Important note: Information in this article was accurate in 2003. The state of the art may have changed since the publication date. Incarcerated persons are a population long recognized as being at higher risk for tuberculosis (TB) than the general population.8 Of the 15,989 reported cases of active TB in the U.S. in 2001, 3.3% were in residents of correctional facilities at the time of diagnosis.6 At the same time, 0.7% of the total U.S. population was incar-cerated in a prison or jail.17 Correctional facilities have been recognized as reservoirs for the spread of Mycobacterium tuberculosis infection and TB disease among inmates and communities.15 The prevalence of HIV infection among inmates is an additional factor leading to higher rates of TB disease and TB infection in prison and jail settings. Control of TB in these high-risk environments is important for the health of inmates, their contacts (once released), and for the continued decrease in the national TB case rate.
TB is a disease caused by the organism M. tuberculosis. In most cases, TB affects the lungs, although the disease can occur in any organ system of the body. Symptoms of TB include fever, weight loss, night sweats, and fatigue. For those with the pulmonary form of the disease, there is usually a productive cough and abnormal chest radiograph. In advanced forms of pulmonary TB, hemoptysis may be present.
M. tuberculosis is transmitted by airborne particles called droplet nuclei that are generated by coughing when a person has pulmonary TB. The particles are an estimated one to five microns in size, and can remain suspended in an enclosed room for periods of 30 minutes or longer. Although not all exposed persons become infected, infection occurs when a susceptible person inhales droplet nuclei containing M. tuberculosis, which then reach the alveoli of the lungs. The probability that a person who is exposed to M. tuberculosis will become infected depends mainly on the concentration of infectious droplet nuclei in the air, the person's underlying immune status, nutritional state, and the duration of exposure. The concentration of droplet nuclei in the air is determined by characteristics of the contagious patient and environmental factors. These characteristics include the presence of cough, whether the disease is in the lungs, airways, or larynx, whether acid fast bacilli (AFB) are present on smears of sputum specimens, and whether there are pulmonary cavities on the chest radiograph. Environmental factors include exposure in small, enclosed spaces and poor ventilation.9
A small proportion of persons who are infected with TB will develop disease within weeks to months after exposure. For most infected persons, within two to 12 weeks, the immune system limits multiplication and spread of the organism. When this occurs, some of the organisms remain dormant in the body but are viable for many years. This condition is referred to as latent TB infection (LTBI). Persons with LTBI have no symptoms of TB disease and are not infectious. A proportion of persons with LTBI will develop TB disease during their lifetime. The risk is greatest during the first several years after infection. Immunocompromised persons with LTBI have a high risk for progression to TB disease; HIV infection is the strongest known risk factor for this progression.10 Treatment for LTBI greatly reduces the likelihood that TB disease will develop.
The tuberculin skin test (TST) can be useful in the diagnosis of LTBI and TB disease. In most cases of LTBI or disease, the TST is positive. However a negative test by itself should never be used to rule out infection or disease if there is a high clinical suspicion for either of these conditions or there are symptoms consistent with TB disease, especially in HIV-infected patients - where TST can be negative despite active TB disease.
Most cases of TB are caused by organisms susceptible to all antituberculosis medications, and disease cure rates are high when there are at least six months of effective treatment and good adherence. If rifampin is not included in the regimen then the length of treatment is prolonged. Cases caused by organisms with resistance to antituberculosis medications may require longer treatment and therapy that includes less effective second-line agents. Multidrug resistant (MDR) TB, defined as TB caused by organisms demonstrating resistance to at least isoniazid and rifampin (the two most potent antituberculosis medications), is the most difficult form of TB to treat and requires prolonged therapy, the use of less effective, more toxic second-line antituberculosis drugs, and an occasional need for surgery. MDR TB has a high rate of mortality and morbidity, although this has improved in recent years.2.
