PHWR Public Health Weekly Report

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis and has traditionally been referred to as the “disease of poverty.” Despite economic growth and improvements in living standards, the Republic of Korea (ROK) continues to have a high TB incidence rate, ranking second among Organisation for Economic Co-operation and Development member countries as of 2023 [1]. In 2024, a total of 17,944 TB cases were reported. Although the overall number of cases has shown a declining trend since 2011, the proportion of socioeconomically vulnerable groups, such as older adults aged 65 years and above (58.7%), foreign nationals (6.0%), and medical aid beneficiaries (11.3%), has increased [2]. People experiencing homelessness represent a particularly vulnerable population. Due to nutritional imbalance and poor living conditions, they have a lower overall health status and are at a higher risk of contracting various diseases, including TB. Furthermore, the absence of stable housing makes early detection and treatment difficult, while factors such as alcohol use and mental illness contribute to low treatment adherence, thereby increasing the risk of treatment failure. According to the 2024 survey on the status of homelessness, the total number of people experiencing homelessness, including those living in substandard single-room accommodations (jjokbang), was 12,725 (9,865 men, 2,851 women, and nine unspecified), comprising 1,349 unsheltered individuals, 6,659 sheltered individuals, and 4,717 residents of substandard housing [3]. In 2021, the TB screening program targeting people experiencing homelessness reported a case detection rate of 199.2 per 100,000 population, approximately 5.6 times higher than the TB incidence rate among the general population (35.7 per 100,000 population) in the same year [4]. People experiencing homelessness constitute a highly vulnerable population with a substantial global burden of TB. A synthesis of multiple studies reported that the prevalence of TB among this population is approximately 1,100 cases per 100,000 individuals. This prevalence was more than 25 times higher than that observed in the general population [5]. These findings indicate that people experiencing homelessness are particularly vulnerable to infectious diseases such as TB, underscoring the need to expand TB screening and to establish systematic treatment and management of this disease.

In 2019, the government established a plan for strengthened TB prevention and control to reinforce screening and case management for vulnerable populations, including people experiencing homelessness, and promote TB prevention and early detection through outreach screening programs [6]. However, unstable housing and social isolation among people experiencing homelessness remain major barriers to early detection. TB patients experiencing homelessness can be identified through multiple pathways, including mobile screening, mandatory screening for facility use, visits to healthcare institutions, and counseling processes. However, limited access to screening opportunities due to social isolation often results in delayed diagnosis, with TB frequently detected only when individuals seek care for other illnesses or emergency conditions. This delay leads to worsening health status and prolonged treatment duration. Diagnosed TB patients experiencing homelessness are typically hospitalized in public medical institutions for treatment. However, in some cases, treatment is interrupted due to unplanned discharge. Even when discharge is planned, long-term pharmacological treatment and management of adverse effects are essential. However, due to social isolation, it is difficult to secure support resources, rendering independent health management challenging. In addition, entry into homeless shelters is often restricted, even for patients who have been confirmed as non-infectious for M. tuberculosis, due to misconceptions about transmission risk. As a result, individuals are discharged without stable housing or adequate social and medical support, which leads to poor medication adherence and an increased risk of treatment failure.

People experiencing homelessness face a series of sequential barriers in the TB treatment process, including delayed diagnosis after disease onset, interruption of inpatient treatment, and non-adherence to medication following return to the community. These barriers might lead to reduced treatment success rates and an increased risk of community transmission. Therefore, TB management for people experiencing homelessness requires an integrated approach that goes beyond medical treatment to include housing stability and social welfare support. Since 2011, the Korea Disease Control and Prevention Agency (KDCA) has established and operated specialized TB care facilities for patients experiencing homelessness, providing stable housing along with systematic treatment and management [7]. Misokkumteo, the only TB care facility for people experiencing homelessness currently operating in the ROK, began full-scale operation following its opening in 2011. In 2006, the Korea Centers for Disease Control and Prevention (now KDCA) recognized the TB situation in the ROK as a crisis and established the “TB Elimination 2030 Plan” to strengthen TB control among vulnerable populations. A 2009 survey conducted to assess the status of TB among people experiencing homelessness found that the prevalence of pulmonary TB was 5.8%, which was 23 times higher than that of the general population (0.25%). The prevalence of latent TB infection was also markedly high at 75.8%, highlighting the need for systematic management [8]. In response, the KDCA established residential TB care facilities to provide medication guidance and health management for TB patients experiencing homelessness, with the goals of improving cure rates and preventing transmission. Furthermore, the initiative aimed to support patients’ reintegration into society as self-reliant individuals after TB cure by integrating treatment with self-reliance support. Initially, Misokkumteo was operated under a commission arrangement, with its management entrusted by the Korean National Tuberculosis Association (KNTA) to the Anglican Church of Korea. Since 2015, it has transitioned to a directly managed system under KNTA, which has continued to the present. This study aims to examine the characteristics and status of admitted patients, operational outcomes, and future challenges of this TB care facility for people experiencing homelessness.

