Perspectives in Disease Prevention and Health Promotion Tuberculosis Control Among Homeless Populations

Homeless persons suffer disproportionately from a variety of health problems, including tuberculosis. Although there is no generally agreed upon definition of homelessness, the homeless can be defined, on a general level, as those who do not have customary and regular access to a conventional dwelling or residence (1). Since 1984, three outbreaks of tuberculosis in shelters for the homeless have been reported to CDC (unpublished data) (2), and recent investigations have shown a prevalence of 1.6%-6.8% for clinically active tuberculosis among selected homeless populations (3). These prevalence rates are 150 to 300 times higher than the nationwide prevalence rate. The prevalence of asymptomatic tuberculosis infection among the homeless has been reported to be as high as 22%-50% (3-5), thus indicating that a large reservoir of infection may exist from which future cases will emerge unless large-scale preventive measures are undertaken.

In January 1987, CDC convened a group of individual consultants * to assist in developing strategies for dealing with this problem. After reviewing these strategies, CDC developed the following recommendations. State and local health departments are urged to consider implementing these recommendations where applicable.

1. Assessment of the Magnitude of the Problem

Each community should assess the nature and magnitude of the problem by determining the proportion of tuberculosis patients who are homeless. Health departments should obtain as much information as possible about where each tuberculosis patient lives. Homeless patients sometimes give the mailing address of a friend or relative; therefore, a mailing address does not necessarily indicate whether or not a patient is homeless. Health departments also should maintain, and regularly update, listings of single-room-occupancy hotels and shelters for the homeless in their areas so that patients' addresses can be compared with locations on the list.

B. Case Finding

Passive Approaches. Shelter employees should be educated about tuber- culosis, particularly regarding its mode of spread and the potential hazards of transmission in shelters. Any person with a persistent cough should be promptly evaluated at the shelter or transported to a health care facility. If tuberculosis is suspected, more definitive diagnostic tests should be done as soon as possible.

Active Approaches. Where homeless populations are housed in relatively stable groups and where a tuberculosis problem has been identified, periodic mass tuberculin skin testing and/or chest radiography should be considered. Local health departments should work with persons who are caring for the homeless to develop and implement appropriate policies for surveillance of tuberculosis in these communities. Health departments may need to establish special record systems to keep track of the dates and results of screening activities, medical recommendations, and indications of compliance with those recommendations.

C. Case Reporting

The local health department should be notified by telephone as soon as a case of tuberculosis is suspected or diagnosed. Delay or failure to notify the health department may result in a patient's being lost to follow-up, with little or no chance for treatment.

D. Case Holding

Homeless patients with newly diagnosed tuberculosis should be appro- priately housed to allow full supervision of initial therapy and to preclude transmission of infection to their contacts (e.g., other shelter clients and shelter employees). This usually means a period of hospitalization in an isolation room of an acute-care facility until other arrangements can be made. Some communities have developed cost-effective alternatives to hospi- talization, such as half-way houses and special shelter areas (Pima County Health Department, unpublished data). If, despite the best efforts of health care providers, an infectious patient refuses treatment, temporary invol- untary isolation should be instituted in accordance with state and local public health laws and regulations until the patient has been rendered noninfectious by treatment. This option should be used only in rare instances and after due process.

Rarely, hospitalization or institutionalization throughout the course of therapy may be necessary, but most patients can be effectively managed as outpatients. A staff member of the health department should serve as a liaison between the attending medical team and the patient, interpreting the patient's perspective to the medical team and vice versa and assessing the likelihood of compliance (3,6). The initial visit with the patient should include the development of a long-term treatment plan that the patient understands and can reasonably be expected to follow. Rapport with the patient must be established. A physical description of the patient, and possibly a photograph (with the patient's permission), should be included in the chart.

Clinic schedules should include hours that accommodate patient schedules. Enabling incentives -- that is, incentives that allow the patient to overcome barriers to obtaining treatment -- should be considered. These might include items such as free meals, special lodging, bus tokens, priority in food lines, assistance in filing for benefits, taxi vouchers, and personally needed articles. In many communities, local merchants and affiliates of the American Lung Association have cooperated to provide incentives to be used by the health department (7).

E. Treatment

With rare exceptions, a patient's medications should be taken while he or she is being observed by a responsible person, thus preventing treatment failure, the emergence of resistant organisms, and continued transmission. In many instances, treatment can be given and observed by designated persons at the shelter or at some other location convenient for the patient. Treatment should include intensive multidrug, bactericidal regimens for 6 months (8). Although currently recommended regimens specify that medications should be administered daily for the first 1-2 months of treatment, the supervision of daily therapy for homeless outpatients may not be feasible. Therefore, two alternatives should be considered: 1) provide directly observed therapy 5 days per week (asking the patient to take drugs on his/her own the other 2 days) or 2) provide directly observed therapy 3 days per week using higher drug dosages: isoniazid 15 mg/kg, rifampin 600 mg (or 450 mg for persons weighing 50 kg), ethambutol 30 mg/kg, and pyrazinamide 2.5 g (or 2 g for those weighing 50 kg) (9). Mycobacterium tuberculosis in sputum should be evaluated at 2- to 4-week intervals until sputum smears become negative. Patients with initially positive sputum smears or cultures can return to the shelter when bacteriologic and clinical evidence shows they have responded to therapy and when the health care provider is satisfied that the outpatient treatment plan is being followed.

