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Objectives: Our objective was to describe and determine the factors contributing to a recent drug-resistant tuberculosis (TB) outbreak in Georgia. Methods: We defined an outbreak case as TB diagnosed from March 2008 through December 2015 in a person residing in Georgia at the time of diagnosis and for whom (1) the genotype of the Mycobacterium tuberculosis isolate was consistent with the outbreak strain or (2) TB was diagnosed clinically without a genotyped isolate available and connections were established to another outbreak-associated patient. To determine factors contributing to transmission, we interviewed patients and reviewed health records, homeless facility overnight rosters, and local jail booking records. We also assessed infection control measures in the 6 homeless facilities involved in the outbreak. Results: Of 110 outbreak cases in Georgia, 86 (78%) were culture confirmed and isoniazid resistant, 41 (37%) occurred in people with human immunodeficiency virus coinfection (8 of whom were receiving antiretroviral treatment at the time of TB diagnosis), and 10 (9%) resulted in TB-related deaths. All but 8 outbreak-associated patients had stayed overnight or volunteered extensively in a homeless facility; all these facilities lacked infection control measures. At least 9 and up to 36 TB cases outside Georgia could be linked to this outbreak. Conclusions: This article highlights the ongoing potential for long-lasting and far-reaching TB outbreaks, particularly among populations with untreated human immunodeficiency virus infection, mental illness, substance abuse, and homelessness. To prevent and control TB outbreaks, health departments should work with overnight homeless facilities to implement infection control measures and maintain searchable overnight rosters.

Background: During an outbreak of tuberculosis (TB) in the homeless population of metropolitan Atlanta, education of homeless service providers (HSPs) about the implementation of local infection control measures was imperative to limiting the spread of TB and to preventing future outbreaks. Methods: By use of educational sessions and teaching posters, two interventions were designed to focus educational efforts from November 2014 to August 2015: 1) a spatially-targeted approach that identified HSPs within an area of Fulton County, GA (which includes downtown Atlanta) with high TB case density (cases per square mile) from 2009 – 2014, and 2) an organizational meeting approach that included scheduled meetings of professionals who had regular contact with homeless individuals at risk of TB infection. Results: Of the 18 HSPs targeted in the identified high-TB density area, 9 engaged in educational activities, and 9 were closed at time of contact or unreachable by email or phone. Through organizational meetings, 36 additional facilities were reached. Conclusions: The HSPs with successful contact were amenable to educational efforts, and a combination of spatially targeted and organizational meeting approaches with teaching aids was feasible in developing sustainable TB educational programs in the homeless community

Standard tuberculosis case reporting captures incarceration at diagnosis only. This retrospective analysis of 106 US-born adults with prevalent tuberculosis in 2011 found that 46.2% had documented histories of being in jail or prison, including 16.0% during the year before diagnosis.