This study retrospectively analyzed the operational status and TB treatment outcomes of patients admitted to Misokkumteo, the only TB care facility for people experiencing homelessness in the ROK, from its opening in 2011 through 2024. The analysis data were obtained based on the original facility records of Misokkumteo, and descriptive statistical analysis was performed while focusing on patient characteristics and treatment outcomes.

The study population comprised a total of 458 individuals who were first admitted to the facility between 2011 and 2024. Baseline characteristics, including sociodemographic characteristics, legal and economic status, and clinical TB information, were analyzed. The facility’s operational performance and treatment outcomes were analyzed among 428 discharged patients, excluding 30 patients who were transferred to other institutions based on their most recent admission records.

The collected data included patient sociodemographic characteristics (sex, age, marital status, family relationships, and housing type), legal and economic status (resident registration status and credit delinquency), TB-related clinical information (history of TB, presence of drug resistance, and presence of comorbidities), facility utilization (referral pathway and length of stay), treatment outcomes, and community reintegration status (post-discharge housing and livelihood status). The TB treatment success was defined according to the World Health Organization (WHO) criteria, including “cure” and “treatment completed.” Patients who self-discharged but subsequently completed treatment through continuous case management were also classified as treatment successes.

1. Overview of Facility Operation

Misokkumteo provides a stable housing environment for TB patients experiencing homelessness who have completed initial inpatient treatment at TB treatment hospitals and are no longer infectious. It offers medication management, healthcare, linkage to social welfare services, and support for self-reliance until treatment completion. Through these efforts, the primary objective is to ensure that patients complete TB treatment without interruption and are able to achieve a cure and subsequently settle in the community. Misokkumteo is located in an area near Seoul Station, with a high concentration of people experiencing homelessness, thereby enhancing on-site accessibility. The facility has a total capacity of 25 individuals, including 23 for long-term care and two for temporary protection. In particular, a separate temporary protection unit is operated to provide short-term accommodation for patients suspected of TB who cannot be immediately linked to hospital care, after which they are promptly referred for medical evaluation and hospitalization. Eligible individuals for admission are vulnerable populations, including people experiencing homelessness who have been confirmed as non-infectious for M. tuberculosis. Most patients are referred through TB treatment hospitals. Seoul Metropolitan Seobuk Hospital serves as a key referral institution, where Misokkumteo staff directly visit patients during hospitalization to provide counseling and establish trust, thereby supporting continued treatment and facilitating admission to the facility after discharge without interruption. In addition, referrals for admission are also made from public health centers and homeless service facilities, and patients who cannot be adequately supported in individual facilities or who require medication adherence support and health management are linked to Misokkumteo from the community. Facility life minimizes restrictions and ensures autonomy, except for essential rules such as anti-TB medication adherence and taking meals, in order to facilitate residents’ adjustment. For patients who refuse admission or have difficulty with communal living, community-based medication management programs provide support for housing and initial settlement, along with medication adherence monitoring and health management services through home visits and telephonic contact. Following admission, individualized support is provided through the development of social welfare and medical case management plans based on initial counseling and assessment. All medications, including anti-TB drugs, are administered through directly observed therapy. For patients with comorbidities, care is coordinated with healthcare institutions to ensure continuity of treatment. In addition, through education on TB and comorbidity management and on lifestyle improvement, patients’ capacity for self-management is strengthened, and rehabilitation and self-reliance support programs are provided to promote physical and psychological recovery and enhance motivation for self-reliance. Various programs are also operated to help restore self-esteem diminished by prolonged experiences of homelessness, enhance interpersonal confidence, strengthen motivation for treatment and self-reliance, and support social adaptation. For individuals who face difficulties in securing stable housing after treatment completion, affordable rental housing is arranged for those with willingness for self-reliance, thereby alleviating housing instability. For those capable of working, vocational training and employment opportunities are provided to support economic independence. Conversely, for individuals who are unable to work due to age, disability, or health conditions, linkage to the National Basic Livelihood Security System is provided to support basic living in the community. Patients who face challenges in achieving self-reliance or require long-term care are transferred to medical institutions or welfare facilities to ensure continuity of treatment and daily living support (Figure 1).

