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Stacking the Deck Against Tuberculosis

 Denver VOICE (USA) 20 May 2019

Denver’s TB card program for homeless shelters gives public health officials an edge in stemming the spread of Tuberculosis. According to the Denver Rescue Mission men’s shelter the program is beneficial because, even if there are few cases of TB in the homeless shelters, catching one case can prevent it from getting bigger or spreading to shelter staff. “The risk of not managing it is too high: if we become lax in any way, then there’s a risk of it exploding.”  - Tim Covi

Denver's TB card program for homeless shelters gives public health officials an edge in stemming the spread of Tuberculosis.


It's 1990. A homeless man packs his belongings in New Orleans and heads northwest. Fourteen hundred miles of a patchwork of highways lay ahead before he'll reach Denver, and the whole way he carries with him something he thought he was leaving behind.


A dormant infection he had been treating for two to three months hides inside his lungs. When he reaches Denver he moves into a homeless shelter, and as time passes, he starts to feel sick again. He relapses and develops a cough. Before going to the hospital or seeing a doctor, his tuberculosis disease (TB) will spread to several others inside the shelter. Over the next six years, 18 more people with active cases of TB in Denver will be found and traced back to this one source-11 homeless people, two hospital acquired cases, and five others in the general population.


Almost two decades later-in January 2007-a comparable chain of events occurs, but with a critical difference that spared many people the potential fate of getting TB. This time, a homeless man arriving in Denver checks into a shelter, and before he spends the night, is asked by homeless shelter staff for his TB card-a small piece of white construction paper that indicates a positive or negative tuberculosis test result. Before long, he tells them he was on treatment for TB, but was feeling better and stopped taking the medications just before he came to Denver. An appointment is immediately set for him to see a nurse from Denver Health's Tuberculosis Clinic, and the clinic quickly gets him back on medication before he can become contagious again. Though there is a 50 to 60 percent chance of relapse in cases where someone stops medication after only a couple months of treatment, his case was spotted early enough that it didn't spread to anyone else inside or outside the shelter.


These two cases, consisting of similar events and circumstances, but separated by a decade of education, interest and medical outreach, resolve with completely different outcomes. According to public health professionals and homeless shelter staff in Denver, a screening program put in place requiring shelter residents to be tested for TB before being able to stay at the shelter more than a few nights, has played an important role in identifying active TB cases before they become large outbreaks.


The impact of the program now has public health officials in Pueblo, considering TB cards for their shelters as well, as they respond to three cases of active TB in their homeless population since October 2007.


Tuberculosis (mycobacterium tuberculosis) is a highly contagious, curable disease typically spread through coughing or sneezing. It can manifest in several parts of the body, but most commonly the bacteria grow in the lungs, causing the productive cough that allows it to be spread. TB can either be latent, in which case the bacteria live in the body without causing symptoms, or active, in which case a person has physical symptoms of the disease and is Contagious to others. TB is most easily spread in congregate settings-one of the reasons targeted screening programs have been started with homeless shelters.


Denver's TB card screening program for homeless shelters started voluntarily in 1993, with only one day shelter and a clinic for the homeless participating. The program was organized by Denver Public Health at a time when, according to Dr. Randall Reves, Medical Director for the Denver Metro Tuberculosis Program, "annual TB rates in Denver's homeless population were as high as what you'd see in Africa or India-over 100 cases per 100,000 population." Reves added, "A delay in diagnosis in that setting is a real hazard."


At the outset, most shelters were hesitant to get on board with a program that would put stipulations on who could sleep in their facility. "There was a lot of resistance, because it's not a law, it's a recommendation to protect people. So we basically had to prove to shelters by cases that [the program] was effective," said Darla Blackburn, outreach nurse for Denver Health's TB clinic.


Kathleen Collins, Clinic Supervisor at the Denver Rescue Mission, an organization with several service programs including free clinical services and a large men's shelter, said when the TB card program started there was concern about turning people away.


"If someone [didn't] have a TB card, and it's freezing outside, we didn't want to turn them away," Collins said, "But we worked it out to be more flexible-so we could let people in for a few days before getting the card."


During the spate of incidences that spanned the early 1990s and resulted in 18 cases of TB in Denver, many shelters that were initially skeptical returned to the idea as a potential safeguard. Today, almost all the shelters in Denver are part of the program.


Shelters that participate in the TB screenings require residents to present their TB card before staying the night. At most of these shelters, a person can stay for up to three to four nights while getting tested and acquiring the card. An outreach program has been established in which an outreach nurse will go to the site and provide skin tests, physical exams and education about the disease.


If someone tests positive, the health department will determine their level of infectivity and decide whether they can safely stay in the shelter, or if they need to move to a hotel or hospital room for treatment.


"If they come back with a positive skin test, and they don't have any symptoms, then we tell them to go to the clinic as a walk in, usually within the week," Blackburn said. She said to her knowledge there hasn't been a case where a person went without a place to sleep because of the program.


Risk factors for contracting TB are associated with length of exposure and proximity to the person with active TB. It isn't likely to contract the disease, for instance, outdoors or in line at a grocery store. Dr. Reves, says the long-term infectiousness of TB is what makes it so dangerous.


