Global TB Center



Slide 1: TB Among the Homeless: Dealing with Unique ChallengesObjectivesUpon completion of this seminar, participants will be able to:Describe the extent of homelessness as a social problem in the USDiscuss the burden of TB among the homeless populationOutline effective strategies for prevention and treatment of TB among homeless persons and their contactsDiscuss how health departments and homeless services agencies can work as partners to coordinate clinical care and contact investigations to effectively prevent TBSlide 2: Faculty (1)Bill L. Bower, MPHDirector of Education and Training, Charles P. Felton National TB Center at Harlem HospitalAssistant Clinical Professor, Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia UniversityJames J. O’Connell, MDPresidentBoston Health Care for the Homeless ProgramSlide 3: Faculty (2)Dean Carpenter, MSN, FNP-BCNeighborhood Service OrganizationTumaini Center, DetroitMonica Heltz, RN, MPHTB Program CoordinatorMarion Country Public Health Department, Indianapolis Slide 4: Polling QuestionApproximately how many homeless clients with TB disease does your program see each year?01-1011-20>20Slide 5: Homelessness in the US and the Connections Between Homelessness and TB James J. O’Connell, MDBoston Health Care for the Homeless ProgramFebruary 7, 2012Slide 6: HUD Definition of Homelessness December 5, 2011(1) Individuals and families who lack a fixed, regular, and adequate nighttime residence and includes a subset for an individual who resided in an emergency shelter or a place not meant for human habitation and who is exiting an institution where he or she temporarily resided (90 days now rather than 30); (2) individuals and families who will imminently (within 14 days) lose their primary nighttime residence (home, motel, hotel, doubled up);(3) unaccompanied youth and families with children and youth who are defined as homeless under other federal statutes who do not otherwise qualify as homeless under this definition (new category: no lease or ownership within 60 days, or have had 2 or more moves in last 60 days, and who are likely to continue to be unstably housed because of disability or multiple barriers to employment); and(4) individuals and families who are fleeing, or are attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family memberSlide 7: Homeless Persons Point in Time Count 2010 Table 1: Homeless Persons Point in Time Count (2010)Household TypeNumber% of All Homeless Persons% of SubcategoryTotal PeopleSheltered403,54362.1%Unsheltered246,37437.9%Total649,917100.0%IndividualsbSheltered212,21832.7%52.0%Unsheltered195,74830.1%48.0%Total407,96662.8%100.0%Persons in FamiliesSheltered191,32529.4%79.1%Unsheltered50,6267.8%20.9%Total241,95137.2%100.0%Family HouseholdsSheltered62,305-78.4%Unsheltered17,141-21.6%Total79,446-100.0%a The sheltered homeless count includes people using safe havens.b Individuals includes persons in households without children and persons in households with only children.Source: 2010 Continuum of Care Applications: Exhibit 1, CoC Point-in-time Homeless population and SubpopulationsThis table shows the HUD homeless point in time count in 2010. The number of sheltered people is about 400,000 or about 62 percent of the population. The number of unsheltered is about 250,000 or approximately 38%. The table also shows the breakdown of different population groups (individuals, persons in families and family households) by sheltered/unsheltered status.Slide 8: Exhibit 2-3: Trends in Homelessness PIT Counts, (2007-2010)This graph shows a trend in homelessness point-in-time counts from 2007 through 2010. The trends are remaining the same or decreasing slightly. There are twice as many single unattached adults as there are people living in families.Slide 9: Cluster Distributions: Persons and Shelter Days ConsumedSingle Adults in Philadelphia (Graph)This graph shows the cluster distribution of homeless shelter stays among single adults in Philadelphia. 80 percent of the people, who came into shelters during a 10 year period, came in and stayed for one visit that was usually about a month or less and did not return.Slide 10: Exhibit 2-4: Trends in Chronic Homelessness 2007-2010This graph shows the trends in chronic homelessness from 2007 through 2010. The total numbers have been going down, but the total number in 2010 was about 109,000 – 110,000 people.Slide 11: Characteristics of Outbreaks Lax screening policies at shelters Unrecognized infectious casesMobility of guests between shelters and other facilities (jails) and jurisdictions (NY)Inability to provide preventive treatment to high-risk, infected persons (contacts)High costs of screening and follow-upPersonal costs: TB morbidityActual screening costs: DollarsNY 1,093 contacts; 4 cases foundME 1,069 contacts; 0 