F. Prevention

Case finding and treatment should be implemented as early as possible, since they are the most important measures for preventing the further spread of infection and disease. Efforts should be made to locate contacts of patients so they also may be evaluated and treated, if necessary.

Because crowding and poor ventilation are conducive to tuberculosis transmission, steps should be taken to improve defective housing conditions. Although the use of ultraviolet (UV) lights is controversial because no epidemiologic evaluations of its effectiveness have been conducted, the consultants felt that consideration should be given to installing UV lights in crowded shelters where transmission of tuberculosis infection is a problem. CDC currently recommends UV lights to reduce transmission of tuberculosis in hospitals (10). If UV lights are used, they must be installed and maintained according to accepted guidelines to remain effective and to avoid injury to the skin or eyes of shelter clients and staff (11). An updated reference on the rationale and methodology for using UV lights will be published soon (12).

Except for special surveys, tuberculin skin testing of homeless populations should be undertaken only if there is a commitment to complete the diagnostic evaluation and prescribed therapy. Priorities for preventive therapy should follow established guidelines (8). A poorly implemented preventive therapy program may lead to a worsening of the tuberculosis problem, e.g., if isoniazid preventive therapy is not strictly adhered to, isoniazid-resistant disease may occur. Incentives may improve patients' compliance with preventive treatment. For high-risk individuals who are likely to be noncompliant, directly observed isoniazid preventive therapy given twice a week in a dose of 15 mg/kg should be considered (8,13).

Staff members and persons who work regularly as volunteers in shelters for the homeless should receive a tuberculin skin test, with appropriate follow-up, upon employment and every 6-12 months thereafter (2).

Reported by: Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

References

1. Rossi PH, Wright JD, Fisher GA, Willis G. The urban homeless: estimating composition and size. Science 1987;235:1336-41

2. CDC. Drug-resistant tuberculosis among the homeless -- Boston. MMWR 1985;34:429-31.

3. Slutkin G. Management of tuberculosis in urban homeless indigents. Public Health Rep 1986;101:481-5.

4. Sherman MN, Brickner PW, Schwartz MS, et al. Tuberculosis in single-room- occupancy hotel residents: a persisting focus of disease. NY Med Quart 1980;Z:39-41.

5. Barry MA, Wall C, Shirley L, et al. Tuberculosis screening in Boston's homeless shelters. Public Health Rep 1986;101:487-98.

6. McAdam J, Brickner PW, Glicksman R, Edwards D, Fallon B, Yanowitch P. Tuberculosis in the sro/homeless population. In: Brickner PW, Scharer LK, Conanan B, Elvy A, Savarese M, eds. Health care of homeless people. New York: Springer, 1985:155-75.

7. Snider DE, Anders HM, Pozsik CJ. Incentives to take up health services. Lancet 1986;2:812.

8. American Thoracic Society. CDC. Treatment of tuberculosis and tuber- culosis infection in adults and children. Am Rev Respir Dis 1986;134: 355-63.

9. Hong Kong Chest Service, British Medical Research Council. Controlled trial of 4 three-times-weekly regimens and a daily regimen all given for 6 months for pulmonary tuberculosis -- second report: the results up to 24 months. Tubercle 1982;63:89-98.

10. CDC. Guidelines for prevention of TB transmission in hospitals. Atlanta, Georgia: US Department of Health and Human Services. Public Health Service, 1982; DHHS publication no. (CDC)82-8371.

11. Riley RL. Principles of UV air disinfection. Washington, DC: US Depart- ment of Health, Education, and Welfare, Public Health Service, 1972; DHEW publication no. 00-2215.

12. Riley RL. Ultraviolet air disinfection for control of respiratory contagion. In: Kundsin RB, ed. Building design and indoor microbial pollution. New York: Oxford University Press (in press).

13. Committee on Chemotherapy of Tuberculosis, American College of Chest Physicians. Standard therapy for tuberculosis 1985. Chest 1985;87(suppl): 117S-124S.

V Taylor, Pima County Health Dept, Tucson, Arizona; WW Stead, MD, Dept of Health, Little Rock, Arkansas; G Schecter, MD, San Francisco Dept of Public Health, San Francisco, California; M Skinner, MD, My Sister's Place, Baltimore, Maryland; MA Barry, MD, Boston Dept of Health and Hospitals, Boston, Massachusetts; EA Nardell, MD, Dept of Public Health, Boston, Massachusetts; PW Brickner, MD, St Vincent's Hospital and Medical Center, New York, New York; M Hansen, American Thoracic Society, New York, New York; S Schultz, MD, A Vennema, MD, New York City Dept of Health, New York, New York.

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