Homeless shelter workers want more TB protection

Some question whether OSHA standard is answer

One reason the National Health Care for the Homeless Council wants more time to mull over the proposed OSHA TB standard is that the standard presents both an opportunity and a burden, says its executive director, and it’s not easy to sort out one from the other.

"We are concerned that TB remains such a serious problem for the population we serve and the attendant risk to the people who serve them," says John Lozier, who heads the Nashville-based umbrella organization representing more than 25 agencies providing heath services to the homeless. "At the same time, we can’t say yet that we need the kind of enforcement provided in the OSHA standard."

The proposed standard goes beyond existing federal guidelines by making homeless shelters subject to the same TB control and prevention regulations as health care facilities. If adopted, the standard would force shelters to reduce the risk of TB infection through engineering and procedural controls. And while recent research has shown that much of primary TB infection occurs in homeless shelters, many operations don’t have the financial support to provide all the basic needs of its clients, much less those for an adequate TB control program.

"We recognize the importance of the need for symptom monitoring at the point of entry, but how far do you go in mandating that, and what is the capacity of the existing system to comply without it utterly collapsing and potentially resulting in more transmission of communicable diseases?" Lozier asks.

OSHA is taking those concerns seriously and has undertaken a separate study of homeless shelters to better determine the extent of the problem and the resources needed to address it. At the same time, a national study has been launched to assess the feasibility and efficacy of using ultraviolet light (UV) irradiation as a cheaper engineering control for preventing transmission in shelters. Homeless shelters in New York City and Birmingham, AL, are participating in the project, and shelters in four other cites are slated to join them as data are gathered over the next five years. Designed at St. Vincent’s Hospital and the Harvard School of Public Health in Cambridge, MA, the project may lead to guidelines for using UV equipment in settings other than shelters as well.

"This project is intended to determine efficacy once and for all," says Philip W. Brickner, MD, one of the project organizers and chairman of the department of Community Medicine at St. Vincent’s Hospital and Medical Center in New York City.

If nothing else, the proposed OSHA rule has brought attention to the problem of TB among the homeless and the lack of government funding to control it, Lozier says. Either more government funds must be committed, or the requirements for shelters must be modified, Lozier asserts.

"The proposal presents an important opportunity for us to find some feasible middle ground approach to the control of TB in this population," he says, "because what is proposed is not feasible."

The council has been surveying its members to find out what TB control measures shelters have already implemented and what resources they have for maintaining them. Lozier has concern for local health providers and how they will handle homeless people who are diagnosed with TB.

"If, say, 5% of the homeless meet the definition of suspected cases and need to be isolated, where are you going to put them?" he asks. "If the health system doesn’t have that capacity, it means those people will be kicked out of shelters and be out on the street with TB."