cases foundWA 471 contacts (+ intensified screening); 11 cases foundSlide 12: TB and Homelessness in BostonTuberculosis (TB) among homeless persons traditionally is a great public health concern Boston's Pine Street Inn (PSI) shelter has been the center of several TB outbreaksOutbreak in mid-1970’s triggered Public Health Nurse intervention: on-site clinical TB services Following a 2nd outbreak, with a peak incidence of 29 cases of active disease in 1990, rates have declined to approximately 4-8 annually A recent one-year increase (15 Boston cases in 2000) likely represented coincident reactivation of latent infection11/15 similar RFLP; no epi contacts Targeted Public Health Intervention:Increased surveillanceDevelopment of a specialized, public health TB clinic at Pine StreetSlide 13: TB Cases Among the Homeless Massachusetts 1974-1994This slide shows the numbers of cases of TB among homeless in Massachusetts beginning in 1974 and ending in 1994. Beginning around 1983 - 84 there was an upsurge in tuberculosis cases that lasted right through until 1994 and then began to go down with the exception of a slight upsurge in 1990. Slide 14: Pine Street InnThis shows a picture of Pine Street Inn - the oldest and largest shelter in New England.Slide 15: Pine Street Inn PatronThis shows an elderly patron of the Pine Street Inn. He is very thin, has scabies, and he has basal carcinoma on the front of his ear. Slide 16: Chest X-RayThis is the chest X-ray of the elderly patient from the previous slide. Despite normal vital signs, the X-ray shows cavitary tuberculosis.Slide 17: MMWR ReportThis is an image of the MMWR report from July 1985 which discussed the first 26 cases of the outbreak. Slide 18: Shelter StaffThis is a picture of the staff workstation in the shelter from the 1980s. It shows a nurse case manager and a nurse practitioner engaged in a conversation.Slide 19: Outreach WorkerThis a picture of an outreach worker and the state TB outreach nurse speaking with a patient in an outdoor location back in 1986. They have their bicycle equipment there and they would just get on their bikes every day to track down each patient and give them their treatment. Slide 20: Pine Street Inn DormitoryThis a picture of a typical dormitory at Pine Street Inn with beds located closely to one another and UV lights suspended from the ceiling. Slide 21: HEPA FilterThis is a picture of a communal area in the shelter with a prominently featured HEPA filter.Slide 22: Cough LogThis is a picture of the “Cough Log Binder” which was implemented by the nursing staff in order to document which one of the patrons was coughing overnight and to bring them into the clinic for evaluation the following day.Slide 23: Tuberculosis in Boston (Graph)This graph shows the trends in tuberculosis in Boston between 1984 and 2006 by homeless vs. non-homeless. There is a large upsurge in homeless cases in the '80s and early '90s.Slide 24: Shelter Clinic StaffThis is a picture of Dr. Bernardo and Claire Murphy who were the doctor and nurse that would come to the shelter clinic every week.Slide 25: Public Health NurseThis is a picture of the public health nurse at the shelter.Slide 26: ReferencesAlvaro Cortes, Josh Leopold, Louise Rothschild, Larry Buron, Jill Khadduri, and Dennis P. Culhane. 2011. "The 2010 Annual Homeless Assessment Report to Congress.”. 1985. Epidemiologic Notes and Reports Drug-Resistant Tuberculosis among the Homeless – Boston. MMWR, 34(28);429-31 , DP, Metraux, S, Park, JM, Schretzman, M & Valente, J. 2007. “Testing a Typology of Family Homelessness Based on Patterns of Public Shelter Utilization in Four U.S. Jurisdictions: Implications for Policy and Program Planning.” Housing Policy Debate, 18(1): 1-28“Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH): Defining “Homeless” Final Rule,” 76 Federal Register 233 (5 December 2011), pp. 75994 - 76019. 27: Perspective of shelter staff Dean Carpenter FNP-BCFebruary 7, 2012Slide 28: NSO servicesSubstance Abuse Treatment and Prevention ServicesOlder Adult ServiceEmergency Telephone ServiceHarper-Gratiot Multi-Service CenterFood bankClothingUtilitiesYouth Initiative ProjectGambling Addiction TreatmentEmployment Training ServicesLife Choices (developmental disabilities)Homeless ServicesSupportive HousingRoad HomeTumaini CenterSlide 29: Bell building This is a picture of the Bell Building in Detroit and picture of the NSO President and CEO – Sheila Clay with Mayor Dave Bing. 155 One-bedroom apartmentsNSO Corporate HQFQHCLaundryChapelWalk-out gardensSlide 30: Road Home These are pictures of the Outreach Homeless Services – seen here supporting Occupy Detroit at Grand Circus Park.Slide 31: NSO Tumaini Center This is a picture of the Tumaini Center - the shelter of last resort in the Cass CorridorSlide 32: Scope of the problem The first