Outbreak of Drug-Resistant Mycobacterium tuberculosis Among Homeless People in Atlanta, Georgia, 2008-2015

Abstract

Objectives: Our objective was to describe and determine the factors contributing to a recent drug-resistant tuberculosis (TB) outbreak in Georgia. Methods: We defined an outbreak case as TB diagnosed from March 2008 through December 2015 in a person residing in Georgia at the time of diagnosis and for whom (1) the genotype of the Mycobacterium tuberculosis isolate was consistent with the outbreak strain or (2) TB was diagnosed clinically without a genotyped isolate available and connections were established to another outbreak-associated patient. To determine factors contributing to transmission, we interviewed patients and reviewed health records, homeless facility overnight rosters, and local jail booking records. We also assessed infection control measures in the 6 homeless facilities involved in the outbreak. Results: Of 110 outbreak cases in Georgia, 86 (78%) were culture confirmed and isoniazid resistant, 41 (37%) occurred in people with human immunodeficiency virus coinfection (8 of whom were receiving antiretroviral treatment at the time of TB diagnosis), and 10 (9%) resulted in TB-related deaths. All but 8 outbreak-associated patients had stayed overnight or volunteered extensively in a homeless facility; all these facilities lacked infection control measures. At least 9 and up to 36 TB cases outside Georgia could be linked to this outbreak. Conclusions: This article highlights the ongoing potential for long-lasting and far-reaching TB outbreaks, particularly among populations with untreated human immunodeficiency virus infection, mental illness, substance abuse, and homelessness. To prevent and control TB outbreaks, health departments should work with overnight homeless facilities to implement infection control measures and maintain searchable overnight rosters.

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

“…As an illustration, an earlier investigation of this TB outbreak determined that the average estimated infectious period was greater than 3 months, 85% of cases required hospitalization, and there were 10 TB-related deaths. 7 Similar themes of health de-prioritization and symptom normalization relating to delayed presentation for care were identified in two qualitative studies involving homeless persons in the UK. 13,14 Our findings add to this work by highlighting the influence of the social environment of the homeless shelter on these suboptimal health care-seeking behaviors.…”

“…The sex distribution of the participants was representative of that in the outbreak (90% of cases were male). 7 Of the nine cases who had sputum culture-positive disease, genotyping demonstrated that five (56%) had the same TB strain as that associated with the ongoing homeless shelter outbreak (Table 2). Jail (primary), shelters <GED Sought care while acutely ill ED 10 NFA (primary), jail <GED Sent to hospital by family ED * Defined as place where one stayed overnight, with 'primary' being the majority of nights when more than one site of habitation was reported.…”

“…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.…”

“…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 Design In-depth interviews were conducted with a purposive sample of 10 PEH with active TB disease.…”

“…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.…”