Tuberculosis Among Residents of Shelters for the Homeless -- Ohio, 1990

During 1990, 17 cases of clinically active pulmonary tuberculosis (TB) occurred among residents of homeless shelters in three Ohio cities (Cincinnati, Columbus, and Toledo). This report summarizes the results of investigations of these cases by the Ohio Department of Health. Cincinnati

During March 1990, health officials in Cincinnati were notified of three TB cases among residents of a 200-bed shelter for homeless adults. One of these (index case) occurred in a man with a history of alcohol abuse who died from respiratory failure and at autopsy was found to have cavitary pulmonary TB. From April through November 1990, eight additional cases of pulmonary TB were identified among residents of the shelter (Figure 1). Of the 11 total case-patients, seven were sputum-smear-positive, indicating potential infectiousness, and 10 were culture-positive. Four case-patients were known acquaintances of the index patient (Figure 1).

Mycobacterial isolates from the 10 culture-positive patients and isolates obtained from 10 persons not associated with the outbreak (controls) were sent to CDC for typing by restriction fragment length polymorphism (RFLP) (1). The control isolates were obtained from a convenience sample of 10 persons with apparently unrelated TB cases reported during 1990 from Cincinnati and nearby counties in Ohio and Kentucky. Nine of the 10 outbreak-related isolates, including the isolate from the index patient, and two control isolates had identical RFLP banding patterns. The two control isolates that shared an RFLP banding pattern with outbreak isolates were obtained from patients who, like the index patient, resided in Cincinnati and had a history of alcohol abuse. Columbus

During March 1990, staff from a local hospital emergency room notified the public health department in Columbus of a case of sputum-smear-positive pulmonary TB in a resident (index patient) of a homeless shelter; TB had been diagnosed during January, but the patient had been lost to follow-up for 2 months. During those 2 months, he had resided in a shelter in Toledo, 135 miles north of Columbus. The public health department notified the Columbus shelter director and initiated a voluntary, citywide TB screening and case-finding program for residents and staff of men's shelters and soup kitchens; 95% of these facilities participated.

On average, 768 persons daily occupied the participating men's shelters and soup kitchens in Columbus. During April 24-May 24, 1990, the city health department administered Mantoux tuberculin skin tests (5 tuberculin units (TU) of purified protein derivative (PPD)) to 363 residents and 123 (69%) of 178 staff. Of the 486 skin tests administered, 403 (83%) were read (291 residents and 112 staff). Among 81 skin-tested residents of the shelter in which the index patient resided, 32 (40%) had tuberculin skin test reactions greater than or equal to 10 mm induration, compared with 47 (22%) of 210 skin-tested residents of other Columbus men's shelters and soup kitchens (relative risk=1.8, 95% confidence interval=1.2-2.5). Among the 27 staff members at the shelter in which the index patient resided, seven (26%) had tuberculin skin test reactions greater than or equal to 10 mm induration, compared with nine (11%) of 85 staff members in other men's shelters and soup kitchens (p=0.06, Fisher's exact test, 2-tailed).

Following the screening program in Columbus, vouchers for chest radiographs were issued to 95 persons with tuberculin reactions greater than or equal to 10 mm induration (previous tuberculin status not reported) and 30 persons with previously known tuberculin reactions. Of these 125 persons, 111 (89%) had radiographs and 40 (32%) reported to the TB clinic for evaluation and treatment after the radiograph. Isoniazid (INH) prophylaxis was recommended for 37 of the 40 persons; 28 (76%) of the 37 did not return after their initial clinic visit, eight (22%) completed prophylaxis, and one (3%) stopped treatment because of adverse reactions. One resident who had a tuberculin reaction greater than or equal to 10 mm induration and who refused a chest radiograph had culture-negative pleural TB diagnosed in June 1990.

From May through December 1990, five additional cases of clinically active pulmonary TB were identified among residents of men's shelters and soup kitchens in Columbus. Results of investigations of these cases are pending. Toledo

In Toledo, voluntary screening for TB was initiated at the shelter that had been visited by the index patient from Columbus and was offered to persons who resided in the shelter within 10 weeks of the potential exposure. Of the 80 residents in the shelter, 20 (25%) were considered to be long-term (greater than or equal to 3 months) residents; 18 of these were evaluated. Two of the 18 had histories of tuberculous infection. Mantoux tuberculin skin tests (5 TU PPD) were administered to the remaining 16; of the 15 skin tests that were read, four (27%) patients had reactions greater than or equal to 10 mm induration. Reported by: P VonVille, F Holtzhauer, PhD, T Long, MD, Columbus Health Dept; A Phurrough, D Murphy, Hamilton County Tuberculosis Control Program; BK Mortensen, PhD, G Horst, MD, TJ Halpin, MD, State Epidemiologist, Ohio Dept of Health. Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; Div of Tuberculosis Elimination, National Center for Prevention Svcs; Div of Field Epidemiology, Epidemiology Program Office; CDC.