Figure 1. Service flow diagram of Misokkumteo
TB=tuberculosis; DOT=directly observed therapy.

2. Utilization Status

From 2011 to 2024, a total of 484 TB patients (including 26 readmissions) were admitted to Misokkumteo, and the average length of stay for those discharged after cure was 196 days. Examination of annual admission trends revealed that the number of admissions has shown a decreasing pattern since 2020. This finding might be attributed to disruptions in the admission referral system caused by the coronavirus disease 2019 pandemic, as well as a decline in the overall number of TB patients (Figure 2). The proportion of patients with comorbidities other than TB, as well as those who are older or in unstable health conditions, has been gradually increasing. As a result, the demand for individualized treatment and care has risen, and the length of stay has also shown an increasing trend (Figure 2).

Figure 2. Service utilization of Misokkumteo (2011–2024)
The number of admissions is based on 484 resident patients from 2011 to 2024. The length of stay is based on 367 resident patients who completed treatment, representing the annual average duration of stay for discharged patients.

3. Characteristics of Admitted Patients

Among the 458 patients at first admission, 455 (99.3%) were male, accounting for the vast majority. The mean age of the patients was 53 years, with the largest proportion belonging to the middle-aged group (50–64 years). Regarding marital status, 59.6% had never married, accounting for more than half of the sample, indicating that many individuals had no experience of marriage despite being in middle adulthood. In terms of family relationships, 97.8% either had no family or were out of contact with family members, reflecting extremely limited social support networks. In terms of housing status prior to admission, the most common situation was unsheltered homelessness (57.2%), indicating prolonged exposure to unstable and poor living conditions. Unstable legal and economic status, such as cancellation of resident registration (22.5%) and credit delinquency (59.2%), was also identified as a major barrier to self-reliance. Regarding the admission pathway, 81.0% of the patients were hospital referrals. A history of TB was reported in 28.6% of patients, and 5.9% of patients had drug resistance. In addition, 70.5% of patients had comorbidities, and among them, 28.8% had two or more conditions. In terms of lifestyle, high rates of alcohol-related problems (41.3%) and smoking (68.3%) were observed, indicating marked vulnerability in health-related behaviors (Table 1).

Table 1 Demographic characteristics of residents at Misokkumteo (2011–2024)

Category		n	(%)
Total		458	(100.0)
Gender	Male	455	(99.3)
	Female	3	(0.7)
Age	≤49	155	(33.8)
	50–64	262	(57.2)
	≥65	41	(9.0)
Marital status	Single	273	(59.6)
	Married	61	(13.3)
	Divorced	124	(27.1)
Family status	Has family and is in contact	10	(2.2)
	Has family and is estranged	139	(30.3)
	No family	309	(67.5)
Housing type	Facility	107	(23.4)
	Homeless	262	(57.2)
	Nonstandard housinga)	89	(19.4)
Resident registration	Possession	272	(59.4)
	Loss	83	(18.1)
	Deregistration	103	(22.5)
Credit status	Delinquent	271	(59.2)
	Normal	183	(40.0)
	Unknown	4	(0.9)
Sources of admission referrals	Health care institutions	371	(81.0)
	Social welfare agencies	50	(10.9)
	Others	37	(8.1)
TB history	No previous TB	327	(71.4)
	Previous TB	131	(28.6)
Drug-resistant TB statusb)	Non-resistant TB	431	(94.1)
	Resistant TB	27	(5.9)
Number of companion diseases	None	27	(5.9)
	1	135	(29.5)
	≥2	191	(41.7)
Alcohol problemc)	No	269	(58.7)
	Yes	189	(41.3)
Smoking status	Non-smoker	145	(31.7)
	Smoker	313	(68.3)

