Important note: Information in this article was accurate in March 2000. The state of the art may have changed since the publication date. | The online version of HEPP News displays the main article only, to view the entire newsletter download the following PDF:
|
In 1998, 3.6% (5,874/100,000) of all active M. tuberculosis (TB) cases reported in the United States were residents of correctional facilities - a TB case rate that is 50 times that of non-incarcerated individuals 1. This high proportion of cases is due to a combination of factors, including the high prevalence of TB infection in the incarcerated population, aggressive case finding among a high-risk group that often has limited access to other health care services, and the ready transmission of TB in these congregate living environments.
The factor that most increases the probability that TB infection will progress to active disease is immune deficiency, such as that caused by co-infection with HIV. At year-end 1996, 21,799 (2.3%) of all state and federal prison inmates were known to be infected with HIV 2. The overall rate of confirmed cases of AIDS among the nation's prison population (0.54%) was six times the rate in the U.S. population (0.09%) Thus, one reason residents of correctional facilities have a high risk for TB disease is that a disproportionately high number of them have HIV infection.
The Advisory Council for the Elimination of Tuberculosis (ACET) has recently published a document that advocates developing, implementing, and focusing strategies for TB control among segments of the population identified as having a high TB risk. 3. One strategy that will be reviewed in this article is maintaining aggressive policies for screening the inmates for TB infection, and initiating and completing therapy regimens for latent M. tuberculosis infection (MTB infection) when indicated. Updated guidelines highlighting new regimens and clinical practices for persons with MTB infection are scheduled for release this spring in MMWR and the American Journal of Respiratory Critical Care in Medicine 4 Footnote 1. This article discusses current guidelines for treating and preventing TB in corrections. Footnote 2
The following procedures should be used for the initial screening of inmates, depending on their length of stay in the facility and the type of facility 5, 6. According to the Essential Standard P-32 of the National Commission on Correctional Health Care Prison Standards, symptom screening should be done during intake for all new inmates, regardless of anticipated length of sentence ("Standards" available at www.ncchc.org). Any inmate with symptoms suggestive of TB (chronic productive cough, fever, and/or weight loss) should be immediately placed in a negative pressure respiratory isolation room (TB isolation room) and promptly evaluated for TB disease. In addition, tuberculin skin test (TST) screening of all inmates without a documented positive Mantoux skin test result should be mandatory, although this may not be feasible for short-term inmates. Persons with a positive skin test reaction should receive a chest radiograph, a thorough medical evaluation, and consideration for therapy for latent TB infection once active TB is ruled out. Inmates known to have HIV infection should have a chest radiograph as part of the initial screening, regardless of their TST status.
To prevent transmission in some large jails, TB control officials should consider using on-site chest radiography in addition to skin testing to screen all inmates for TB disease at entry into the facility Footnote 3. Such screening is particularly important for large jails where a combination of risk factors (i.e., an incarcerated population with a very high incidence of TB infection and disease, a high prevalence of HIV infection and drug injection, and a rapid turnover of inmates that make TST-based screening inefficient) are present. Jail officials should consult the local TB control officer for assistance in assessing the need and cost-effectiveness of such screening.
Long-term inmates who have a negative skin test reaction at intake should be skin tested annually to detect skin test conversions. Persons with a documented positive TST result who have not previously received a course of therapy for MTB infection and who do not qualify for MTB prophylaxis should be screened each year for symptoms of TB disease (see qualifications below). Annual chest radiographs are not necessary for the routine follow-up of infected persons, providing a qualified health provider interviews the patient for symptoms of TB disease.
A positive skin test reaction in a person without symptoms or signs suggestive of TB disease is considered indicative of latent MTB infection. Whenever latent TB infection is suspected, an evaluation to rule out active TB and assess the need for treatment of latent TB infection should be conducted. This evaluation consists of a medical history, physical examination, chest radiography, and, when indicated, bacteriologic studies. HIV testing is also recommended. Any inmate who has symptoms suggestive of TB should be immediately placed in a TB isolation room and promptly evaluated for TB disease. Inmates should not be returned to the general prison housing, until infectious TB disease has been ruled out by qualified medical personnel (See Isolation Guidelines, HEPP News, March 1999).
The new guidelines simplify treatment by setting the same duration of dosing regardless of whether patients are co-infected with HIV, by increasing the options for using intermittent (i.e., twice weekly) regimens, and by recommending the use of Rifampin-based shortduration (i.e., 2-4 months) drug regimens 7. Implementation of the new MTB infection management recommendations may lessen some of the continuing problems with adherence to MTB infection treatment in correctional settings. The major changes and additions, some important background information, and the potential applicability of the new guidelines for correctional facility-settings are summarized here.
