TB Prevention & Control for Homeless Shelters

Homeless shelters have been associated with TB outbreaks in the United States including Iowa. Homeless persons are included in the high-risk classification for developing TB disease by CDC as they suffer disproportionately from a variety of health problems, including TB. There is substantial potential for TB transmission in shelters, especially in the winter when they are likely to be more crowded and ventilation from the outside may be diminished.

Detecting, treating, and preventing TB in this special population benefits not only persons who are homeless, but society at large. The goal of prevention and control of TB among the homeless is difficult and challenging, but it can be achieved.

Shelter staff play an important role in communicable disease detection and prevention. Staff who screen guests for signs/symptoms of TB disease and follow “Cough Alert Policies” help to find active cases of TB and prevent the spread of TB to others. Observe shelter guests for signs of TB and refer individuals who are coughing for 3 weeks or more or who have other signs of TB to the local health department for evaluation.

The TB Control Program recommends Homeless Shelters in Iowa consider implementing the following screening and testing recommendations. These recommendations are adapted from Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 MMWR December 30, 2005 / 54(RR17);1-141:

Annually, each shelter should conduct a TB risk assessment to evaluate the risk for transmission of TB. The risk assessment should include the number of person with infectious TB encountered in the shelter.

Shelter Risk Classification

The shelter risk classification is used to determine frequency of TB screening and testing. The shelter risk classification may change due to an increase or decrease in the number of TB cases during the preceding year. The shelter risk classification may also change due to a change in adherence or lack of adherence to recommended TB Control measures. The shelter should determine if they are either Low or Medium risk classification. The TB Control Program can assist shelters in determining their risk classification. Contact the Program Manager at 515-281-7504 to discuss.

Low Risk

Shelters are classified as low risk if one or less infectious TB patients were encountered in the shelter during the preceding year and all of the following TB Control measures apply:

• Shelter guest are screened for signs/symptoms of TB disease upon admission
• Cough alert policy is in effect
• The local public health agency (LPHA) has confirmed exposure occurred in the shelter during the preceding year - the LPHA conducted a contact investigation

Medium Risk

Shelters are classified as medium risk if two or more infectious TB patients were encountered in the shelter in the preceding year or either one of the following measures are not in effect:

• Shelter guest are not screened for signs/symptoms of TB disease upon admission
• Cough alert policy is not in effect

Staff

Baseline Screening/Testing for Staff

All Shelter staff members should receive baseline TB screening upon hire. Baseline TB screening consists of two components: (1) assessing for current symptoms of active TB disease and (2) using two-step TST or a single IGRA to test for infection with M. tuberculosis.

Serial TB Screening Procedures for Staff

• Shelters Classified as Low Risk: After baseline testing for infection with M. tuberculosis, additional TB screening of staff is not necessary unless an exposure to M. tuberculosis occurs.

• Shelters Classified as Medium Risk: After baseline testing for infection with M. tuberculosis, staff should receive TB screening annually (i.e., symptom screen for all staff members and testing for infection with M. tuberculosis for staff members with baseline negative test results). Annual screening recommendation ceases if the shelter attains a low risk classification.

Guests

• Shelter guest should be screened for signs/symptoms of TB disease upon admission. Use of TB Signs/Symptoms Screening Form or similar is recommended.
• Classic signs/symptoms of TB disease include a chronic cough (> 3 weeks), chest pain, night sweats/fever and unexplained weight loss.
• Symptomatic shelter guest should be referred for medical evaluation. Contact your local public health agency for assistance.
• Routine tuberculin skin testing (TST) or interferon gamma release assay (IGRA) (blood) testing of homeless persons is not necessary.
• Routine testing of homeless persons should be carefully considered and weighed with the individual’s commitment to completion of treatment. Therapy consists of regular clinical monitoring and taking antibiotics daily for six to nine months.
• Asymptomatic shelter guests who want TB testing should be referred to the local health department, free clinic or community health center.

The Curry International Tuberculosis Center (a partner of the CDC) has developed this video and viewer’s guide to help shelters create a healthy and safe environment. The goal of this program is to help address concerns and reduce fears that shelters may have about working with clients, or staff, who may have TB. This fundamental TB infection control information can help you and your staff prevent the spread of TB.

Please Click here to be directed to the Curry Center web page and the video and viewer's guide.