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In the United States, the number of cases of TB disease has been falling since the beginning of the century. The availability of highly effective treatment accelerated this decline, and by 1970 the Advisory Council for the Elimination of Tuberculosis (ACET) committed to the goal of eliminating TB in the United States by the year 2010. Elimination was defined as less than one case per one million persons per year.
After decades of success, the nation became complacent and lackadaisical about TB. Monies that had been targeted toward TB prevention and control were diverted to other programs, and the country witnessed a resurgence of TB. Between 1985 and 1992, the number of TB cases reported increased over 20%. Fueled by both the deterioration of the public health system and the HIV epidemic, TB cases and drug resistance grew at a worrisome pace throughout the latter part of the eighties and early nineties.
It has been estimated that it takes 100- 200 individuals living together in close contact to support the ongoing transmission of tuberculosis (TB). Therefore, it should not have been surprising that when prisoners with high rates of LTBI and HIV infection were clustered in overcrowded, poorly ventilated congregate living environments, that the situation was perfect for cultivating TB. The first documentation of transmission of multidrug-resistant TB (MDR-TB) in a correctional system occurred in 1991, when 8 cases of MDR-TB developed in a correctional facility in New York. Those with active disease included seven prisoners, all HIV-infected with CD4 counts <60, and one employee who had undergone radiation treatment for a malignancy and had a CD4 count of 110. All eight individuals died.1
Contemporaneously, an inmate in California with MDR-TB had multiple lapses in unsupervised therapy during which he was not housed in negative pressure respiratory isolation. A contact investigation revealed skin test conversions among staff.2
Subsequently during 1995-1996, staff from the California Department of Corrections and health services and local health departments investigated two outbreaks of drug-susceptible TB. The outbreaks occurred in two state correctional institutions with dedicated HIV housing units. In each outbreak, all cases were linked by IS6110-based DNA fingerprinting of MTB isolates. In all, 30 cases of TB were diagnosed, including one case in a visitor. The findings indicated that MTB can spread rapidly among HIV-infected inmates and be transmitted to their visitors and prison employees, with secondary spread to the community.3
And finally, demonstrating that those who do not learn from the past are condemned to repeat it, South Carolina experienced an outbreak in 1999-2000 in a unit housing HIV infected prisoners. In all, TB disease developed in 31 prisoners and one medical student.4
Nationwide, the rate of active TB cases in the incarcerated is 10-20 times greater than that in the general U.S. population. Data from 2000 reveals an inordinate number of TB cases in residents of correctional facilities as compared to the nation as a whole (Table 1, p. 1).
In 2000, the Institute of Medicine (IOM) released a report entitled Ending Neglect: The Elimination of Tuberculosis in the United States. This report stated "… without question the major reason for the resurgence of tuberculosis was the deterioration of the public health infrastructure essential for the control of tuberculosis." The report went on to say, "The question now confronting the United States is whether another cycle of neglect will be allowed to begin or whether, instead, decisive action will be taken to eliminate the disease." Additionally, "at the current rate of decline, … it will take more than 70 years to reach the target for elimination of tuberculosis of 1 case … per million population." One recommendation of the IOM was to increase targeted skin testing and treatment of LTBI programs for high-risk groups such as inmates of correctional facilities.6
Another area of concern is the increasing proportion of TB cases in this country that develop among the foreign born. During 2000, a total of 16,377 U.S. cases of TB were reported, representing a 39% decrease from 1992 (26,673 cases). However, the case rate among foreign-born persons remains at least seven times higher than among U.S.-born persons. Of the 26,673 cases in 1992, 7,270 (34.2 per 100,000 population) cases were reported among foreign-born persons, representing 27% of all cases. Of the 16,377 cases in 2000, 7,554 (25.8 per 100,000 population) were among foreign-born persons, representing 46% of all cases (Figure 1).7 The number of states with >50% of their annual total of reported TB cases among foreign-born persons increased from four in 1992 to 21 in 2000. Of these 21 states, California, Hawaii, Massachusetts, Minnesota, and New Hampshire had >70% of their annual total of cases among foreign-born persons.7
The proportion of patients with MDR-TB decreased from 486 (3%) of 17,684 in 1993 to 141 (1%) of 12,056 in 2000. However, of the total number of reported MDR-TB cases, the proportion occurring in foreign-born persons increased from 31% in 1993 to 72% in 2000.7
Clearly, TB will not be brought under control in this country without a greater emphasis being placed upon the diagnosis and treatment of LTBI among the incarcerated. In the nation's largest correctional systems (California, Texas, Florida, New York) foreign-born prisoners make up a significant number of the total detainees. Studies have demonstrated the prevalence of LTBI among prisoners to be from 14% to 25%. Other studies have shown that the longer prisoners are incarcerated, the more likely they are to have a positive tuberculin skin-test result. This data supports the probability that transmission of TB is occurring within correctional facilities. Once again, as with HIV, hepatitis, mental illness, STDs, and innumerable other public health issues it becomes clear that as goes the health of the incarcerated, so goes the health of the nation.