1. Isoniazid for treatment of MTB infection
For all persons deemed to be candidates for MTB infection therapy, regardless of age, and HIV serostatus, the preferred regimen is INH daily for at least 9 months. ACET based this decision on: (1) a review of the findings from prospective, randomized clinical trials conducted in HIV-negative persons that show that 12 months of INH treatment is more effective than 6 months for the prevention of active TB; (2) the results of subanalysis of some of these trials that showed that maximal beneficial effect of INH was mostly associated with therapy that lasted for at least 9 months, and minimal additional benefit was observed for clinical trial participants who had longer (i.e., 12 months) therapy duration; and (3) HIV status is not a significant factor in the effectiveness of TB prophylactic regimens 8, 9, 10, 11, 12, 13. Thus, whenever possible, correctional facilities with long-term stays should opt for using a 9-12 month INH regimen for inmates who are deemed eligible for treatment of MTB infection. This treatment may be administered daily or twice weekly under directly observed therapy (DOT).
2. Rifampin and Pyrazinamide for treatment of MTB infection
The 2-month daily regimen of rifampin and pyrazinamide (PZA) is recommended based on a prospective randomized trial of treatment of MTB infection in HIV-infected persons that showed the 2-month regimen to be similar in safety and efficacy to a 12-month regimen of INH. A similar large-scale clinical trial has not been conducted in HIV negative persons; however, the antituberculosis activity of rifampin and PZA is not expected to differ for those with HIV infection and those without HIV infection. Some experts recommend that the 2-month regimen of daily rifampin and PZA also be given by DOT, which can consist of five observed and two self-administered doses each week.
3. Treatment of INH-Resistant TB Infection
Some alternative options for therapy for MTB infection are recommended for use in special situations. For example, for contacts of patients with Isoniazid-resistant, rifampin-susceptible TB, the recommended regimen is Rifampin and Pyrazinamide given daily for 2 months; however, for patients with intolerance to Pyrazinamide, Rifampin given daily for 4 months is recommended. A 4-month Rifampin regimen is recommended based on the efficacy of a similar regimen in both a prospective randomized trial of tuberculin-positive persons with silicosis and non-randomized trial in persons exposed to persons with Isoniazid-resistant TB.
4. Treatment of MTB Infection in those receiving antiretroviral therapy
Complex pharmacologic interactions occur when rifamycins (Rifampin & Rifabutin) are co-administered with some antiretroviral agents, notably protease inhibitors and non-nucleoside reverse transcriptase inhibitors. These drug-drug interactions may result in either an increase or decrease of the blood levels of both rifamycins and antiretrovirals, leading to adverse effects such as a decrease in antiretroviral activity or drug toxicities. Thus, therapy for active TB or MTB infection with rifamycins in HIV-infected persons should always be done in consultation with a physician experienced in the care of patients with TB and HIV co-infection. Except for Efavirenz, Rifampin use is to be avoided with PIs and NNRTIs (see HEPPigram on page 4).
Before the start of treatment for MTB infection, all inmates should receive a clinical evaluation. They should also receive follow-up evaluations for questioning about side effects and a brief physical assessment to check for signs of hepatitis at least monthly (if receiving Isoniazid alone or Rifampin alone) and at 2, 4 and 8 weeks (if receiving Rifampin and Pyrazinamide). Inmates should be educated about the side effects associated with treatment of MTB infection and at each visit reminded of the need to stop treatment and promptly report to medical personnel if signs and symptoms of hepatoxicity appear (e.g., anorexia, abdominal pain, nausea, vomiting, change in color of urine and feces, jaundice).
Baseline laboratory testing is not routinely indicated for all persons at the start of treatment for MTB infection, however, based on the relatively high prevalence of chronic liver disease (e.g., Hepatitis B or C, alcoholic hepatitis, or cirrhosis) among the inmate population, baseline hepatic measurements of serum AST (SGOT) or ALT (SGPT) and bilirubin should probably be considered for all persons in this setting. Active hepatitis and end-stage liver disease are relative contraindications to the use of Isoniazid or Pyrazinamide for treatment of MTB infection.
Routine laboratory monitoring during treatment of MTB infection is indicated for persons whose baseline liver function tests are abnormal (>3 times upper level of normal), women who are pregnant, and other persons with a risk of hepatic disease. Laboratory testing may also be indicated for the evaluation of possible adverse effects that occur during the course of treatment (e.g., liver function studies for patients with symptoms compatible with hepatoxicity or a uric acid measurement to evaluate complaints of joint pain). Persons with HIV infection are often treated with multiple drugs in addition to antituberculosis drugs. During the course of treatment for MTB infection all other medications that a person is taking should be reviewed and assessed for potential drug interaction with TB medications. Efforts to manage these potential problems related to drug interactions require the coordinated efforts of clinicians responsible for HIV and TB care.