Editorial Note

Editorial Note: In this report, the large number of TB cases among residents of one 200-bed shelter in Cincinnati and the results of RFLP typing suggest that transmission of TB occurred in the shelter. RFLP is a recently developed laboratory tool for identifying genetic differences among Mycobacterium tuberculosis strains (1). This technique provides highly specific and reproducible identification of isolates and, with further refinements, should aid health departments in conducting epidemiologic investigations. The two control isolates that shared a banding pattern with the outbreak strains may reflect the finite number of regional strains or represent an epidemiologic link to patients affected in the outbreak. Other possible, but less likely, causes for the matching patterns include misidentification or contamination during collection or processing of specimens or isolates.

At least four factors contribute to an increased risk for TB among homeless persons. First, in different locations, the prevalence of clinically active TB has ranged from 2% to 7%, and the prevalence of latent infection has ranged from 12% to 50% (2-5). Second, characteristics of shelter environments (e.g., crowding and insufficient ventilation) facilitate transmission of TB (6). Third, the increased prevalence of some conditions (e.g., human immunodeficiency virus (HIV) infection, poor nutrition, alcoholism, illicit drug use, and psychological stress) among homeless persons may increase their risk for active TB if infected (4,5,7-10). Fourth, because shelter residents are transient, they often do not complete TB therapy, and the likelihood of relapse, drug resistance, and further transmission of TB among shelter residents is increased (3,4,8,10).

In Columbus, the prevalence of TB infection was higher among residents and staff of the shelter where the index patient resided. Despite efforts to screen and treat shelter residents in Columbus, only 22% of persons for whom INH preventive therapy was prescribed were known to have completed the recommended course. Some shelters have reported improved adherence to TB therapy among shelter residents through convenient, on-site medical examinations and treatment; directly observed therapy; and behavioral incentives (e.g., transportation and more comfortable sleeping areas for residents receiving TB treatment) (5-7).

Because of the difficulties in controlling the airborne spread of TB among shelter residents, as well as the increased risk for TB among homeless persons, especially that associated with HIV infection, the following measures are needed to decrease this risk:

1. early identification and effective treatment of active TB cases among shelter residents; 2) hospitalization in an acute-care or long-term-care facility or appropriate housing for such patients with active TB until they are no longer infectious or, ideally, until completion of therapy; 3) directly supervised therapy until completion of treatment for active TB; 4) directly supervised preventive therapy for shelter residents at high risk for TB; 5) awareness of HIV-infection status for appropriate selection and monitoring of TB treatment and preventive therapy (11); 6) appropriate ventilation and other environmental control measures in shelters; 7) routine surveillance of shelter staff for tuberculous infection; and 8) close cooperation between programs and staff operating homeless shelters and the health department for ongoing control of TB among homeless populations.

References

1. Cave MD, Eisenach KD, McDermott PF, et al. Conservation of sequence in the Mycobacterium tuberculosis complex and its utilization in DNA fingerprinting. Mol Cell Probes 1991;5:73-80.

2. Sherman MN, Brickner PW, Schwartz MS, et al. Tuberculosis in single-room occupancy hotel residents: a persistent focus of disease. New York Medical Quarterly 1980;2:39-41.

3. Barry MA, Wall C, Shirley L, et al. Tuberculosis screening in Boston's homeless shelters. Public Health Rep 1986;101:487-94.

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

5. McAdam JM, Brickner PW, Scharer LL, et al. The spectrum of tuberculosis in a New York City men's shelter clinic (1982-1988). Chest 1990;97:798-805.

6. Nolan CM, Elarth AM, Barr HA, et al. An outbreak of tuberculosis in a shelter for homeless men: a description of its evolution and control. Am Rev Respir Dis 1991;143:257-61.

7. Torres RA, Mani S, Altholz J, Brickner PW. Human immunodeficiency virus infection among homeless men in a New York City shelter: association with Mycobacterium tuberculosis infection. Arch Intern Med 1990;150:2030-6.

8. Brudney K, Dobkin J. Resurgent tuberculosis in New York City: human immunodeficiency virus, homelessness, and the decline of tuberculosis control programs. Am Rev Respir Dis 1991;144:745-9.

9. Reichman LB, Felton CP, Edsall JR. Drug dependence, a possible new risk factor for tuberculosis disease. Arch Intern Med 1979;139:337-9.

10. Pablos-Mendez A, Raviglione MC, Battan R, Ramos-Zuniga R. Drug resistant tuberculosis among the homeless in New York City. N Y State J Med 1990;90:351-5.

11. CDC. Tuberculosis and human immunodeficiency virus infection: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR 1989;38:236-8, 243-50.

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