By Virginia Johnson explores the issue of tuberculosis (TB) among the homeless population. TB rates are 100 times higher among the homeless due to factors like poor nutrition, substance abuse, and overcrowded living conditions. The document outlines a plan to test for TB in homeless shelters, including educating the homeless on TB symptoms and treatment. Volunteers will draw blood from shelter residents to test for TB. Those who test positive will receive a 12-week treatment plan with monitoring to ensure compliance. The goal is to improve TB detection and treatment for the homeless population.

1. By Virginia Johnson

2. What do you see?

3. Photo
P – Problem of homelessness. As the economy took a downturn, more people
struggled to pay their bills and many ultimately became homeless.
H – Housing, lack of affordable housing. More line up daily for beds in shelters.
Those who sleep on the streets risk harm from violence and the elements.
O – Ostracized, feelings of rejection drive the homeless further underground
making it difficult to provide ongoing healthcare.
T – Tuberculosis (TB)thrives amongst the homeless. Latent TB is a particular
problem of the homeless. Cramped settings in shelters make spread of the
infection difficult to control.
O – Obscurity. I chose this picture because the first impression is of a majestic
tree standing in a parking lot. It is only when you look closely under the trees
that you see, what looks like, a pile of old clothes or trash. They are the
homeless, huddled in sleeping bags early one Sunday morning.

4. Assessment
Annually TB accounts for more than 2,000,000 deaths worldwide
(Maurer & Smith, 2013)
TB amongst the homeless is 100 times greater than that of the general
population, within the USA(Feske, Teeter, Musser, & Graviss, 2013)
Homelessness is associated with inadequate nutrition, substance
abuse, HIV, poor health, lack of sleep and overcrowding leaving the
homeless vulnerable to infection. (Proudfoot, 2005)
The homeless are at high risk for latent TB and have a history of
incomplete TB treatment(Craig et al., 2007).
Monitoring and treatment of the homeless is made more difficult by
their inconsistency and failure to comply with medication regimens,
along with the need for extended periods of treatment - 6-9 months
("Trends in Tuberculosis," 2004)

5. Assessment
Arkansas has one of the lowest incidence rates of TB in the
United States of America ("ASTHO," 2013).
July 2012, the Arkansas Department of Health (ADH) converted
from “TB skin tests to blood tests” for those at high risk of
contracting the disease. ("ASTHO," 2013).
Arkansas implemented the “new latent TB regimen of 2 pills per
week for 12 weeks”. This has improved compliance ("ASTHO,"
2013).
Unfortunately, only people who reside in shelters for more than
fourteen days are required to be tested for TB . There is a
deficiency in detection of TB in the homeless who do not stay in
one shelter for more than 14 days.

6. Plan
Meet with interested parties, e.g. community leaders,
public health/community nurses, physicians and local
business people to develop a strategy for testing the
homeless who reside in shelters < 14 days.
Fundraiser to cover expenses of food and gifts for
participants – seek out local venders who are willing to
donate items.
Salvation Army Shelter selected for 21 day trial.

7. Plan
Educate homeless on signs and symptoms of TB – use
pictures to demonstrate e.g droplet spread of disease.
Perform blood tests on all volunteer shelter residents in
the selected shelter.
Educate homeless on need to return for test results and
follow treatment plan if they test positive.
Establish method of monitoring compliance with 12 week
follow up plan. Implement direct observation technique
(DOT) for medication administration.

8. Implementation
4 weeks before trial - recruit volunteers from nursing
schools, churches and the community to draw blood and
collect patient data during the trial. Arrange for meeting
with them and shelter staff to ensure unity of effort.
2 weeks prior to testing place posters announcing the
program including dates, times and benefits for the
participants.
Be personally available to assist at each session of the 21
day trial.
Provide a healthy hot meal and snacks for all who attend a
short presentation and have blood drawn.

9. Implementation
Notify each participant when they will need to return for
their results. Stress importance of this and stimulate
compliance with meal and gift (e.g. sleeping bag, socks,
underwear) when they return.
When participants return, reinforce signs and symptoms
of TB prior to meal and gift.
Ensure those who test positive for TB are transferred to a
local facility to begin treatment.
Educate those who test positive that it is crucial they
complete the 12 weeks of treatment.

10. Evaluation
Participants will return for results
Participants will be able to identify signs and symptoms of
TB.
Participants who test positive will be compliant with 12 week
course of treatment.
If outcomes are statistical significant, then plan to repeat
process in shelters city wide.

11. References
Arkansas takes steps to combat tuberculosis. (2013). Retrieved from
www.astho.org
Craig, G. M., Booth, H., Story, A., Hayward, A., Hall, J., Goodburn, A., & Zumla,
A. (2007, January 27). The impact of social factors on tuberculosis
management. Journal of Advanced Nursing, 58(5), 418-24.
Feske, M. L., Teeter, L. D., Musser, J. M., & Graviss, E. A. (2013, March 14).
Counting the homeless:A previously incalculable tuberculosis risk and its social
determinants. American Journal of Public Health, 103(5), 839-48.
http://dx.doi.org/10.2105/AJPH.2012.300973
Homelessness & health: what’s the connection. (2011). Retrieved from
www.nhchc.org
Maurer, F. A., & Smith, C. M. (2013). Community/public health nursing practice:
Health for families and populations (5th ed.). St Louis, MO.: Elsevier Saunders.
Proudfoot, C. (2005, March). Tuberculosis and homeless people. Primary
Health Care, 15(2), 16-9.
Trends in tuberculosis. (2004). Retrieved from
http:www.cdc.gov/mmwr/preview/mmwrhtml/mm5410a2.htm