Control of TB is an essential element in correctional health care. All correctional facilities, even those in which few cases of TB are expected, should have a written plan for the screening and prevention of tuberculosis. State TB officials are available for consultation on the development of this plan. The strategic application of these interventions, however, should be based on the size and type of the facility and the length of stay of the facility's inmates. All TB control personnel and clinicians who treat inmates or staff should be familiar with the special problems that correctional facilities may face arriving at a diagnosis of TB disease or infection. Upon release from correctional facilities, patients should be refered to local health departments in order to keep the disease under control.
When adherence to MTB infection treatment regimens is identified as a problem following the release of the inmates from the correctional facilities, TB control personnel from these institutions, in collaboration with staff from TB control programs at the local level, should seek and develop well-defined procedures for discharge planning, interagency collaborations, and incentives to return for follow-up appointments. The use of new ultra-short course of therapy that may be completed before release may also significantly benefit the control of correctional facility-related TB.
Footnote 1 The CDC's National Center for HIV, STD and TB Prevention website has the most updated guidelines on TB prevention and treatment, as well as very useful algorithms on TB management. Local TB control officials for each state are also listed at this site.
Footnote 2 Abt Associates is currrently working with CDC on a study of the extent of adherence to CDC's guidelines for TB control in a group of large jail systems serving cities with higher than average TB incidence. Later this spring, Abt Associates will be sending a mail survey to these jail systems and the public health departments in these jurisdictions. Following the mail survey they will be conducting site visits to about 20 jurisdictions. CDC will use the study results to review the guidelines and consider strategies for enhancing TB control in jails. Jail systems and health departments that are contacted regarding this study are urged to participate. For further information, contact Dr. Mark Lobato, the CDC Project Officer (404-639-8131) or Dr. Ted Hammett, the Abt Associates Project Director (617-349-2734)
Footnote 3 Correctional clinicians might find it useful to employ the mini-chest x-ray cassette-type machines with rolls of 1,000 100x100mm exposures. These avoid excessive radiation exposure to frequent visitors to the jail, save space for the storing of films, and are less expensive than full size films.
1. Centers for Disease Control and Prevention. Reported Tuberculosis in the United States, 1998. August 1999: 1-67. Available at www.cdc.gov/nchstp/tb.
2. U.S. Department of Justice. 1996-1997 Update: HIV/AIDS, STDs and TB in Correctional Facilities. July 1999: 1-97. Available at www.ojp.usdoj.gov/bjs
3. Centers for Disease Control and Prevention. "Tuberculosis Elimination Revisited: Obstacles, Opportunities, and a Renewed Commitment -- Advisory Council for the Elimination of Tuberculosis (ACET)". MMWR August 13, 1999 / 48(RR09);1-13
4. American Thoracic Society/Centers for Disease Control and Prevention. "Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection." Am J Respir Crit Care Med. 2000 Apr;161(4 Pt 2):S221-47
5. Centers for Disease Control and Prevention. "Prevention and Control of Tuberculosis in Correctional Facilities Recommendations of the Advisory Council for the Elimination of Tuberculosis", MMWR June 07, 1996 / 45(RR-8);1-27
6. Core Curriculum on Tuberculosis: What the Clinician Should Know, Third Ed. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 1994.
7. American Thoracic Society/Centers for Disease Control and Prevention." Treatment of Tuberculosis and Tuberculosis infection in Adults and Children." Am J Respir Crit Care Med 1994 May;149(5):1359-74
8. U.S. Department of Health and Human Services. Controlling TB in Correctional Facilities. Atlanta, Georgia: Centers for Disease Control and Prevention, 1995
9. Ferebee SH. Controlled chemoprophylaxis trials in tuberculosis: a general review. Adv Tuberc Res 1970;17:28-106.
10. Ferebee SH, Mount FW. Tuberculosis morbidity in a controlled trial of the prophylactic use of isoniazid among household contacts. Am Rev Respir Dis 1962;85:490-521.
11. International Union Against Tuberculosis Committee on Prophylaxis. "Efficacy of various durations of isoniazid preventive therapy for tuberculosis: five years of follow-up in the IUAT trial. International Union Against Tuberculosis Committee on Prophylaxis", Bull World Health Organ 1982;60(4):555-64.
12. Comstock GW, Ferebee SH. "How much isoniazid is needed for prophylaxis?", Am Rev Respir Dis 1970 May;101(5):780-2.
13. Comstock GW. "How much isoniazid is needed for prevention of tuberculosis among immunocompetent adults?" Int J Tuberc Lung Dis 1999 Oct;3(10):847-50.
2000-0310
HEPP2000-0301
©1997,1998,1999,2000. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.
ÆGiS is made possible through unrestricted grants from Boehringer Ingelheim, Elton John AIDS Foundation, iMetrikus, Inc., the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 2000. This material is designed to support, not replace, the relationship that exists between you and your doctor.
ÆGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.
Copyright ©1990, 2000. ÆGiS & the Sisters of Saint Elizabeth of Hungary. All materials appearing on ÆGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of ÆGIS and the Sisters of Saint. Elizabeth of Hungary, or the party credited as the provider of the content.