The analysis is based on the first admission of resident patients from 2011 to 2024, excluding 26 patients who were readmitted or duplicated. TB=tuberculosis. ^a)Nonstandard housing, including jjokbang (small rooms), goshiwon (single-room accommodation), guesthouses, and monthly rental rooms, representing unstable or temporary housing. ^b)Multidrug-resistant and rifampicin-resistant status among tuberculosis patients. ^c)Alcohol-related problems identified during the facility stay..

4. TB Treatment and Self-Reliance Status

Among the 458 patients at first admission, 30 patients who were transferred to other institutions were excluded. Thus, 428 discharged patients were analyzed. The types of discharge were cure (367 patients, 85.7%) and self-discharge (interruption) (61 patients, 14.3%). TB treatment success was recorded in 406 patients (94.9%), including “cure” and “treatment completed,” and treatment failure was observed in 22 patients (5.1%). Treatment failure included cases of treatment interruption and cases with unknown whereabouts. Among patients who were voluntarily discharged, those who subsequently completed treatment through continued case management after discharge were classified as treatment successes. In terms of housing status immediately after discharge, 317 individuals (74.0%) resided in individual housing (e.g., substandard single-room accommodations, dormitory-style units, monthly rental rooms, or inns), 68 (15.9%) entered other facilities or were hospitalized, and 26 (6.1%) fell into other categories (e.g., homelessness, dormitories, or return to family homes). Although a substantial proportion of those in individual housing remained in non-standard housing (e.g., substandard single-room accommodations and dormitory-style units), compared with the 262 individuals (57.2%) who had experienced unsheltered homelessness prior to TB treatment, many were found to have moved out of homelessness and secured more stable housing. Regarding livelihood status after discharge, 145 individuals (33.9%) were engaged in employment, 222 (51.9%) were recipients of the National Basic Livelihood Security System, and 42 (9.8%) were neither receiving benefits nor employed. During the period of facility admission, vocational training and employment activities were provided for patients capable of working, and after discharge, participation in both private-sector and public-sector employment (including employment programs for people experiencing homelessness) was supported (Table 2). These findings demonstrate the facility’s effectiveness in promoting stable living conditions and self-reliance alongside TB treatment.

Table 2 Tuberculosis treatment outcomes and postdischarge self-reliance at Misokkumteo (2011–2024)

Category		Total		Housing status before TB treatment
				Facility		Homeless		Non-standard housing
Total patients		428	(100.0)	102	(23.8)	247	(57.7)	79	(18.5)
Facility discharge types	Treatment completion discharge	367	(85.7)	92	(21.5)	211	(49.3)	64	(15.0)
	Premature dischargea)	61	(14.3)	10	(2.3)	36	(8.4)	15	(3.5)
Treatment outcome	Successb)	406	(94.9)	100	(23.4)	229	(53.5)	77	(18.0)
	Failure	22	(5.1)	2	(0.5)	18	(4.2)	2	(0.5)
Housing after discharge	Independent housingc)	317	(74.0)	77	(18.0)	182	(42.5)	58	(13.6)
	Hospital or facility	68	(15.9)	22	(5.1)	36	(8.4)	10	(2.3)
	Others	26	(6.1)	3	(0.7)	15	(3.5)	8	(1.9)
	Unknown	17	(4.0)	0	(0.0)	14	(3.3)	3	(0.7)
Postdischarge livelihood	Employmentd)	145	(33.9)	37	(8.6)	84	(19.6)	24	(5.6)
	National basic livelihood security	222	(51.9)	50	(11.7)	127	(29.7)	45	(10.5)
	No income	42	(9.8)	14	(3.3)	23	(5.4)	5	(1.2)
	Unknown	19	(4.4)	1	(0.2)	13	(3.0)	5	(1.2)

Values are presented as number (%). Of 484 resident patients admitted from 2011 to 2024, 26 readmissions and 30 transfers were excluded; analysis was based on the last admission. TB=tuberculosis. ^a)Resident patients discharged before completing tuberculosis treatment. ^b)Includes patients who were cured or completed tuberculosis treatment. ^c)Individual housing, including jjokbang, goshiwon, guesthouses, and other personal residences. ^d)Including public and private employment, as well as work in unstable employment conditions and vulnerable working environments..

