Table 1.
Summary of recommendations for tuberculosis (TB) diagnosis, treatment, and prevention among people experiencing homelessness (PEH), United States, 2022
| Recommendation | Reference |
|---|---|
| 1. TB programs should ascertain the housing status of people being evaluated for TB using as many modalities as possible (eg, interview, medical record review, homeless registry) | • CDC
9
• CDC 41 |
| 2. Public health departments should maintain and regularly update listings of single-room occupancy hotels and homeless shelters so that addresses of PEH with TB can be checked against these listings | • CDC 9 |
| 3. Organizations that provide shelter and other types of emergency housing for PEH should develop institutional TB-control plans | • American Thoracic Society/CDC/Infectious Diseases Society of America 27 |
| 4. Homeless shelters should use administrative control interventions as a first line of defense to reduce TB exposure risk of shelter clients and staff | • Cole et al (Advisory Council for the Elimination of Tuberculosis and the National Tuberculosis Controllers Association)
6
• Jensen et al (CDC) 26 • CDC 73 • Curry International Tuberculosis Center 74 |
| 5. TB programs should have written guidance or policies for investigating the index PEH with TB and sites of transmission | • National Tuberculosis Controllers Association/CDC 66 |
| 6. Targeted testing and treatment for TB infection is recommended for residents and staff of homeless shelters, following current TB diagnostic guidelines | • CDC
9
• Lewinsohn et al (American Thoracic Society/Infectious Diseases Society of America/CDC) 20 • Jensen et al (CDC) 26 • US Preventive Services Task Force 28 • CDC, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Division of Tuberculosis Elimination 61 |
| 7. Appropriate diagnostic tests (eg, sputum smears and cultures, NAAT of sputum and extrapulmonary specimens, chest radiographs, IGRAs, TSTs) should be used to evaluate people for TB; rapid diagnostic tests (eg, NAAT) are useful to quickly diagnose TB and prevent transmission | • CDC
9
• Lewinsohn et al (American Thoracic Society/Infectious Diseases Society of America/CDC) 20 • CDC 21 • CDC 22 • CDC, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Division of Tuberculosis Elimination 61 • National Institutes of Health 78 |
| 8. Shelters should maintain and share clinical data on PEH between shelters | • CDC 9 |
| 9. Health care providers and organizations serving PEH should promptly notify the public health department of possible or confirmed TB cases among PEH or shelter staff | • CDC
9
• Nahid et al (American Thoracic Society/CDC/Infectious Diseases Society of America) 43 • National Tuberculosis Controllers Association, CDC 66 |
| 10. PEH with newly diagnosed infectious TB disease should be appropriately housed to allow initial therapy to be directly observed and to preclude continuing transmission of TB in the community | • CDC
9
• CDC 41 • Nahid et al (American Thoracic Society/CDC/Infectious Diseases Society of America) 43 • Chaulk and Kazandjian (Public Health Tuberculosis Guidelines Panel) 46 |
| 11. TB programs should treat using a patient-centered approach to ensure that ancillary services, such as treatment for substance use disorders and evaluation and treatment of HIV, are provided to newly housed PEH with TB and to PEH in temporary housing facilities | • CDC
9
• Nahid et al (American Thoracic Society/CDC/Infectious Diseases Society of America) 43 • Chaulk and Kazandjian (Public Health Tuberculosis Guidelines Panel) 46 |
| 12. Public health department staff should visit PEH with possible or confirmed TB, in the hospital or elsewhere, as soon as possible during diagnosis, to obtain patient consent on treatment plans | • CDC
9
• National Tuberculosis Controllers Association, CDC 66 |
| 13. Before hospitalized PEH with TB are discharged, arrange for their first visit to the clinic or other place of intended outpatient care | • CDC
9
• Nahid et al (American Thoracic Society/CDC/Infectious Diseases Society of America) 43 |
| 14. Consider involving a social worker on the TB treatment team for PEH to facilitate access to food, shelter, and safety | • CDC
9
• Chaulk and Kazandjian (Public Health Tuberculosis Guidelines Panel) 46 • National Tuberculosis Controllers Association, CDC 66 |
| 15. Use directly observed therapy and incentives to enhance treatment adherence | • CDC
9
• Nahid et al (American Thoracic Society/CDC/Infectious Diseases Society of America) 43 • Chaulk and Kazandjian (Public Health Tuberculosis Guidelines Panel) 46 |
| 16. If TB clinics are not close to the location of PEH, transportation to the clinic should be provided or services should be brought to the PEH | • CDC 9 |
| 17. If PEH with infectious TB refuse treatment, temporary, enforced isolation should be instituted in accordance with state and local public health laws and regulations | • CDC
9
• National Tuberculosis Controllers Association, CDC 66 |
| 18. TB and LTBI treatment should follow CDC guidelines. Health care providers should prescribe short regimens when possible and avoid critical drug interactions | • CDC
9
• Sterling et al (National Tuberculosis Controllers Association and CDC) 32 • Nahid et al (American Thoracic Society/CDC/Infectious Diseases Society of America) 43 • Carr et al 44 • University of Liverpool 45 |
| 19. Public health departments and service providers for PEH should work together to conduct active case finding to identify TB cases and their contacts early, especially during outbreaks | • American Thoracic Society, CDC, Infectious Diseases Society of America
27
• National Tuberculosis Controllers Association, CDC 66 |
| 20. TB programs should conduct a thorough, location-based contact investigation for every patient, based upon testing with IGRA (or TST), followed by chest radiographs and NAAT for those with positive test results | • CDC
9
• Lewinsohn et al (American Thoracic Society/Infectious Diseases Society of America/CDC) 20 • CDC 21 • CDC 22 • National Tuberculosis Controllers Association, CDC 66 |
| 21. All PEH initiating treatment for TB should be screened routinely for HIV | • CDC
9
• Nahid et al (American Thoracic Society/CDC/Infectious Diseases Society of America) 43 • Branson et al (CDC) 87 |
| 22. The presence of HIV in a person with a positive IGRA or TST result is an indication for LTBI treatment following current guidelines; LTBI treatment should be started only after excluding pulmonary or extrapulmonary TB disease | • Lewinsohn et al (American Thoracic Society/Infectious Diseases Society of America/CDC)
20
• Sterling et al (National Tuberculosis Controllers Association and CDC) 32 |
| 23. PEH with HIV who have contact with infectious TB should receive a chest radiograph, be screened for signs and symptoms of TB, and be examined for evidence of extrapulmonary TB, regardless of IGRA or TST result; if abnormalities are noted, additional diagnostic studies for TB should be undertaken | • Lewinsohn et al (American Thoracic Society/Infectious Diseases Society of America/CDC)
20
• CDC 21 • CDC 22 • National Tuberculosis Controllers Association, CDC 66 • National Institutes of Health 78 |
| 24. TB programs can access CDC-funded Tuberculosis Centers of Excellence for Training, Education, and Medical Consultation for resources and training to prevent and manage TB among PEH | • CDC
9
• CDC 88 • CDC 89 |
| 25. TB programs can consult with local and national programs focusing on PEH (eg, through the Bureau of Primary Health Care at the Health Resources and Services Administration, the National Health Care for the Homeless Council, and Ryan White programs for health care and supportive services for PEH) | • CDC 9 |
Abbreviations: CDC, Centers for Disease Control and Prevention; IGRA, interferon-gamma release assay; LTBI, latent tuberculosis infection; NAAT, nucleic acid amplification test; TST, tuberculin skin test.