Tuberculosis: Behind Bars and Beyond

Assessing the burden of correctional TB and its role as a driver of

community risk in Atlanta, Georgia

Mary Foote MD, MPH1

Infectious Disease Fellow

Anne Spaulding MD, MPH1,2

1Emory University Schools of Medicine and 2Public Health Atlanta, Georgia

Georgia Department of Public Health, TB Division

TB and Correctional FacilitiesConditions that facilitate spread of TB

infectionCongregate setting, delayed diagnosis,

inadequate treatment, poor ventilation and repeated transfers  

Populations at increased risk for active TB diseaseActive disease TB transmission

Community reservoirs for TB Staff, visitors and inadequately treated former

inmates

Correctional TB: EpidemiologyTB in incarcerated persons

1% of total US population incarcerated4.2% TB cases diagnosed in CFs (2011)

Higher TB incidence rates in prisons Prisons = 29.4/100K (fed) and 24.2/100K

(state)General population = 6.7/100K persons

Reporting methods limit better estimates …

Bureau of Justice Statistics (2011)/CDC TB report 2011/MacNeil (2005)

Report of Verified Case of TB (CDC)Only one question on current incarceration

No questions on prior incarceration

Prior StudiesHammett, AJPH, 2002Estimate for TB burden in U.S. inmate/releasee

population in 1997Of 31,000 persons with TB in U.S. 40% went through

CF

Baussano, PLoS Med, 2010Systematic review: 14 studies reporting prison TB

incidence in high-income countries (50% U.S.)Incidence rate ratio = TB incidence in prisons =23

incidence in gen population% attributable fraction (PAF) = 8.5%

Study Hypotheses1. Incarceration plays a significant role in

TB transmission

2. A high proportion of TB cases may have had exposure to a CF

The longer the exposure greater the TB risk

3. There is an association between adherence to TB control guidelines and jurisdictional TB rates

Study Setting: Atlanta, GAGeorgia incarceration rates = 975 per 100K

personsIn 2011, Georgia had:

11th highest TB incidence in the United States

3.5 cases/100K persons10% of TB cases diagnosed in a CF (31/321

cases)53% of the new TB cases reported from the

Atlanta metropolitan area

Specific Aims: Part IAnalysis of TB transmission in Atlanta CF

populations(Fulton/DeKalb counties)

AIM I: To estimate proportion of Atlanta TB cases

detained in a CF in 2011Aim II: Among incident TB cases 2009-2012

Assess proportion that may have acquired and/or transmitted TB while incarcerated

Methods: Part IIdentify Atlanta TB cases 2009-2011

Cross-match with Atlanta CF prisoner databases

Chart review for incarceration history

Identify indirect exposure to CFGenotype and contact investigation data

Specific Aims: Part IIFacilities evaluation

AIM 3: For each CF, describeTB infection control plans and practices Population characteristicsIncident TB case rate per 100K admission

AIM 4: For each CF, calculate TB case identification rate Missed TB case rate

Expected ResultsAnticipate 40-60% of TB cases in

Fulton/DeKalb Counties have been exposed to CF

All CFs will have a TB infection control plan Fair to moderate adherence to guidelines

Correlation between adherence to guidelines and community TB ratesIncreased correctional genotypes found in

community

SignificanceBetter understand true burden of TB in

correctional populations

Identify problem areas in TB infection control and practices in Atlanta CFs

Advocate for more resources Improve TB case identification and treatment

in hard to reach populations Improve transitional linkages to care

AcknowledgementsSusan Ray, MD1

Russell Kempker, MD, MSc1

Rose-Marie F. Sales, MD, MPH2

David Maggio, MPH2

Carolyn Martin, RN2

Mille Reeves, RN4

Anne Spaulding, MD, MPH1,3

1Emory University College of Medicine, Division Infectious Diseases2Georgia Department of Public health, TB Division3Emory University, Rollins School of Public health 4Georgia Department of Corrections

Thank You!!!Happy World TB Day

Extra Slides

Background: TB~1/3 of the world infected with

Mycobacterium tuberculosis (MTB)TB is spread by airborne droplets

Open air and UV light decreases transmission10% of persons infected with MTB will

develop active TB diseaseHigher risk of disease in certain conditions

(eg. HIV infection, malnutrition, DM, substance/EtOH abuse)

Methods: Part IICF evaluations: Site visits

Assess TB infection control plans and adherence to guidelines

Analyses% TB cases acquired though CF exposureRate of TB cases diagnosed and missed for

each CFAttributable risk of TB due to correctional

exposure TB Incidence (exposed) – TB Incidence (unexposed)

Next stepsScale-up evaluationPotential interventions:

Dedicated correctional TB case managersImproving transitional retention in TB care Improved TB diagnostics Short course LTBI treatment Electronic TB management/surveillance

program

TB Control in CFsCDC Guideline, 2006

Early identification of TB diseaseSuccessful treatment of TB disease and latent

TBAppropriate use of airborne precautions Comprehensive discharge planningThorough and efficient contact investigation

Francis J. Curry National Tuberculosis Center: TB Infection Control Plan Template for Jails, 2002

Source of Map: Pew Center, 1:100

Prevalence: Selected Conditions in Prisoners

0

5

10

15

20

25

Source: Hammett T. AJPH 2002; 92(11) 1789

Mean %

Source: Hammett T. AJPH 2002; 92(11) 1789

0

25

50

75

100

HIV/AIDS TB disease

Percentage of US Population with Condition

Disease

Releasees (1997) with Condition as % of US Population with Condition

Other

Releasee

HCV

= Approx. 150,000 cases