TB & the Homeless

The incidence of tuberculosis (TB) is increasing rapidly among homeless people in large cities

New York, Los Angeles, Miami, San Francisco, and Washington, D.C. The health crisis primarily impacts people lacking proper adequate health care and hygienic living environment, those living in low income communities with a high prevalence of HJV infection and homelessness, and people working with those populations. Homeless people have a rate of infection 15-20 times greater than the general public.

How is TB Spread?

The tubercle bacilli is spread as a result of coughing or sneezing by a person with active TB. It usually takes prolonged contact with someone with active TB, such as occurs in the home, work place, hospital, shelters, or jails, for a person to contract TB. Even then, infection leads to full-blown illness in only 5-10 percent of cases. Symptoms of TB include cough, fever, weight loss, and night sweats.

There is a difference between tuberculous infection and active TB disease. To determine the difference, a skin test is done. A positive skin test indicates that a person has been exposed to TB but does not necessarily mean that the person has active TB. A chest X-ray and sputum smear are performed to test for the bacilli, lithe two tests are positive, the patient is considered "active" for TB, and should be admitted to a hospital for treatment.

People in dose contact with TB patients should have a skin test done every six months. Frequent tests are also advised for at-risk individuals. However, since the skin test may be unreliable for HIV+ individuals, sputum tests are advised.

One reason for the rise in TB rates is the high correlation between H1V and TB infection. People infected with H1V, because of their depressed immune systems, have a 10 percent or greater likelihood of developing TB.

TB Prevention

A voluntary testing program for residents and staff is the first step in TB prevention. People who have a positive skin test but negative subsequent tests, should be encouraged to take their medication to avoid becoming active. Those who test positive for active TB should be admitted to a hospital.

Experts also advise environmental precautions, such as increasing outside air flow to prevent long-term exposure to germs. In addition, both sunlight and ultraviolet light kill the bacillus and should be maximized.

Treatment

Generally, infected persons are treated with one drug, isoniazid, for 6 to 12 months. If successfully completed, this course of treatment is 70 to 90 percent effective in preventing the development of active TB. For those with active TB, treatment requires the use of two or more drugs for 6 to 24 months. Any lapse in treatment of more than one week may result in reactivation of the disease.

In these cases, drug treatment must begin all over again. Respiratory isolation of contagious persons is considered important in containing the disease until the individual is no longer considered contagious. In the past, a patient was considered no longer contagious after 10 to 14 days of treatment. Today, because of the current drug-resistant strains and immune deficiency, health practitioners are more cautious in declaring that a person is no longer contagious.

While taking medication for six months to two years may sound like an easy method to avoid a fatal disease, for people without a stable home or doctor it is a precarious prescription. Patients can be encouraged to take their medicine through accessible clinics, outreach workers, and incentive programs. (free hot lunches, food coupons, store vouchers, or cash). In Los Angeles, the Homeless TB patient Incentive Program gives vouchers for meals and rooms at a nearby SRO hotel to clients who take their pills.

In cities where drop-in centers or clinics encourage people to come in and take their daily medication, a patient who misses a day can be sought out by a clinic worker. Known as DOT (directly observed therapy), this therapy is currently practiced at methadone maintenance centers, mental health outpatient treatment centers, and shelters. It is a form of therapy that is gaining popularity as a TB treatment strategy. Clearly, prevention is most effective and cost efficient but must often compete with acute treatment programs for scarce resources. Many jurisdictions are focusing their efforts on prompt diagnosis and treatment and expanded health clinics. Some cities are even considering reviving the sanitarium in order to provide a place where compassionate and effective care allows people to recover and live during the long treatment time. Cuts in public health funding have left jurisdiction less able to deal with the current rise TB during the height of the TB in the 5O's.

—used by permission from ALLIANCE publication, National to End Homelessness . Originally appeared in Rescue Magazine, Fall 199220