Research article
Treatment for latent TB in correctional facilities: A challenge for TB elimination

https://doi.org/10.1016/S0749-3797(02)00583-4Get rights and content

Abstract

Background

To eliminate tuberculosis (TB) in the United States, more information is needed on how to gain access to difficult-to-reach, high-risk populations to evaluate people who would benefit from treatment for latent TB infection (LTBI).

Methods

A field study was conducted of people at risk for co-infection with TB and the human immunodeficiency virus (HIV) and to demonstrate that treating LTBI in inmates is feasible. Inmates were tested for LTBI using the Mantoux tuberculin skin test (TST). Outcomes measured were skin test results and the start and completion of treatment for LTBI.

Results

In 49 correctional facilities in 12 states, 198,102 inmates had a skin test read. The mean skin test positivity rate among inmates was 17.0%. Of those who had a known HIV test result, 14.5% tested HIV positive. Inmates with a positive TST were 4.2 times more likely than those with a negative TST to be HIV infected (95% confidence interval [CI]=3.9–4.4). Therapy for LTBI was completed in 55.9% of patients started on treatment. Patients who were HIV positive and started on a 12-month treatment regimen were less likely than HIV-negative patients (40.0% vs 68.1%, respectively) to complete treatment (odds ratio [OR]=0.24, 95% CI=0.20–0.28). Patients treated in jails were less likely than those treated in prisons (33.6% vs 57.7%, respectively) to complete treatment (OR=0.29, 95% CI=0.26–0.32).

Conclusions

Correctional facilities offer a venue for identifying and treating high-risk individuals for LTBI. However, completing treatment is more problematic in jails than in prisons.

Introduction

During the recent resurgence of tuberculosis (TB) in the United States in the late 1980s and early 1990s, correctional facilities were noteworthy arenas for transmission of drug-sensitive and drug-resistant TB.1, 2, 3 Multiple factors, especially the housing of high-risk individuals in overcrowded conditions, made TB an important health threat within correctional facilities.4, 5 Transmission from former inmates to the community has also been documented and is a serious public health concern.3, 6, 7 Yet, despite a recent decline in the overall number of TB cases, correctional facilities continue to report TB outbreaks.8 These outbreaks raise the concern that infectious TB cases are missed during the entry screening process and may result in TB transmission to other inmates or correctional staff.3, 9, 10

Recently, the Centers for Disease Control and Prevention (CDC) re-emphasized the possibility and importance of eliminating TB in the United States.11 As part of its TB-elimination strategy, CDC has recommended that populations at high risk for TB disease be targeted with interventions to reduce their chance of TB exposure and infection. Owing to medical and social risk factors for TB (e.g., infection with HIV, homelessness, and use of alcohol and other drugs), inmates are at higher risk for latent TB infection (LTBI) than are members of the general population.12 Because the correctional setting provides an opportunity for large numbers of persons with risks for TB to be reached by public health interventions,13 these facilities are increasingly becoming a focus of TB prevention and control efforts.14

From 1990 to 1997, CDC sponsored the HIV-Related TB Prevention (HRTP) project in response to numerous concerns, including the resurgence of TB in prisons and jails (with outbreaks of multidrug-resistant TB) and the growing problem of TB related to co-infection with HIV. Because treatment of LTBI can be difficult owing to the length of treatment, which was previously recommended for 6 to 12 months but was recently changed to 9 months,15 the goals of HRTP were to demonstrate that it was feasible to access high-risk populations in correctional facilities and to screen inmates for TB disease and LTBI, and that at least 80% of TB-infected patients would start treatment. Although many correctional facilities have since improved their efforts to control TB as a result of implementing CDC recommendations,16 the effectiveness of TB screening procedures and treatment efforts has been evaluated only to a limited extent. We reviewed the operational outcomes of HRTP in the correctional setting and drew lessons from that experience.

Section snippets

Methods

Through collaboration between health departments and correctional facilities, the HRTP project implemented a common protocol that created electronic information systems for the evaluation of tuberculin skin testing and TB treatment in settings with logistical barriers. Seventy-five percent of inmates participated between 1993 and 1996, and 43% were incarcerated in the New York State prison system. The other project areas and the percent of inmates from each area were Arkansas (1%), California

Results

A total of 199,399 inmates in 46 correctional facilities and systems (six jails) located in 12 states had a TST placed; 99.3% (198,102) of these inmates had their TST read. Inmates had a median age of 30 years and were predominately male (90.1%) and non-white (74.6%) (Table 1). Overall, 33,653 inmates (mean, 17.0%; median, 13.9%; range, 4.6% to 32.8%) had a positive TST (Table 2). The proportion of inmates with a positive TST declined steadily, from 15.8% in 1992 to 8.4% in 1996. Inmates with a

Discussion

The HRTP project included the largest number of HIV-infected and HIV-uninfected inmates about whom TB testing and treatment outcome data have been collected. These data help define the feasibility of gaining access to incarcerated populations and provide useful information about LTBI testing and treatment outcomes. Although treatment for LTBI was previously completed in 24% of TST-positive inmates, other inmates had a previous positive TST and had not completed treatment, thus retaining a

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