A comprehensive public health approach that included mandatory screening helped stop an outbreak of drug-resistant tuberculosis in Atlanta homeless shelters, according to research published in Emerging Infectious Diseases.
“Despite an ongoing downward trend of TB in the United States, outbreaks among persons with a history of homelessness continue to occur regularly,” David P. Holland, MD, MHS, chief clinical officer for communicable diseases in the Fulton County health departments and assistant professor of medicine and infectious diseases at Emory University, and colleagues wrote.
According to Holland and colleagues, in 2008, seven genetically linked cases of active TB were reported in Fulton County, which encompasses Atlanta. All cases exhibited low-level isoniazid resistance and were linked to one Atlanta homeless shelter.
Additional cases with the same genotype were reported at other locations. By the end of 2017, there were 110 outbreak cases identified in Fulton County, 17 cases in other Georgia counties and 47 cases in 15 other states, Holland and colleagues reported. Thirty-seven percent of the patients with TB in Fulton County were coinfected with HIV.
In 2014, the Fulton County Board of Health and Mercy Care, a local federally qualified health center, created a TB task force to target the entire homeless population in the Metro Atlanta area. Until that time, Holland and colleagues explained, none of the county’s six homeless shelters had adopted effective TB control guidelines, and staff awareness of the disease was minimal.
The interventions implemented by the task force included mandatory TB screening of shelter residents within 7 days of entry and every 6 months afterward. From 2015 to 2017, 14,496 people were screened for latent TB, compared with 2,451 from 2008 to 2014, according to Holland and colleagues. In those 2 years, three cases of active TB were identified, 430 people were diagnosed with untreated latent TB and 391 started treatment, they reported. Of those patients, 53% completed a full treatment course.
According to Holland and colleagues, only two cases of outbreak-associated TB were reported in 2017.
“As previously reported, the mobility of persons experiencing homelessness rendered standard contact tracing activities in this investigation difficult. Greater success was achieved with a systematic approach targeting all shelter resident for testing rather than just individual facilities in which cases had been identified,” they wrote.
Other interventions included placing a TB liaison at each shelter, isolating or separating residents with a cough, and maintaining a bed log to include every resident’s name.
According to Holland and colleagues, people diagnosed with latent TB infection were assumed to be infected with an isoniazid-resistant strain and offered daily treatment with rifampin for 4 months. Patients were offered weekly $5 grocery store coupons for completing all doses.
Before 2015, approximately 30% of patients tested with the tuberculin skin test (TST) did not return for reading results. Starting in 2015, the task force replaced the TST with a single-step blood test as the primary test. – by Bruce Thiel
Disclosures: The authors report no relevant financial disclosures.