What then, is the role of this nation's correctional health care providers when it comes to TB? Much of the information that follows is based upon the guidelines for the Prevention and Control of Tuberculosis in Correctional Facilities: Recommendations of the Advisory Council for the Elimination of Tuberculosis, MMWR 1996 45 (RR-8).8
As with any other medical effort in the correctional setting, success of a TB infection control program depends upon the active cooperation of custody. The first step therefore is to involve each facility's sheriff or warden in the implementation of a TB control plan. All medical and custodial staff must be trained about their role in this plan.
All correctional facilities, even those in which few TB cases are expected to occur, should designate a person or group of persons who will be responsible for the facility's TB infection-control program. These persons should have the authority to develop, implement, enforce, and evaluate TB infection-control policies. If supervisory responsibility is assigned to a committee, one person should be designated as the contact person to whom questions and problems can be addressed. In systems with more than one facility, one person should be designated to oversee TB infection-control activities throughout the system.
TB infection-control officials and all clinicians who treat inmates or employees of correctional facilities should be familiar with current guidelines concerning TB from the Centers for Disease Control and Prevention, the American Thoracic Society/CDC,9 and the National Commission on Correctional Health Care (NCCHC).10,11
Medical facilities located within correctional facilities should conduct a thorough risk assessment and follow the recommendations in the CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities.12 Last month HEPP News editors participated in the drafting of a revision to this document, attempting to ensure that the unique challenges of correctional TB control will be addressed.
Correctional facility officials should form close working relationships with their state and local health departments, which can assist correctional facilities in formulating, implementing, and evaluating TB control activities. Correctional staff should ensure that they have access to same day chest radiographs, induced sputum collection, 24-hour turn around time for AFB sputum smears, and a sufficient number of negative pressure respiratory isolation rooms. In addition, laboratories processing AFB specimens must utilize rapid culture techniques (i.e. bactec systems) and perform gene probe assays on positive cultures to ensure prompt species identification. Access to DNA fingerprinting of positive cultures is an important tool in the event of an outbreak situation.
The TB infection control program should be responsible for the following three essential TB control activities:
The remainder of this article will focus on screening for and treatment of active TB and LTBI.
Screening for active TB and LTBI should take place a) at the time of intake, b) at least annually thereafter, and c) whenever signs or symptoms develop that might be due to TB disease.
a. At intake
During medical evaluation at intake (“bus screening”), inmates should be asked if they have had active TB disease or if they have been treated for latent TB infection or active TB disease. This information should be recorded in each inmate's medical record. Any inmate who has a history of inadequate treatment for TB disease should undergo a thorough medical evaluation followed by prompt re-initiation of therapy.All new arrivals should be evaluated for signs or symptoms consistent with active TB. Those with symptoms of TB (e.g., a productive, prolonged cough {a cough lasting for greater than or equal to 3 weeks}; hemoptysis {coughing up blood} fever, chills, night sweats, easy fatigue, loss of appetite, or weight loss) should be masked and then placed in respiratory isolation until active TB can be ruled out. (See HEPPigram, p. 6)
All HIV-infected persons, regardless of whether they are symptomatic or have a positive skin test, should be screened with a chest radiograph. TB can be difficult to diagnose in HIV-infected persons or other severely immunosuppressed persons.13 The chest radiographs of severely immunosuppressed persons who have pulmonary TB might not have a classical appearance; for example, infiltrates without cavities in any lung zone or mediastinal or hilar lymphadenopathy might be present. In rare situations, the chest radiograph of a severely immunosuppressed person who has pulmonary TB disease may appear normal.13
Skin testing
All new arrivals should undergo screening for TB infection with the Mantoux tuberculin skin test using 0.1 ml of 5 tuberculin units (TU) of PPD. Those who have a documented history of a positive skin-test result, a documented history of TB disease, or a reported history of a severe necrotic reaction to tuberculin should be exempt from routine tuberculin skin-test screening. Neither pregnancy, lactation, nor previous vaccination with Bacillus of Calmette and Guerin (BCG) vaccine is a contraindication for tuberculin skin testing.
The reaction to the Mantoux skin test should be interpreted by an experienced worker 48- 72 hours after the injection by measuring the area of induration (i.e., the palpable swelling) at the injection site. The diameter of the indurated area should be measured across the width of the forearm. Erythema (i.e., the redness of the skin) should not be measured. All reactions, even those classified as negative, should be recorded in millimeters of induration.