picture shows a sign on the closed doors that says “Keep off, no sleeping” and the second picture depicts a homeless elderly man holding an illegible sign on a dark snowy street.Estimated 19,000 homeless in DetroitUnemployment rate 27% (officially)Jobless rate near 50%16 FQHC’s, no public hospitalSlide 33: Detroit’s homeless are dispersedThis picture shows the geographic footprints of San Francisco, Boston and Manhattan fitting inside the map of Detroit with room to spare.Slide 34: Detroit’s homeless are well hiddenThis picture is showing 2 abandoned residential buildings in Detroit, the so-called “abandominiums”. There are an estimated 12,000-20,000 abandoned houses.Slide 35: Detroit’s homeless are vulnerable (Table)Table 2: Vulnerability Index: Homeless Death Prevention Study April 2010Risk IndicatorNationallyDetroitSample Size8575211Tri-morbid54%51%3x ER or Hospital last year34%66%*3x ER last 3 months25%43%*>60 years old20%13%HIV+/AIDS6%7%Liver Disease19%10%Kidney Disease9%9%Cold/Wet Weather Injury15%21%*% vulnerable42%51%**Indicates higher than national averageSource: Corporation for Supportive Housing, 2010This table shows the vulnerability index results from the Homeless Death Prevention Study. Percentage of people meeting the criteria of Vulnerable is 9% higher than national average. Percentage of people using the ER is almost twice the national average. Number of seniors answering survey is significantly lower than the national average. Slide 36: Detroit’s homeless are transient This picture shows the outside of the Tumaini Center on a winter afternoon. People are seen coming and going, high turnover.Slide 37: Legal/social Barriers to service There are three pictures on this slide. Picture 1 shows Dean Carpenter talking to a woman on the street. Picture 2 is a snapshot of a Mexican community in Detroit. Picture 3 is a mosque.Parole violations/ open warrantsEscaping domestic abuseAsylum seekers/ illegal immigrants“Going ghost”Use of Street namesMental illness Organic brain diseaseSubstance abuseTraumatic brain injurySlide 38: Traumatic brain injuryThis is a photo of Willie Edwards, a boxer, and a photo of a news story about him.Slide 39: Undocumented immigrantsThis is a picture of the US Coast Guard boat with 4 employees onboard. Detroit is the busiest international border crossing in North America.Slide 40: TB Skin testing- Low follow up This is a snapshot of a page from the TB skin testing log book. It shows that only 20.2 % of individuals who had PPD placed had the test read.Slide 41: Steps Taken to Mitigate OutcomesImproving FiltrationUtilizing database for screening, referral and contact investigationSwitching from TST to interferon – γ release assay (IGRA) testingEstablishing close relationship with Detroit Health Department/other homeless service providersSlide 42: VentilationThe picture on the left shows the old fiber filter and the picture on the right shows the new pleated filter.Fiber filters capture no pathogensUVGI and HEPA filters are cost-prohibitivePleated filters show some efficacy are affordableSlide 43: Filter efficacy (Graph)This graph shows the efficacy of the pleated filter compared with the HEPA filter. HEPA filter captures 99.9% of M. tuberculosis droplet nuclei while the pleated filter captures approximately 70% of Mycobacterium.Slide 44: HMIS – homeless management information systemThis picture shows a shelter worker using the Homeless Management Information System (HMIS) on her computer. This is a statewide database - provides information on services rendered and a screening tool/searchable database for contact investigation.Slide 45: Scanning a consumer into HMISThis picture shows a shelter employee holding up an ID card of one of the patrons and scanning it with a handheld infrared scanner.Slide 46: Quantiferon – TB Gold testingThis picture shows the Quantiferon – TB Gold In-Tube testing kit including the three sets of tubes needed to collect the specimen for the test.Slide 47: TB Testing – Detroit health departmentThis is a picture of the Detroit Health Department testing “Crew” – providing not only Quantiferon TB testing, but also HIV and syphilis testing.Slide 48: Results of testing92 Registered and screened61 Tested (66.3% )31 Refused (33.7%) or not available5 Positive (8%)+2 cases from contact investigation (not homeless and previously identified)0 Active disease in reactors1 Positive syphilis (1%)0 Positive HIV testSlide 49:This is a picture of the Detroit skyline as seen from the river.Slide 50: ReferencesBrudnell, Mike. 2011. “Fame, fortune have faded away for Detroit boxer Willie Edwards.” Farmer News. 2008 “Acres of Barren Blocks Offer Chance to Reinvent Detroit.” for Supportive Housing. 2010. Post. 2009. “Over Half Of Detroit Homeless Population At Risk Of Dying On City Streets.” State University, 2011. Spartan Sagas. 