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TLANTA ― Just three years ago, a tuberculosis outbreak here put Georgia on the verge of a public health emergency.

The drug-resistant TB had quietly spread for the better part of a decade among this city’s homeless population. Then in 2014, the stubborn strain turned fatal, killing at least three men and infecting dozens. The deadly “Atlanta strain” also cropped up in more than a dozen states nationwide. Alarmed, the Centers for Disease Control and Prevention intervened with emergency aid.

A multimillion-dollar effort to screen and treat vulnerable residents has worked: Officials announced this week that TB cases in Fulton County, which includes most of Atlanta and and some of its surrounding suburbs, have dropped by nearly a third. They say the approach here can offer valuable lessons to other communities battling public outbreaks.

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“The spread of TB was below the radar screen,” said Fulton County Chairman John Eaves. “Then, boom! It put us in the crossfires of national blame.”

Tuberculosis is the world’s deadliest infectious disease — killing an estimated 1.8 million people worldwide in 2015. The number of cases in the United States, just under 9,300 last year, has steadily declined since the early 1990s. But health officials warn that we’re not on pace to eradicate the disease from the US. And drug-resistant strains can wreak havoc in a community.

That seemed to be happening in Georgia in 2013 and 2014. Eighty percent of the state’s TB cases linked to this strain were coming from a county that’s home to just a tenth of the state’s population.  Fulton County was responsible for more than half of all reported US tuberculosis cases caused by this strain during those two years.

The largest reason was thought to be homeless shelters. During 2013 and 2014, the CDC found that more than 50 people infected by this drug-resistant strain had stayed at four different shelters. Health officials said it had originated at the city’s largest shelter, Peachtree-Pine, which can house up to 700 homeless individuals. The homeless tend to be more susceptible to contracting tuberculosis, due to in part to exposure to harsh weather conditions — and also to the rapid spread of the disease through the cramped quarters of shelters.

“TB always affects people on the margins of society,” said Dr. David Holland, chief clinical officer of Fulton’s health and wellness department. “In 2014, we had a really rough winter, and that contributed to a gigantic rise in cases among the homeless.”

Though officials knew how dangerous the situation was, they responded slowly. Bureaucratic dysfunction plagued local health workers. And some homeless service providers worried about political motivations of government agencies. (Atlanta Mayor Kasim Reed later called for the closure of Peachtree-Pine, the city’s largest homeless shelter, citing the TB outbreak.)

“We always wanted TB screenings but didn’t want [the homeless] to be refused admission because they haven’t been screened,” said Anita Beaty, executive director of the Metro Atlanta Task Force for the Homeless, a group that oversees the operation of Peachtree-Pine.

Finally, in 2015, Eaves launched a TB task force that sought to ease tensions between health workers and shelter staffers in service of a shared goal: saving lives.

They agreed, for instance, that TB screenings should mostly be conducted in shelters, rather than forcing the homeless to travel to the health department. The county now sends a team to Peachtree-Pine three days a week to test new arrivals. They also visit other shelters, too. As incentive for clients to cooperate, many shelters require TB tests for anyone seeking a bed in their facility.

“Tuberculosis patients often reflect disenfranchised populations,” former CDC Director Dr. Thomas Frieden said. “Effective TB control programs figure out a way to establish a bond with patients and people and programs and organizations that are important to those patients’ lives.”

If a client tests positive, health workers can administer medicine — a handful of pills a day, taken for months — right at the shelter. Local and state health departments also trained shelter staffers to recognize TB symptoms; when necessary, they they hand out masks or move TB-positive clients away from the general population to prevent outbreaks.

Every quarter, county officials perform unannounced spot checks to ensure shelters comply with the new guidelines.

“If we have workers who go to every single person, ensuring that person is taking their meds, we can have high success rate,” said Dr. Patrick O’Neal, director of health protection with the Georgia Department of Public Health. “… The consequences [of not acting] would’ve been the further spread of a very dangerous germ that could been [even more] fatal.”

So far, it’s worked: Fulton recorded just 44 TB cases last year, the lowest total in nearly three decades and a decline of nearly half from 2009 levels. More importantly, all but two of those individuals received treatment of some kind after they tested positive. But O’Neal does caution that a brutal winter, one in which the homeless are crammed in shelters again, could trigger another outbreak without constant vigilance.

To be successful in the long run, Frieden suggests taking a page from the playbook of that stubborn “Atlanta strain.”

“The fundamental characteristic of TB bacteria is persistence,” he said. “Persistence is how the bacteria succeeds. Persistence is how we beat it.”

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