| 1. |
Homelessness and TB
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Homelessness is a significant risk factor for TB infection and progression to active TB disease. A homeless person may face an increased risk of TB infection due to: overcrowding in shelters, where the person may be exposed to a person who has active disease; poor ventilation in shelters that can result in the concentration of contaminated air; and underlying medical conditions of homeless persons such as HIV infection, alcohol or drug use and poor nutrition, which make the person more susceptible to developing TB disease. Persons who are homeless also may have difficulty in taking medications on a regular basis or attending scheduled medical appointments resulting in their disease not being recognized or effectively treated.
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| 2. |
Reducing the Risk of TB Spreading in Homeless Shelters |
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Shelters should develop and implement a TB management program based on the recommendations provided in the references below. The Francis J. Curry National TB Center (see reference below) has made the following recommendations that will assist shelter operators and staff to reduce the risk of TB transmission in homeless shelters.
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| 2.1 |
General Measures |
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Education: The shelter should provide education and information on TB to their staff, volunteers and clients.
Tissues: The shelter should make tissues available. Clients, staff and volunteers should be instructed to cover their noses and mouths with tissues when coughing and sneezing.
Bed placement: Beds should be arranged as far from neighbouring beds as possible, with a head to foot arrangement.
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| 2.2 |
Administrative and Work Practice Measures |
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Identifying Suspect Cases of TB: TB should be suspected in any homeless person who has a fever
and a productive cough (not a dry cough) that lasts over three weeks. Other symptoms of TB include
coughing up blood, night sweats, weight loss, fatigue and loss of appetite. If a person in a shelter has
a cough and one or more of the other symptoms, they should be considered a suspect case of TB.
The shelter staff should:
Immediately separate the suspect case of TB and arrange for medical care. The person with TB
symptoms should be immediately separated from other staff and residents by placing them in a
separate room. A surgical mask should be placed over the client's mouth and nose. Medical care
should be arranged as soon as possible. This may mean sending the person to the Emergency Department of the hospital as persons with suspect TB are often identified after regular clinic hours.
Notify the local public health unit. The shelter staff should also immediately notify their local public health unit.
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| 2.3 |
Ventilation, Filters, Ultraviolet Germicidal Irradiation (UVGI) |
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Ventilation can reduce the spread of TB by diluting the concentration of TB particles and removing
contaminated room air. Use of fans, opening windows, and the installation of
High- Efficiency Particulate Air (HEPA) filters and UVGI can dilute the air and/or remove TB
organisms.
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| 2.4 |
Use of Respiratory Protection |
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TB Suspect case
It is most important that the suspect TB case wear a regular surgical mask.
Staff at the shelter
Staff should only use N95 respirator masks when transporting a resident suspected of having TB or
when entering a room in which a suspect case of TB has been placed temporarily to separate him or
her from other staff and residents.
Staff assigned to use an N95 respirator mask should be fit-tested to ensure the mask fits properly and
be trained in the use, care and limitations of the mask. It is generally not necessary for shelter staff to
wear an N95 respirator mask to carry out their duties in other situations. It is not necessary to have
all shelter staff prepared to use an N95 respirator mask. One staff person per shift may be sufficient
to meet operational needs for most shelters.
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| 2.5 |
Tuberculosis testing for staff and volunteers pre-placement |
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Shelter workers and volunteers should be screened for TB infection prior to placement (post-hire) to
provide a baseline in the event of a future exposure. A baseline two-step Mantoux test should be
performed unless there is appropriate documentation of a previous tuberculin skin test (TST) with the
result recorded in mm, not "positive" or "negative".
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| 2.5.1 |
Contraindications to a Mantoux TST: U ( Canadian TB Standards, 6th Edition, 2007) |
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The following persons should not have a TST:
- Persons with severe blistering reactions in the past.
- Persons with documented active TB or a clear history of treatment for TB infection or disease in
the past.
- Persons with extensive burns or eczema.
- Persons who have major viral infections or who have had live-virus vaccinations in the past
month (this does not include persons with a common cold).These persons can be tested 4-6
weeks after the viral infection or the live-virus vaccination.
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| 2.5.2 |
Negative Mantoux TST: |
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An individual who can provide documentation of a Mantoux TST within the preceding year should
have a single initial skin test performed and should be managed on the basis of that result. There is no need for a second test (i.e. the second step of the two-step test) since the earlier test is, in effect,
the first of a two-step test. A history of BCG (Bacille Calmette-Guerin) vaccine is not a
contraindication to TST. |
| 2.5.3 |
Routine TST: |
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Annual routine repeat screening of employees and volunteers would only be recommended after an assessment by the local public health unit. The shelter should contact the TB control program staff of their local public health unit to see if annual screening of employees and volunteers should be conducted in their shelter.
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| 2.5.4 |
Testing Following Contact with an Active Case of TB |
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Staff, residents, and volunteers should be tested if they are exposed to a case of TB in the shelter or drop-in centre or elsewhere in the community.
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| 2.5.5 |
Previously Positive Mantoux TST: |
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Persons who have a documented positive Mantoux TB skin test should have a baseline pre-placement chest X-ray and be medically assessed in order to rule out active TB disease. They should be instructed to promptly report any symptoms suggestive of TB (e.g. cough, fever, anorexia, weight loss).
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| 3. |
Proper Documentation in Homeless Shelters |
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Shelter workers should be reminded to always keep adequate and accurate documentation including bed logs, client health history and TB symptoms (such as coughing).
In the event that there is a case of TB in the shelter, adequate and accurate documentation will assist the local public health unit in carrying out their investigation of the disease, determining the infectious period of the TB case, and identifying the contacts.
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| 4. |
Resources and Information |
| 4.1 |
Local Public Health Unit |
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Your local public health unit can assist you by providing information and education sessions about TB and infection control. Your local Ministry of Labour office can provide information on the requirements under the Occupational Health and Safety Act. |
| 4.2 |
TB in Homeless Shelters: Reducing the Risk through Ventilation, Filters, and UV (PDF). Francis J. Curry National Tuberculosis Center.
Centers for Disease Control. Prevention and Control of Tuberculosis Among Homeless Persons Recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1992;41(RR-5).
Health Canada. Canadian Tuberculosis Standards (PDF file size 3.39MB), 6th edition, Public Health Agency of Canada.
Public Health Agency of Canada. Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and Other Institutional Settings. CCDR Volume: 22S1, April 1996.
Tuberculosis Prevention and Control Guidelines for Homeless Service Agencies in Seattle-King County, Washington
San Francisco Department of Public Health. Tuberculosis (TB) Infection Control Guidelines for Homeless Shelters (PDF).
Ministry of Labour local offices
Local public health units in Ontario |