Generally, a tuberculin skin-test reaction of greater than or equal to 10 mm induration is considered a positive result in inmates and correctional-facility employees. However, an induration of greater than or equal to 5 mm is considered a positive result in persons in the following groups:
Vaccination with BCG, a TB vaccine used in many countries, can cause a reaction to the tuberculin skin test. No reliable method can distinguish tuberculin reactions caused by BCG from those caused by infection with M. tuberculosis. A diagnosis of LTBI and the use of preventive therapy should be considered for any BCG-vaccinated prisoner who has a tuberculin skin-test reaction of greater than or equal to 10 mm of induration.
Persons who have a positive skin-test result and no symptoms suggestive of TB should be screened with a posterior-anterior chest radiograph. If an inmate has a positive skin-test result and a diagnosis of active TB disease has been excluded, the inmate should be considered for preventive therapy (see Section IIb on page 5).
Sputum-smear and culture examinations should be conducted for inmates whose chest radiographs are suggestive of active TB disease, regardless of their skin-test results. In some large jails, TB control officials should consider using on-site chest radiography to screen all inmates for TB disease. Such screening is particularly important for jails in which a) the prevalence of TB disease is high, b) the inmate population changes rapidly, and c) the prevalence of HIV infection and illicit-drug injection is high. Jail officials should consult the local TB control officer for assistance in assessing the need for, and cost-effectiveness of, such screening.
b. Annual follow-up screening
Inmates who had a negative skin-test result at intake should have an annual PPD skin test. Those who have a history of a positive skin-test result and who have not completed a course of preventive therapy should be screened for symptoms of TB disease. Annual chest radiographs are unnecessary for the follow-up evaluation of infected persons.
c. At any time when symptoms are detected
Inmates who at any time have symptoms suggestive of TB disease should immediately receive a thorough medical evaluation, including a tuberculin skin test, a chest radiograph, and, if indicated, sputum examinations. While under investigation, suspect cases should be housed in a negative pressure respiratory isolation room.
For most inmate-patients, the preferred initial treatment regimen includes four drugs: isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin (for dosing see Table 2; for recommended regimens, see HIV101). Because pyrazinamide and streptomycin should not be used to treat pregnant women, pregnancy must be excluded in women of child-bearing ages before treatment for TB disease is initiated. Furthermore, TB infected patients who are also HIV- positive AND are on a HAART regimen containing a PI or NNRTI should receive rifabutin (RFB) instead of rifampin (RIF) and may also require dose adjustments in their HIV medications (Table 3).
Patients with sputum smear positive TB should remain in negative pressure respiratory isolation until they have satisfied all of the following conditions:
Failure to respond to treatment usually is caused by patient non-adherence to therapy, but can also be caused by a drug-resistant strain of MTB. Drug-susceptibility testing should be performed on all initial MTB isolates, regardless of sputum-smear results. If an inmate is to be released or transferred out of the facility before completing therapy, the public health department or receiving correctional facility should be notified as far in advance as possible and should be provided with appropriate medical records to ensure continued adherence to and timely completion of therapy.
All inmates being treated for active TB disease should be on DOT to ensure adherence to therapy. Inadequate or interrupted treatment for TB can result in relapse, continued transmission, and the development of drug-resistant disease. Therefore, after effective therapy has begun, continued treatment without interruption is critical until patients complete an entire course of therapy.
The recommended regimen for preventive therapy in inmates, because they are at high risk for TB, regardless of HIV status is a single daily dose of 300 mg of isoniazid for 9 months given by DOT. For those who are known to be HIV sero-negative, a six month course of therapy may be acceptable. If daily-supervised therapy is not feasible, twice-weekly supervised therapy with isoniazid (15 mg/kg of isoniazid per dose, with a maximum dose of 900 mg) is a suitable alternative (see HIV101). Before release or transfer of an inmate, provisions should be made for the public health department or receiving facility to oversee completion of an appropriate course of preventive therapy.
During the entire treatment period, persons receiving preventive therapy should be monitored monthly by medical personnel for signs and symptoms of adverse reactions. Because of the high rate of underlying liver disease in inmates, baseline transaminase measurements should be obtained at the initiation of preventive therapy. Those who are found to have abnormal baseline transaminases and those who have other factors associated with an increased risk for hepatitis (chronic liver disease, daily use of alcohol, injecting- drug use, or current use of another medication that might cause interactions) should have transaminases measured monthly during the course of treatment.