"TB on a minute to minute basis is not that infectious," Reves said. "The way TB makes up for that is that it can be infectious for years. The cumulative risk is the issue."


Additionally, Blackburn says in order to have a serious risk of infection you need to be breathing the same air as an infected person for more than three to four hours.


The homeless community is among the most at risk for TB infection due to living conditions and health problems. Homeless shelters can become the nucleus of TB transmission because of breathing common air in tight quarters over long periods of time.


Walking into the Denver Rescue Mission's dormitory, you get a sense of how easily an airborne bacteria like TB could spread in this setting. The Mission is one of Denver's larger shelters, located a few blocks northeast of downtown on the corner of Lawrence and Park Ave. Inside the second floor dormitory, two hundred bunk beds are stacked in neat rows head-to-toe and only a couple feet apart side-to-side. On any given night, all the beds are full. On overflow nights, when it's extremely cold outside and there's concern about exposure, tired men crowd into the chapels and hallways on the first floor of the building. A little over 300 people might be sleeping at the Rescue Mission on such a night, neatly arranged in the dormitory, head to toe on mats pushed up against the corridor walls, in whatever space is available. An insidious cough has the potential to reach several people near a sick person in that atmosphere.


But by testing each person within the first two to three days of staying at the shelter, Blackburn says they are able to detect and address TB cases before they have the potential to spread. "We're noticing we're catching cases early… through the screening program."


Larry Griffin, director of the Denver Rescue Mission men's shelter, says he thinks the program is beneficial because, even if there are few cases of TB in the shelters, catching one case can prevent it from getting bigger or spreading to shelter staff.


"I think the risk of not managing it is too high," said Griffin. "Because if we become lax in any way, then there's a risk of it exploding."


While Denver Public Health and shelter workers have pointed to the strengths of the program, outside on the street a few blocks away from the Rescue Mission, a homeless man stands at the entrance of the Stout Street Clinic after an appointment and tells a different story. Gerald Smith, who has used Denver shelters on and off over the past six years, questioned how useful the TB screenings are, pointing to holes in the system.


Looking down the block, he gestures toward the Rescue Mission, saying he had to get a card when he stayed there. "You only have to get a card once a year." Smith says. "If you get sick, you could walk right back into the shelter with [TB]. So it just shows how backward parts of the system are," he concluded, adding that a TB test isn't high on his priority list when it's cold out and he's looking for a place to sleep.


"You could get sick in that year," says Blackburn. "But whether we need to test people more than once a year-I don't know that that's being done anywhere in the United States. If we were getting more cases, and more infectious cases, we would bump it up, but we're just not seeing evidence that there's transmission happening out there."


Blackburn also said it's important to not rely exclusively on the skin test. "The main thing is to keep the education out there-what symptoms to look for. And to educate other agencies that work with the homeless." Staff at the Denver Rescue Mission, for instance, are told to alert TB outreach workers and the shelter director if anyone staying there has TB like symptoms.


Denver's TB screening program for the homeless has drawn the attention of other Public Health departments in Colorado. Most recently, Pueblo Public Health has said they are interested in creating a similar system.


In the last half of 2007 and beginning of 2008, 5 cases of active TB were found in Pueblo, 3 of which were in Pueblo's homeless community. Since 2002, Pueblo has had between 2 and 3 cases per year on average.


Jody Carrillo, Director of the Disease Prevention and Emergency Preparedness Division at Pueblo Public Health said that, although the recent increase in cases is taken seriously, it's not the reason Pueblo Public Health is interested in the TB card program.


"We had been considering the TB card program before these cases came up, but the question was, 'How will we coordinate all the agencies involved to provide the services?'"


Carrillo says the cost of organizing a screening system needs to be weighed against its outcome, pointing out that none of the three homeless men with TB in Pueblo used the shelter.


"The first case was found when he was tested after being put in jail. The others were found when one of the nurses from the health department did further testing of those who had spent time around him. Still," she said, "the program would give the ability to catch other cases before they can spread."


Despite attempts to mitigate the spread of TB in the U.S. by using screening programs that target the most at risk populations, TB is a problem that won't go away with such a narrow focus, according to Dr. Reves. Reves says we're managing the problem in the U.S., not solving it, because of a lack of resources globally. The majority of TB cases in the U.S. start in countries with poorer health systems and weaker controls.


The number one risk factor, both nationally and within Colorado, for having active TB is being born in a high TB prevalence country. In 2006 in Colorado, 67 percent of active TB cases were in people who were born in countries with high levels of tuberculosis. Following this, excess alcohol consumption accounted for 8.9 percent of Colorado cases, and homelessness 5.6 percent.


"Clearly in the long haul the most important thing would be for us to improve TB control around the world," Reves said, "and there's been a big push to do that." Reves added that lack of funding in research for more effective, less time-consuming treatments is also an obstacle in eliminating TB.


Overall Colorado is a low incidence state for tuberculosis. The national rate of tuberculosis infection is 4.6 cases per 100,000. In 2006, Colorado had 2.6 per 100,000.

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