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TB Notes 2, 2000

Update from the Research and Evaluation Branch

Update on the Management of Homeless TB Patients

Homeless TB patients account for about 6% of reported TB cases in the United States. Some areas have greater concentrations of homeless TB patients: In Atlanta, Dallas, Miami, and San Francisco, homeless persons account for 11% of the area TB patients; in Houston, 10%; and in Los Angeles, 8% of TB patients are homeless.1 A few areas have much greater concentrations: In Orlando, homeless persons comprise 18% of the city's reported TB cases; in Seattle, they comprise 15%. In terms of numbers, in 1998, Los Angeles reported 106 cases and New York reported 88 TB cases among homeless persons, levels about twice as high as the remaining urban reporting areas.

Results from the CDC Study of Hospitalization of Tuberculosis Patients, recently published, 2 demonstrated the link between homelessness and increased rates of TB hospitalization, longer hospitalization lengths, and greater inpatient costs. Hospitalization tends to cost about $2,000 more for a homeless patient than for a nonhomeless patient. Providing stable housing and needed services may be more cost-beneficial than hospitalization, 3 thus reducing inpatient costs while promoting adherence to TB treatment and limiting the transmission of TB and the development of drug-resistant TB. The study was conducted at 10 US TB program sites (seven metropolitan areas: Chicago, IL; Dallas/Ft. Worth, TX; Fulton County, GA; Houston, TX; Los Angeles, CA; San Diego, CA; San Francisco, CA; a region surrounding New York City; and two states: Mississippi and South Carolina); data collection began in 1995 and ended in early 1996. The participating sites were asked about current policies, procedures, and funding sources for management of homeless TB patients.

Nine of the 10 sites offer homeless TB patients some form of housing as an enabler or incentive to TB treatment adherence. The tenth site only provides referrals of homeless patients to public hospitals when needed.

Of the nine sites providing housing, six provide alternatives to hospitalization when patients are still considered infectious. These alternatives include motels, apartments, mobile homes, cottages, and single-room-occupancy (SRO) apartments. The motels and apartments have single-unit ventilation to prevent sharing of air with other units in the building. Where and when alternatives are unavailable, infectious homeless TB patients are hospitalized at county public hospitals. Three sites located in one state must follow state law requiring local TB program approval before release of an infectious TB patient from the hospital to prevent inappropriate discharges.

Nine sites provide housing alternatives for noninfectious homeless patients until they complete TB treatment. In addition to SROs and apartments, these alternatives include homeless shelters, boarding houses, and substance-abuse treatment halfway houses. Directly observed therapy (DOT) is provided by the TB program or health department to patients at these locations.

Of the nine sites providing alternative housing, two receive funding from their county health departments. Five receive funds from either their state health department or the state TB control program; at one of the sites receiving state funding, counties must apply to the state for funding incentives or enablers that may include housing. TB programs may also access federal or private funding for housing TB patients. One of the nine sites receives federal funding for a demonstration project to provide comprehensive room and board services to homeless TB patients. At another of the nine sites, funding is received from Health Care for the Homeless, a national advocacy group, through a grant from the US Department of Housing and Urban Development (HUD). Two sites receiving state funding are also provided some funding for housing by local affiliates of the American Lung Association.

In 1993, Karen Brudney warned that crowded shelters are especially inappropriate for homeless AIDS patients. Four of the sites access additional funding for housing homeless HIV-infected TB patients through HUD's Housing Opportunities for Persons with AIDS (HOPWA) program, HHS's Ryan White program, or local AIDS service providers.

The TB program sites also mentioned barriers to providing alternatives to hospitalizing homeless TB patients. Six sites mentioned difficulties in locating housing vendors, four because of housing costs or availability and two because of fear and stigma about TB. One rural site mentioned that the number of homeless TB patients in the area is insufficient to make permanent arrangements for alternative housing. The staff of the same site stated that they lack social workers to locate housing and resolve patient needs, relying instead on nurses, who have other responsibilities. One site mentioned concerns about the ability to follow up and manage patients in various alternative housing arrangements and also discussed jurisdictional boundaries as obstacles to finding solutions for highly mobile populations. Two sites listed patients' substance abuse, behavioral problems, or unwillingness to leave the area as barriers to finding and keeping alternative housing arrangements.

Two sites defray basic living expenses (rent, utilities, food) to ensure that patients who otherwise would become homeless due to their illness do not lose existing housing.

This article gives readers a snapshot of how some TB programs manage their homeless TB patients. To reduce inpatient costs, all programs should consider providing alternatives to hospitalizing infectious, as well as noninfectious, homeless TB patients. However, they must first overcome barriers to locating and then funding these housing alternatives. Rural areas, with limited and thinly-stretched resources, face additional challenges. TB providers and health departments may not be aware of existing funding sources for housing, such as Veterans Administration programs or HUD's Shelter Plus Care and HOPWA programs. They can find out about funded housing arrangements in their geographic areas by calling HUD's Community Connections at (800) 998-9999, or they can access HUD's Website at then click on "homeless" under "topics," or go directly to They should also ask HUD about options for applying for new funding and local persons to contact to discuss potential collaboration. Some TB Controllers have been able to work with partners such as local affiliates of the American Lung Association or agencies for the homeless to identify additional alternatives for housing homeless TB patients. TB remains a problem, for a variety of reasons, among the homeless. Providers can help eliminate TB among the homeless by assessing homelessness among TB patients and linking the homeless to existing housing and other resources. When local resources do not exist, providers should work with DTBE consultants to find solutions and prevent future TB outbreaks among the homeless.

—Submitted by Suzanne Marks, MPH, MA
Division of TB Elimination


  1. Moore, M. CDC Division of TB Elimination Surveillance and Epidemiology Branch, personal communication. November 1999.
  2. a. Marks S, Taylor Z, Ríos Burrows N, Qayad M, Miller B. Hospitalization of homeless persons with tuberculosis. American Journal of Public Health. 2000;90(3):435-438.
    b. Taylor Z, Marks S, Ríos Burrows NM, Weis SE, Miller Bess, Stricoff Rachael L. Causes and costs of hospitalization of tuberculosis patients. The International Journal of TB and Lung Disease. In press.
  3. Marks S and Taylor Z. Net benefits of providing housing to hospitalized homeless TB patients. The International Journal of Tuberculosis & Lung Disease. 1998;2(9)(Supplement):S155. Abstract.
  4. Brudney K. Homelessness and TB: a study in failure. J Law Med Ethics 1993;21:360-367.


Released October 2008
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