Homeless shelter context and tuberculosis illness experiences during a large outbreak in Atlanta, Georgia

Abstract

A mong US-born tuberculosis (TB) cases, homelessness represents a major risk factor. 1 Compared with housed individuals, persons experiencing homelessness (PEH) have a 10-fold increased risk of TB disease, 2 are more often hospitalized, and experience worse disease outcomes. 3 Furthermore, TB outbreaks among PEH are associated with increased TB transmission, resulting in larger outbreak clusters. 4 Despite this, an important perspective is underrepresented in both guidelines and research in the field: that of the affected PEH themselves. Understanding this internal, or 'emic' perspective of illness can allow for more defensible public health decision making, and is essential to the implementation of appropriate control measures and effective risk communication. 5,6 A large outbreak of drug-resistant TB involving overnight homeless shelters began in Atlanta, Georgia, USA, in 2008, resulting in over 100 cases of active TB disease and involving nine additional states. 7 The resultant multifaceted response involved public health collaboration with shelters to develop and implement prevention and control measures. 8 It remains unclear, however, how these interventions were experienced by PEH with TB. Utilizing the unique opportunity to interview PEH with active TB disease in the setting of an ongoing outbreak and evolving public health response, this study aimed to explore how individuals experience illness and shelter-based interventions. The goals of this research were to inform ongoing TB control efforts and contribute hypothesis-generating data for further research on TB elimination in this setting. METHODS ContextThis study was conducted in Atlanta, GA, during an ongoing outbreak of drug-resistant TB among PEH that began in 2008. 7 Atlanta has a population of about 5.7 million, with a homeless population estimated at 4317 in 2015. 9,10 The metropolitan area is primarily located in Fulton County, where there was an average of 55 cases of TB per year from 2008 to 2015, and 36% of TB cases occurred among PEH. 7 The county's public health response to the outbreak included shelter-based prevention and control interventions implemented across all homeless facilities, including TB screening requirements for admission to shelters (TB card program), active TB case finding measures (e.g., intake symptom screening, cough logs), increased availability of voluntary latent tuberculous infection (LTBI) screening, TB education activities (e.g., shelter staff/ resident teaching, educational posters), and environmental control measures. 8,11 DesignIn-depth interviews were conducted with a purposive sample of 10 PEH with active TB disease. Study eligibility criteria were age 18 years, clinical diagnosis of active TB disease, homelessness during the year preceding TB diagnosis, and prior contact with Atlanta city shelters. Homelessness was defined as living in an emergency shelter, a transitional housing program, a place not meant for human habitation, or on the streets. The purpose of these criteria was to ensure inclusion of par...

A Cluster-based Method to Quantify Individual Heterogeneity in Tuberculosis Transmission

“…While reactivation of LTBI is the dominant driver of TB incidence for most low-incidence settings, there remains compelling potential for extensive outbreaks of recent transmission that can fuel larger epidemics and lead to secondary outbreaks elsewhere. [7][8][9][10][11][12] Hence, in addition to LTBI interventions, preventing transmission remains a key pillar in global TB control programs.…”

Impact of Targeted Local Interventions on Tuberculosis Awareness and Screening Among Persons Experiencing Homelessness During a Large Tuberculosis Outbreak in Atlanta, Georgia, 2015-2016

“…3,23 Educational efforts to inform PEH, shelter staff members, and shelter volunteers of infection control practices should continue to reduce the incidence of TB among PEH. 7,10,27 Implementing administrative controls in TB control efforts can lead to higher proportions of TB testing and higher TB awareness among PEH, which can help prevent and reduce the burden of TB outbreaks in this population. The results of this evaluation support the widespread implementation of administrative controls in TB control programs as a strategic way to reduce new and resurgent TB outbreaks among PEH in urban areas.…”

“…By summer 2015, the number of outbreak-associated TB cases among PEH was declining, possibly signifying that active TB case finding and educational outreach efforts were effective in reducing the burden of the outbreak. 21,23,26,27 Typically, program success can be assessed through a decrease in the number of new disease cases after an intervention; however, other factors could have an effect on disease transmission. For example, the lower number of persons newly diagnosed with TB could coincide with a mild winter, generally leading to a reduction in overcrowding in shelters and reduced potential for disease transmission.…”