Research articleTreatment for latent TB in correctional facilities: A challenge for TB elimination
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.
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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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