Support for vulnerable TB patients, including people experiencing homelessness, existed even before the establishment of TB management facilities. At that time, programs to monitor medication adherence, based on the provision of temporary housing such as substandard single-room accommodations and meal support, were partially implemented in the public and private sectors. However, although this approach contributed to monitoring medication adherence to some extent, it exhibited limitations in ensuring continuity of treatment and stability of living conditions. Subsequently, with the establishment of TB management facilities for people experiencing homelessness, patients were able to continue treatment within a stable housing environment, and integrated health–welfare management, linking health management and social services, became possible. These changes led to improved treatment outcomes. According to a study conducted at Seoul Metropolitan Seobuk Hospital, the treatment success rate among patients experiencing homelessness who were linked to a TB management facility after completion of hospital treatment was 95%, approximately 25%p higher than the 70% success rate among those who returned directly to the community [9]. This finding demonstrates that community-based management interventions through a stepwise referral system contribute to improving TB treatment success rates. The operational approach of Misokkumteo is also consistent with the policy direction of “patient-centered care” recommended by the WHO. The WHO guidelines strongly recommend material support, including the provision of housing, as an intervention to improve patients’ treatment adherence. Misokkumteo can be regarded as a model that effectively implements these international recommendations by providing stable housing and living support in an integrated manner to TB patients without housing [10].

Recently, policies supporting people experiencing homelessness have emphasized the “housing first” approach, which prioritizes the provision of individual housing over facility-based protection while supporting treatment and care. However, for TB patients experiencing homelessness, maintaining adherence during long-term anti-TB treatment is challenging, and management of adverse drug reactions as well as complex comorbidities is required. Therefore, admission to a TB management facility for a certain period, along with the provision of intensive health management and living support until treatment completion, remains necessary. However, TB management facilities have structural limitations, including limited personal living space, reluctance toward communal living, avoidance of admission due to the suspension of National Basic Livelihood Security System benefits, and cases wherein admission is not possible due to alcohol use or mental illness. In particular, patients who place importance on independent living or have difficulty adapting to communal settings are less likely to choose admission; therefore, selection bias should be considered when interpreting the results of the analysis of admitted patients in this study. In this regard, previous domestic studies have reported that, in addition to facility-based admission, community-based housing support can significantly improve treatment outcomes among TB patients experiencing homelessness [11]. Accordingly, alongside the operation of residential TB management facilities, various forms of community-based medication support and living support programs that take into account the characteristics of people experiencing homelessness need to be implemented concurrently. In addition, vulnerable patients with TB bear a high burden of comorbidities, and even when TB treatment is provided free of charge, the cost of treating comorbid conditions can impose a substantial financial burden on the patients, potentially leading to decreased treatment adherence. Therefore, institutional support for the cost of treating comorbidities is necessary. In summary, providing integrated treatment and welfare services within a stable housing environment to TB patients experiencing homelessness can aid in recovery from the disease and strengthen the motivation for self-reliance and improvements in quality of life. Therefore, beyond the primary objective of improving TB treatment success rates, TB management facilities should play a role in promoting the successful reintegration of patients into society by establishing a comprehensive foundation for self-reliance, including linkage to social services and self-reliance training.

Ethics Statement: This study was approved by the Institutional Review Board of Korea Disease Control and Prevention Agency (KDCA-2026-01-03-P-01).

Funding Source: None.

Acknowledgments: We express our sincere appreciation to the officials of local governments and healthcare institutions for their dedicated efforts in tuberculosis control, patient care, and support for social reintegration.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: AYL, JHJ. Data curation: AYL, JHJ. Formal analysis: AYL. Investigation: AYL, JHJ. Methodology: AYL, JHJ, SRS, SEL. Resources: AYL. Software: AYL, JHJ. Supervision: SRS, SEL. Validation: AYL, JHJ. Visualization: AYL, JHJ. Writing – original draft: AYL, JHJ. Writing – review & editing: AYL, JHJ, SRS, SEL.