In both jails and prisons, TB rates among inmates far exceed those of the general U.S. population. In one study from 1995 to 1997 in the Memphis County, Tenn., Jail, the calculated incidence of TB cases was 274 per 100,000, over 35 times the national rate and 20 times that of Memphis County for the corresponding time period.15 In prisons in New York State during 1993, the reported TB case rate was 139.3 cases per 100,000; for New Jersey prisons the rate reported for 1994 was 91.2 cases per 100,000; and for California prisons in 1991 there were 184 cases per 100,000. In all three states, the TB rates among inmates were six to 10 times that of the state's general population 8.
Some facilities have seen a marked decline in the number of active TB disease due to diligent TB control programs with mandated screening and directly observed treatment of LTBI. In the New York State DOC the rate of TB disease was 225/100,000 in 1991. By 2001, the rate for new cases of active TB disease decreased to 11/100,000. That rate was comparable to the rate in Manhattan even though nearly one-quarter of all incoming inmates were infected with TB.
At California Medical Facility in the California Department of Corrections, similar control measures effectively aborted an outbreak of TB in a dedicated HIV housing unit. After 22 cases of TB disease occurred over a five month period in 1995 (a case rate of 21,100/100,000 person years), there have been no new cases of TB disease in the past seven years 18.
There are a number of factors that contribute to the increased incidence of TB infection and disease among incarcerated populations. These risk factors include HIV infection, substance use and dependence, poor access to health care, and overcrowding and poor ventilation within correctional facilities.8 The strongest of these risk factors is HIV infection. In 1997 HIV infection was present in an estimated 2.1% of persons incarcerated in state and federal prisons, and the rate of AIDS among prisoners was five times than that of the general population. Concurrent with the increasing number of prisoners in the country, there has been an increase in the number of inmates with HIV infection. From 1991 to 2000 the number of HIV-infected prisoners in state and federal facilities increased from 17,551 to 25,088.17 The rising number of prisoners within the country has led to overcrowding within many correctional facilities, increasing the risk of transmission of M. tuberculosis.
There have been several reports of outbreaks of TB within U.S. prisons and jails. 11, 12, 13, 14, 15, 18, 19. In most of these outbreaks transmission of a single strain of M. tuberculosis was verified by epidemiology and strain typing. Some of these outbreaks involved multidrug resistant strains of M. tuberculosis. In several cases there was transmission to correctional facility staff and members of the communities to which inmates were released. In the investigation of TB cases in Memphis County, 43% of all TB cases reported in 1995 through 1997 were in persons who had previous contact with the jail. This suggests that the jail may have played an important role in contributing to the transmission of M. tuberculosis in the community as well as provided a potential location for prevention efforts15.
HIV infection was a major factor in most reported correctional outbreaks. Reasons for this include the increased rate of reactivation of LTBI in those infected with HIV, delayed diagnosis in HIV-infected source cases due to atypical presentation of TB disease, and the rapid development of disease in HIV-infected persons who were newly infected with M. tuberculosis. In one outbreak that occurred in a housing unit for HIV-infected inmates, extensive transmission was documented.3 In this outbreak, there were 30 secondary cases of TB disease and documentation of new infection in approximately 70% of the 115 inmates who shared the same side of the dormitory with the source patient. In this outbreak, as in others involving HIV-infected inmates, low CD4 count was a risk for TB disease.
In a number of former Soviet Union countries, there is a serious problem of transmission of M. tuberculosis within prisons. Epidemic TB among prisoners, spread of disease from the prisons to the community, and high rates of MDR TB has been documented in many prisons in Russia. Rates of TB in these prisons are among the highest in the world. In 1997 in Tomsk Oblast of Siberia, TB notification rates for the incarcerated population were 4,000 cases per 100,000. The mortality rate from TB among prisoners at that time was 485 per 100,000.16 MDR TB rates throughout the former Soviet Union are also among the highest in the world and in some prisons, up to 23% of isolates from newly-diagnosed cases of TB are MDR. For retreatment cases this proportion is even higher. With the combination of increasing rates of incarceration, especially due to sentences related to injection drug use, and increasing rates of HIV infection among these injection drug users, this problem could become even more serious.