51: Case Study: TB and Shelter StaffA TB Control and Case Management PerspectiveMonica Heltz, RN MPHFebruary 7, 2012Slide 52: Day 1“David,” a 31 year-old man, presented to a local emergency department from the street with a two-month history of productive cough, fevers, night sweats and shortness of breathChest X-ray showed infiltrate in left upper lobe, CT showed cavitationHad been staying in local homeless shelterAdmitted for TB rule-outSlide 53: Context This picture is of one of the dormitories in a local shelter. The bunk beds are located close together. This is where the “lucky ones” get to stay, but most homeless patrons end up sleeping on mats on the floor in the hallways and the dayrooms throughout the winter.Slide 54: David’s HistoryPositive Interferon Gamma Release Assay (IGRA ) nine months prior, no treatmentHIV positive for three years, no treatment, lost to follow-upBipolar and schizophrenia, for which he received disabilityAlcohol addictionIncarcerationRecent hospital encounters for: stab wound, suicidal ideation, TB rule out two and five months prior with negative X-raysSeen 1 week prior in emergency department for same. CXR showed patchy airspace opacitiesSlide 55: What do you see as potential problems for TB case management? This is a picture of a lunch patron at a local shelterSlide 56: Day 11-16This picture is a snapshot from the movie “Outbreak” with the three men dressed in full biohazard gear (yellow suits).Client missing from hospital, smear positive, confirmed TB on probeSlide 57: This is a picture of a generic missing person sign.Day 23 – Discharge from hospitalDay 24- Missing from shelterSlide 58: What might you need to consider when discharging clients to shelters? This is a picture of the “regulars” at a local shelter.Slide 59: Remainder of therapy These series of photos show things related to David’ s therapy, including TB medications and bus passes. Slide 60: What about contacts? (Diagram)This diagram represents the results of David’s contact investigation Slide 61: Summary of this case3 shelters involved: 1 day shelter, 1 discharge shelter, 1 overnight shelterMultiple interactions with health care system prior to diagnosis, but little follow-upMultiple co-morbiditiesReluctance or inability to give up contactsMultiple challenges completing therapyChallenging contact investigationCompleted therapySlide 62: If we could do it all over…This picture is of a lunch patron at an area shelter.Bed lists Use shelter staffSocial workCommunicationsHousingAlerts to providersSlide 63: Regarding Homeless ClientsThis slide has a picture of a TB testing patron and M. Heltz.Be persistentFollow through on promisesBe creative with incentives & enablersHousing is good, but don’t forget food and other associated factorsSlide 64: Regarding SheltersThis slide has a picture of a resident and staff at a local shelter.Resources, roles and rules are variableEducationRespectConsistencyExpertiseSlide 65: How can shelters and TB work together?This photo shows Monica Heltz and the director of a local shelter. Inclusive planningTeamworkRegular contactCapitalize on skills and servicesSlide 66: Planning for Homeless ClientsThis is a picture of the front door of a TB clinic.Housing and foodSocial work involvementContact investigationsNotification systemsIncentives & enablersTrust buildingSlide 67: Outbreak PreventionThis slide has a picture of a TB clearance card for shelter residents indicating TST/IGRA/CXR screening results, treatment regimen, its duration and completion date.Plan for homeless clientsMaintaining relationshipsTechnical assistanceScreeningEnvironmental measuresCommunicable disease codeSlide 68: Outbreak ResponseThis slide has a picture of a phlebotomist drawing blood for a TB test.Targeted testing with immediate follow-upIncentives given only for follow-upEpi link investigationShort course therapy treatment DOT for LTBIData management planData sharing planHousingVentilation improvementsSlide 69: Take HomeThese photos show a man and a woman smiling. The more you work with and involve your community partners, the easier it will be to find creative collaborative solutions when the need arisesTrust-building is the most valuable activity you can performSlide 70: Circle CityThis slide has multiple pictures of Indianapolis landmarks.Slide 71: Questions and DiscussionIf you wish to ask a question or make a comment:Un-mute your phone by pressing #6After your question, re-mute your phone by pressing *6 Type your questions to host and panelists; priority will be given to verbal questionsSlide 72: Background Documents These are images of two background documents. Slide 73: INFORMATION LINE 1*800*4TB*DOCS (482-3627)Slide 74:Thank you for your participation!! ................
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