, infl uenza, Streptococcus
(5,11). Snapshot interventions have also identifi ed the risk pneumoniae, and diphtheria. Implementation of systematic
for the homeless of acquiring other louse-borne diseases vaccination schedules to prevent communicable diseases in
such as epidemic typhus and relapsing fever, and enabled the homeless is a major public health priority. The success
the fi rst isolation of A. baumanii from lice (5,32,39). This of these interventions requires the implementation of a na-
strategy of wide systematic testing of infectious diseases in tional public health prevention program for the homeless.
this population also led to the unexpected discovery of an A yearly snapshot intervention is 1 means to achieve these
outbreak of acute Q fever in a homeless shelter in Marseille objectives.
(40). Epidemiologic investigations of this outbreak showed
that exposure to wind from an abandoned slaughterhouse, Acknowledgments
used for an annual Muslim sheep feast, was the main risk
We thank American Journal Experts for the translation of factor for developing Coxiella burnetii infection (Figure).
Dr Badiaga is an infectious diseases specialist in the emer- Conclusions
gency department of the University Hospital in Marseilles, France. Evidence suggests that appropriate public health in- His research interests are management of infectious and tropical terventions can be effective in preventing and controlling diseases in emergency hospital settings and management of trans- the spread of numerous transmitted diseases among home- missible diseases in people in poor living conditions.
less persons, which is a public health concern both for the
homeless and the larger population. These interventions
should be tailored to the targeted populations and focused References
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nert F, et al. Bartonella (Rochalimaea) quintana endocarditis in three 20. Rich JD, McKenzie M, Macalino GE, Taylor LE, Sanford-Colby S, homeless men. N Engl J Med. 1995;332:419–23. DOI: 10.1056/ Wolf F, et al. A syringe prescription program to prevent infectious disease and improve health of injection drug users. J Urban Health. 36. Spach DH, Kanter AS, Dougherty MJ, Larson AM, Coyle MB, 2004;81:122–34. DOI: 10.1093/jurban/jth092 Brenner DJ, et al. Bartonella (Rochalimaea) quintana bacteremia 21. Altice FL, Bruce RD, Walton MR, Buitrago MI. Adherence to in inner-city patients with chronic alcoholism. N Engl J Med. hepatitis B vaccination at syringe exchange sites. J Urban Health. 1995;332:424–8. DOI: 10.1056/NEJM199502163320703 2005;82:151–61. DOI: 10.1093/jurban/jti016 37. Rolain JM, Foucault C, Guieu R, La Scola B, Brouqui P, Raoult D. 22. Wright NM, Campbell TL, Tompkins CN. Comparison of conven- Bartonella quintana in human erythrocytes. Lancet. 2002;360:226–8. tional and accelerated hepatitis B immunisation schedules for home- less drug users. Commun Dis Public Health. 2002;5:324–6.
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26. Jones TF, Schaffner W. Miniature chest radiograph screening for tu- Address for correspondence: Philippe Brouqui, Unité des Rickettsies, berculosis in jails: a coast-effectiveness analysis. Am J Respir Crit Care Med. 2001;164:77–81.
CNRS UMR 6020, IFR 48, Faculté de Médecine, 27 bd Jean Moulin 13385, Marseille CEDEX 5, France; email: firstname.lastname@example.org Now that you’ve read the article, you can listen to the commentary.
Preventing and Controlling Emerging and Reemerging There are an estimated 100 million homeless people worldwide today, and this number is likely to grow. The homeless population is vulnerable to many diseases, including HIV, hepatitis, and tuberculosis. In this podcast, Dr. Marian McDonald, Associate Director for Minority and Women’s Health at CDC, discusses why this population is so vulnerable.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 9, September 2008
Hyperbaric Oxygen Therapy Committee Report 2003 - Skin Grafts and Flaps (compromised) SKIN GRAFTS AND FLAPS (COMPROMISED) William A. Zamboni and Himansu R. Shah Rationale Hyperbaric oxygen (HBO2) therapy is neither necessary nor recommended for the support of normal, uncompromised skin grafts or flaps. However, in tissue compromised by irradiation or in other cases where there