Correctional facilities are settings where intensive measures for TB screening, control and prevention are needed. Screening activities should include inmates as well as employees. Screening should consist of assessing inmates for TB disease and LTBI or histories of either, with a high priority placed upon the prompt diagnosis and isolation of inmates with suspected infectious pulmonary disease. This is important since transmission of M. tuberculosis in correctional facilities can be extensive from persons with undiagnosed, infectious TB.
All newly admitted inmates should be screened for symptoms of TB disease at the time of arrival. If symptoms suggestive of TB disease are present, further diagnostic work-ups should be performed, including a chest radiograph and collection of sputum specimens. If there is any suspicion that the inmate may have pulmonary disease, he or she should be placed in airborne infection isolation as soon as possible to prevent transmission of infection to others in the correctional facility and should remain isolated until there is a determination that the inmate does not have potentially infectious TB. The airborne isolation of the suspected infectious inmate should occur before the initiation of the work-up. If the suspicion is high enough to warrant collection of sputa specimens, especially if HIV co-infection is present, then the inmate should be in isolation.
In addition to screening for symptoms of TB disease upon admission, the index of suspicion for TB should be high for any inmate who presents with cough. In many outbreaks, extensive transmission from undiagnosed cases occurred because TB was not considered as a diagnosis in source cases until late in the course of illness. It is especially important to consider TB early in settings with HIV-infected inmates because of their increased risk of developing disease once infected. In persons with HIV infection, TB may have an atypical clinical and radiographic presentation. There has been extensive transmission documented from HIV-infected source patients who had minimal chest radiograph abnormalities.
Screening for LTBI is important since treatment is an effective prevention tool. This is especially true for incarcerated persons since the risk of reactivation disease is higher than that of the general population due to immune deficiency, drug use, or recent infection. The preferred method of screening for LTBI is the Mantoux method for the TST. Multiple puncture tests are not recommended. Bacille Calmette-Guèrin (BCG) vaccination, pregnancy, or undocumented history of a prior positive skin test are not contraindications to tuberculin skin testing. Because the skin test must be read (always by a trained health care worker) 48 to 72 hours after placement, screening in short-term facilities may be difficult due to high turnover of inmates. In general, 10 mm of induration is defined as a positive skin test, although in special circumstances such as a contact investigation or HIV infection, 5 mm is used to define a positive test.3 In contact investigations and in persons in whom the suspicion of infection is high, treatment of LTBI is sometimes given even when the skin test is negative (especially in the case of HIV infection).
All inmates and employees with initial negative skin tests should have periodic skin testing performed. In most cases, this is performed annually. In all populations where periodic screening occurs, two-step testing (see Table 1) should be initially performed to establish a reliable baseline.8 Periodic screening is an important part of TB control since an unexpected number of positive skin tests or conversions may signal transmission from an undiagnosed case of infectious TB and indicate that an investigation should be initiated.
TB disease and LTBI should ideally be treated by someone experienced in the management of TB, or in consultation with someone with such experience. Treatment guidelines have been published (see below), and new treatment guidelines are expected soon.1, 3, 4, 5, 7, 10 Treatment for all inmates with TB disease and ideally for LTBI should be directly observed to ensure adherence with and completion of treatment. All cases of suspected TB disease should be promptly reported to the local TB control program and a contact investigation should be initiated if indicated.
Isoniazid has been most commonly used for treatment of LTBI. In 2000, the CDC issued recommendations for use of a short course regimen of two months of rifampin and pyrazinamide for treatment of LTBI. Since that time, there have been reports of 44 cases of severe liver injury (including 10 fatalities) associated with this regimen. As a result, isoniazid for nine months is the preferred regimen for treatment of LTBI and should be used whenever possible (an alternative is the use of four months of rifampin. See HIV 101 for use with protease inhibitors and non-nucleoside reverse transcriptase inhibitors.) The use of rifampin and pyrazinamide should be avoided when possible. If rifampin and pyrazinamide are used, there should be extremely close monitoring for symptoms or abnormalities in levels of serum aminotransferases and bilirubin. Rifampin and pyrazinamide should never be used in persons who have experienced liver injury with prior use of isoniazid, or who are pregnant5, 6.
