Administrative Controls

TB Control in Overnight Homeless Facilities Quick Reference Guide

Administrative controls are management measures designed to reduce the risk for exposure to persons with infectious TB.

They work particularly well when homeless facilities in a community collaborate with a TB control program to implement certain core measures, including the following:

• Assigning responsibilities for TB infection control to a point-person at each facility;
• Conducting TB risk assessments for these facilities;
  • An example of a risk assessment worksheet for health care facilities that can be modified for use at a homeless facility is available at https://www.cdc.gov/tb/publications/guidelines/pdf/appendixb_092706.pdf
• Developing a written TB infection control plan for each facility;
  • This plan should include procedures for systematically evaluating clients, staff, and volunteers for TB disease and infection (see additional details in the following discussion).
    – Evaluations for TB should include regular queries to staff and clients as to whether they have symptoms compatible with TB disease;
    – Further medical evaluation should be facilitated for persons with any TB symptoms.
  • Requiring TB diagnostic evaluations for clients who stay longer than a defined period (e.g., after staying 1 day, 3 days, or 1 week) helps ensure all clients have been evaluated and treated, if necessary, for TB disease and infection.
    – This helps minimize exposures to infectious TB within the facility. The grace period during which clients can obtain services without verification of TB diagnostic evaluations can differ by site and should be decided in consultation with the local TB control program.
    – Usage of a shared platform for storing test results might facilitate result verification and prevent duplication of efforts.
• Maintaining bed maps and tracking bed assignments, ideally in a searchable electronic format (e.g., a spreadsheet) rather than paper records to facilitate contact investigations if a TB case is reported;
• Maintaining as much space as possible between beds and positioning beds head to toe to reduce the possibility of transmission;
• Posting signs and informational posters for client awareness and cough monitoring(e.g., see https://www.cdc.gov/flu/pdf/protect/cdc_cough.pdf)
• Considering use of a cough log to document which persons are coughing, particularly at night, so that they can be referred for medical evaluation (e.g., see https://www.tn.gov/content/dam/tn/health/documents/tuberculosis_guidelines/TB_FJCSheters.pdf) and
• Providing ongoing education to staff, volunteers, and clients (see additional details in the following discussion).

Systematic Diagnostic Evaluations for TB Disease and Infection

Treating latent TB infection (LTBI) not only prevents future TB cases, but may also interrupt future M. tuberculosis transmission, because it prevents the latent infection from becoming active, contagious TB.

Two tests for TB infection are available: either (a) the tuberculin skin test (TST) or (b) interferon-gamma release assays (IGRA). Both tests help differentiate persons with M. tuberculosis infection from those who do not have it.

All clients with positive tests for TB infection should be evaluated for TB disease, but a negative test for TB infection does not always exclude the diagnosis of TB disease or LTBI. Decisions regarding patient management should always incorporate epidemiologic, historical, and other clinical information in addition to TST or IGRA results.

Systematically evaluating facility clients for TB is an essential component of strategies for interrupting potential TB transmission. Screening for TB symptoms can be performed by using a standardized questionnaire that can be completed during client intake by agency staff or volunteers. Clients with symptoms compatible with TB should be separated from others until a medical evaluation for TB disease has been performed. They should remain separated until TB disease has been excluded or the patient is not contagious.

 Strategies for Introducing Systematic Evaluation of Clients for TB

• Develop close associations between the TB control program and homeless facilities, even in the absence of a TB outbreak.
• Provide continual education (because shelters have high staff and volunteer turnover) about testing for TB infection.
• Train facility staff and volunteers in implementing cough monitoring and symptom screening.
• Create and implement general infection prevention guidelines for homeless facilities.
• Require proof of TB diagnostic evaluations for all staff and volunteers (e.g., annually).

Strategies for Prioritizing Resource Usage

• Ensure those at highest risk for having TB disease or infection are evaluated first (see https://www.cdc.gov/tb/topic/testing/whobetested.htm)
• Consider on-site clinical services at the homeless facility for providing testing and screening.
• Assist clients in obtaining medical screening if not offered on-site; for example, certain clients are unaware that they have medical insurance, and staff or volunteers can help clients identify and use these resources.

Strategies for Selecting Testing Methods

• Coordinate with the TB control program to ensure successful implementation of a TB testing program in a homeless facility.
• Use up-to-date recommendations regarding targeted testing and treatment (see https://www.cdc.gov/tb/topic/testing/tbtesttypes.htm or https://www.cdc.gov/tb/topic/treatment/default.htm)
• For persons who are at risk for loss to follow-up after a TST (i.e., those who do not return for readings), consider using IGRAs. These tests do not require that clients return to have their test results interpreted (although the results are not back from the laboratory for several days).
  • Moreover, the same blood draw can be used for other tests (e.g., HIV, syphilis, or hepatitis C).
  • Consider having local health department personnel on-site at homeless facilities to help with interpretation and communication of test results.
• Be aware that IGRAs are also preferred for persons who have received bacille Calmette-Guérin (BCG) vaccination or therapy.
• Among facilities with HIV-infected clients, be aware that those clients might not disclose their status and that TSTs are less reliable in identifying TB infection among persons who are immunocompromised.
• During an outbreak or in a community with high TB prevalence, including chest radiograph or even sputum collection can improve screening results; however, mass chest radiograph screenings can be expensive and yield limited results.

Strategies for Managing Testing Results

• Rather than “decision to treat,” think “intention to engage.” Work individually with clients to decide what works for them. For certain clients, short-term incentives and enablers are motivating; others will need longer-term enablers.
• Establish practices that incentivize TB screening and enable treatment. For example, offer vouchers for fast-food restaurants to participants who agree to be screened, or provide TB services (e.g., directly observed treatment [DOT] for LTBI) at meal-delivery sites.
• Emphasize the importance of having regular TB screening results to provide a baseline negative result for persons who might become infected later.
• Work with primary care clinics and shelters to create a data management system for recording who has been screened.
• Ensure the health department has access to the data management system (see section in this report on Homeless Management Information System or HMIS) so that staff can update infection clearances. 

TB Education for Staff, Volunteers, and Clients

Although many persons have heard of TB, few report knowing much about the disease. For this reason, ensuring all staff, volunteers, and clients receive thorough education about TB when they begin working or staying at the facility and on an ongoing basis is crucial. Information shared should include that TB is treatable and curable and that taking certain steps can prevent transmission of TB in homeless facilities.

In collaboration with CDC, the National Health Care for the Homeless Council, United States Interagency Council on Homelessness and other health and social services organizations, the Curry International Tuberculosis Center has developed the “Homelessness and TB Toolkit,” which provides links to many educational resources (see also http://www.currytbcenter.ucsf.edu/products/view/homelessness-and-tb-toolkit)

Examples include:

• Brochures and Cover-Your-Cough Posters in different languages;
• an 18-minute training video, “Shelters and TB: What Staff Need to Know” (2^nd ed.);
• an online, hour-long course for new staff and volunteers, CDC’s “TB 101”