An alternative short course treatment regimen for LTBI utilizing 2 months of rifampin and PZA was found to be safe and highly effective in HIV-infected individuals with LTBI. Subsequently, however, fatal and severe liver injuries have been associated with the use of this regimen in HIV sero-negative individuals.16, 17 It is not clear why those who are HIV sero-negative would be more likely to develop side effects from this regimen than those who are HIV sero-positive. However, it seems prudent to advise that the 2-month RIF-PZA treatment regimen for LTBI should be used with caution, especially in patients concurrently taking other medications associated with liver injury, and those with alcoholism, even if alcohol use is discontinued during treatment. RIF-PZA is not recommended for persons with underlying liver disease or for those who have had INH-associated liver injury. For persons not infected with HIV, 9 months of daily INH remains the preferred treatment for LTBI; 4 months of daily RIF is an acceptable alternative.
Persons for whom TB preventive therapy is recommended but who refuse or are unable to complete a recommended course of therapy should be counseled to seek prompt medical attention if they develop signs or symptoms suggestive of TB. Routine, periodic chest radiographs of persons who have a documented history of a positive skin-test result usually are not useful for detecting disease in the absence of symptoms.
After decades of decline in this country, TB cases rose during the latter part of the eighties. This resurgence was fueled by both the HIV epidemic and the deterioration of the public health infrastructure. With renewed attention and increased resources, TB cases are again beginning to decline. An increasingly disproportionate number of new cases are diagnosed among those who are foreign born and among the incarcerated. MDR-TB cases are also more common in these two populations. Elimination of TB in this country will require intensified screening, treatment, and containment efforts among prisoners and the foreign born. Those of us working in correctional health are on the front line of this effort to rid our nation of TB. Success will require education of all correctional employees and close cooperation with custody staff as well as state and local health departments.
*Nothing to disclose
1. "Transmission of Multidrug-Resistant Tuberculosis Among Immunocompromised Persons in a Correctional System -- New York, 1991" MMWR July 17, 1992 / 41(28);507-509.
2. "Probable Transmission of Multidrug-Resistant Tuberculosis in a Correctional Facility -- California", MMWR January 29, 1993 / 42(03);48-51.
3. "Tuberculosis Outbreaks in Prison Housing Units for HIV-Infected Inmates -- California, 1995-1996" MMWR February 05, 1999 / 48(04);79-82.
4. "Drug-Susceptible Tuberculosis Outbreak in a State Correctional Facility Housing HIV-Infected Inmates --- South Carolina, 1999--2000" MMWR November 24, 2000 / 49(46);1041-1044.
5. "Table 23. Tuberculosis Cases in Residents of Correctional Facilities: 59 Reporting Areas, 2000", Reported Tuberculosis in the United States, 2000.
6. Ending Neglect: The Elimination of Tuberculosis in the United States. Institute of Medicine, 2000.
7. "Tuberculosis Morbidity Among U.S.-Born and Foreign-Born Populations --- United States, 2000" MMWR February 8, 2002 / 51(05);101-4.
8. "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.
9. Bass JB Jr, Farer LS, et al., "Treatment of tuberculosis and tuberculosis infection in adults and children. American Thoracic Society and The Centers for Disease Control and Prevention", Am J Respir Crit Care Med 1994 May;149(5):1359-74.
10. Standards for health services in jails. Chicago: National Commission on Correctional Health Care, 1992.
11. Standards for health services in prisons. Chicago: National Commission on Correctional Health Care, 1992.
12. "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994" MMWR October 28, 1994 / 43(RR13);1-132.
13. [No authors listed] "American Thoracic Society. Diagnostic standards and classification of tuberculosis", Am Rev Respir Dis 1990 Sep;142(3):725-35.
14. Mohle-Boetani J., Bick J. et al. "Tuberculosis outbreak in a housing unit for human immunodeficiency virus-infected patients in a correctional facility: transmission risk factors and effective outbreak control.", Clin Infect Dis 2002 Mar 1;34(5):668-76.
15. Bartlett JG, Gallant JE. Medical Management of HIV Infection 2001-2002 Edition. Johns Hopkins University, Baltimore MD 2001
16. "Fatal and Severe Hepatitis Associated With Rifampin and Pyrazinamide for the Treatment of Latent Tuberculosis Infection --- New York and Georgia, 2000" MMWR April 20, 2001 / 50(15);289-291.
17. "Update: Fatal and Severe Liver Injuries Associated With Rifampin and Pyrazinamide for Latent Tuberculosis Infection, and Revisions in American Thoracic Society/CDC Recommendations --- United States, 2001" MMWR August 31, 2001 / 50(34);733-5.
18. "Prison and Jail Inmates at Midyear 2000", p3. Bureau of Justice Statistics Bulletin, March 2001, NCJ 185989.
19. "Time Series of State Population Estimates: April 1, 2000 to July 1, 2001", U.S. Census Bureau Figures.
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©1997,1998,1999,2000,2001,2002. 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.
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