Because correctional facilities house populations at higher risk for TB, close attention to TB control is very important. Screening for infection and disease can lead to prompt diagnosis of infection or disease, prevention of transmission, and completion of treatment of either infection or disease. Attempts should be made to coordinate all TB control activities with the local health department. Doing so can enhance overall TB prevention and care, for example by ensuring treatment completion for inmates upon release to the community. Good TB control in correctional facilities will lead to decreased transmission of M. tuberculosis and prevention of cases among inmates as well as in the communities from which the inmates return to upon release.
For more information and publications regarding TB treatment prevention and control, visit the CDC's Division of Tuberculosis Elimination website at http://www.cdc.gov/nchstp/tb/.
* Nothing to disclose
1. American Thoracic Society Centers for Disease Control. 1994. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med 1994 May;149(5):1359-74. and http://www.thoracic.org/adobe/statements/tbchild1-16.pdf.
2. Iseman MD. Treatment of multidrug-resistant tuberculosis. N Engl J Med 1993 Sep 9;329(11):784-91.
3. CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR Jun 09, 2000 / 49(RR06);1-54.
4. CDC. Update: Fatal and severe liver injuries associated with rifampin and pyrazinamide for latent tuberculosis infection, and revisions in American Thoracic Society/CDC recommendations, 2001. MMWR Aug 31, 2001 / 50(34);733-5.
5. CDC. Fatal and severe hepatitis associated with rifampin and pyrazinamide for the treatment of latent tuberculosis infection---New York and Georgia, 2000. MMWR Apr 20, 2001 / 50(15);289-291.
6. CDC. Reported tuberculosis in the United States, 2001. Atlanta, GA: U.S. Department of Health and Human Services, CDC, September 2002.
7. CDC. Public health dispatch: Update: Fatal and severe liver injuries associated with rifampin and pyrazinamide treatment for latent tuberculosis infection. MMWR Nov 8, 2002 / 51(44);998-999.
8. CDC. Prevention and control of tuberculosis in correctional facilities: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR Jun 7, 1996 / 45(RR-8);1-27.
9. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR Oct 28, 1994 / 43(RR13);1-132.
10. CDC. Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus: principles of therapy and revised recommendations. MMWR, Oct 30, 1998 / 47(RR20);1-51.
11. CDC. Probable transmission of multidrug-resistant tuberculosis in a correctional facility-California. MMWR Jan 29, 1993 / 42(03);48-51.
12. CDC. Tuberculosis transmission in a state correctional institution-California, 1990-1991. MMWR Dec 11, 1992 / 41(49);927-929.
13. CDC. Transmission of multidrug-resistant tuberculosis among immunocompromised persons in a correctional system-New York, 1991. MMWR Jul 17, 1992 / 41(28);507-509.
14. CDC. Drug-susceptible tuberculosis outbreak in a state correctional facility housing HIV-infected inmates-South Carolina, 1999-2000. MMWR, Nov 24, 2000 / 49(46);1041-1044.
15. Jones TF, Craig AS, Valway SE, Woodley CL, Schaffner W. Transmission of tuberculosis in a jail. Ann Intern Med 1999 Oct 19;131(8):557-63.
16. Kimerling ME. The Russian equation: An evolving paradigm on tuberculosis control. Int J Tuberc Lung Dis 2000 Dec;4(12 Suppl 2):S160-7.
17. Maruschak LM. Bureau of Justice Statistics Bulletin: HIV in Prisons 2000. Washington, DC: U.S. Department of Justice: October 2002.
18. Mohle-Boetani JC, Miguelino V, Dewsnup DH, 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.
19. Valway SE, Greifinger RB, Papania M, et al. Multidrug resistant tuberculosis in the New York State prison system, 1990-1991. J Infect Dis 1994;170:151-6.
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©1997,1998,1999,2000,2001,2002, 2003. 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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