terns and mycobacterial phage typing, Nardell and colleagues convincingly demonstrated transmission of tuberculosis among the clients of a homeless shelter in Boston in 1983 (63). An outbreak of tuberculosis in a poorly ventilated shelter for homeless men in Seattle, Washington, in 1987 was described by Nolan and coworkers (64). In San Francisco, a study conducted in 1993 and 1994 demonstrated by RFLP analysis that the M. tuberculosis isolates from 24 of 34 homeless tuberculosis patients belonged to six clusters, thus providing strong evidence for transmission of infection among these homeless individuals (65).
Despite the well-recognized risks of transmission of tuberculous infection in homeless shelters, there are almost no data concerning infection rates in the staff of these facilities. In fact, many of the workers at these shelters are drawn from the clients themselves, and they tend to be transient, often unavailable for repeated skin testing, and frequently tuberculin-positive. In the only published report giving information on infections among staff found in the author’s literature search, Curtis and colleagues from CDC studied an outbreak occurring in a homeless shelter for men in Syracuse, New York, in 1987 and 1988 (66). Seventy percent of the clients and staff of the shelter were tuberculin-positive. Tuberculin skin test conversions were documented in two of eight previously tuberculin-negative staff members. Perhaps reflective of much of the generally transient nature of shelter staffs, 52 additional staff members who may have been exposed were not available for skin testing.
Layton and coworkers studied a single-room-occupancy hotel used to shelter homeless persons with AIDS (67). Sixteen cases of tuberculosis were found among 116 persons surveyed; 8 of them were compliant with antituberculous therapy, 4 noncompliant, and 4 not under treatment. None of 11 employees had tuberculosis, and the authors found “[no] evidence of recent tuberculous infection” in them, although no skin test data were reported. These employees worked in a small lobby area that was reasonably well ventilated and not conducive to socializing with the residents (P.Kellner, personal communication).
Pierce, Sims, and Holman reported that 11 of 65 (17 percent) of workers in a residential hospice for AIDS patients converted their tuberculin skin tests after a patient with tuberculosis spent 29 days in the facility prior to being recognized as having tuberculosis (68). Information about the HIV infection status of the employees was not given, nor was information about ventilation in the facility. A tuberculin test conversion was documented in one employee of a residential substance abuse facility in Michigan where a client was found to have multidrug-resistant tuberculosis in 1989 (69).