Tuberculosis in Jails and Prisons: United States, 2002-2013

The American Association of Tissue Banks tissue donor screening for Mycobacterium tuberculosis-Recommended criteria and literature review

After two multistate outbreaks of allograft tissue-transmitted tuberculosis (TB) due to viable bone, evidence-based donor screening criteria were developed to decrease the risk of transmission to recipients. Exclusionary criteria, commentary, and references supporting the criteria are provided, based on literature search and expert opinion. Both exposure and reactivation risk factors were considered, either for absolute exclusion or for exclusion in combination with multiple risk factors. A criteria subset was devised for tissues containing viable cells. Risk factors for consideration included exposure (e.g., geographic birth and residence, travel, homelessness, incarceration, healthcare, and workplace) and reactivation (e.g., kidney disease, liver disease, history of transplantation, immunosuppressive medications, and age). Additional donor considerations include the possibility of sepsis and chronic illness. Donor screening criteria represent minimal criteria for exclusion and do not completely exclude all possible donor TB risks. Additional measures to reduce transmission risk, such as donor and product testing, are discussed but not included in the recommendations. Careful donor evaluation is critical to tissue safety.

Quality of Surgical Care Within the Criminal Justice Health Care System

Importance

Individuals who are incarcerated represent a vulnerable group due to concerns about their ability to provide voluntary and informed consent, and there are considerable legal protections regarding their participation in medical research. Little is known about the quality of surgical care received by this population.

Objective

To evaluate perioperative surgical care provided to patients who are incarcerated within the Texas Department of Criminal Justice (TDCJ) and compare their outcomes with that of the general nonincarcerated population.

Design, Setting, and Participants

This cohort study analyzed data from patients who were incarcerated within the TDCJ and underwent general or vascular surgery at the University of Texas Medical Branch (UTMB) from 2012 to 2021. Case-specific outcomes for a subset of these patients and for patients in the general academic medical center population were obtained from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) and compared. Additional quality metrics (mortality index, length of stay index, and excess hospital days) from the Vizient Clinical Data Base were analyzed for patients in the incarcerated and nonincarcerated groups who underwent surgery at UTMB in 2020 and 2021 to provide additional recent data. Patient-specific demographics, including age, sex, and comorbidities were not available for analysis within this data set.

Main Outcome and Measures

Perioperative outcomes (30-day morbidity, mortality, and readmission rates) were compared between the incarcerated and nonincarcerated groups using the Fisher exact test.

Results

The sample included data from 6675 patients who were incarcerated and underwent general or vascular surgery at UTMB from 2012 to 2021. The ACS-NSQIP included data (2012-2021) for 2304 patients who were incarcerated and 602 patients who were not and showed that outcomes were comparable between the TDCJ population and that of the general population treated at the academic medical center with regard to 30-day readmission (6.60% vs 5.65%) and mortality (0.91% vs 1.16%). However, 30-day morbidity was significantly higher in the TDCJ population (8.25% vs 5.48%, P = .01). The 2020 and 2021 data from the Vizient Clinical Data Base included 629 patients who were incarcerated and 2614 who were not and showed that the incarcerated and nonincarcerated populations did not differ with regard to 30-day readmission (12.52% vs 11.30%) or morbidity (1.91% vs 2.60%). Although the unadjusted mortality rate was significantly lower in the TDCJ population (1.27% vs 2.68%, P = .04), mortality indexes, which account for case mix index, were similar between the 2 populations (1.17 vs 1.12).

Conclusions and Relevance

Findings of this cohort study suggest that patients who are incarcerated have equivalent rates of mortality and readmission compared with a general academic medical center population. Future studies that focus on elucidating the potential factors associated with perioperative morbidity and exploring long-term surgical outcomes in the incarcerated population are warranted.

Prevalence of tuberculosis among prisoners in sub-Saharan Africa: a systematic review and meta-analysis

Background

Tuberculosis (TB) is a key community health problem in numerous settings, predominantly in sub-Saharan Africa (SSA). TB is the second most lethal infectious disease worldwide. Around 1.6 million people died from TB in 2021. TB prevention and control strategies are difficult to implement in prison, especially in sub-Saharan Africa, owing to overcrowding and poor ventilation. Thus, this systematic review and meta-analysis aimed to synthesize the estimated pooled prevalence of tuberculosis among prisoners in sub-Saharan Africa.

Materials and methods

Electronic biomedical databases such as Google Scholar, Web of Science, PubMed/Medline, EMBASE, and Science Direct were used to systematically explore candidate studies published until December 2022. Data extraction was performed using a Microsoft Excel spreadsheet. The estimated pooled prevalence of tuberculosis was determined using a fixed-effects model. Cochrane Q-test and I2 statistics were used to check heterogeneity statistically across different studies. Begg's rank and Egger's tests were performed to assess evidence of possible publication bias.

Results

A total of 40 articles involving 59,300 prisoners were included in this systematic review and meta-analysis. The pooled prevalence of tuberculosis was 4.02% (95% CI: 2.68-5.36). We found the highest prevalence using Gene X pert as a diagnostic method, which was 4.97 (95% CI: 2.22-7.73). There is no evidence of publication bias.

Conclusion

The outcome of this review revealed a high prevalence of tuberculosis among prisoners in sub-Saharan Africa. To reach the "End Tuberculosis strategy" by 2030, early identification of cases through screening on entry and periodical active case finding is important. Moreover, prevention and prompt treatment after diagnosis must be implemented to limit transmission to the general population.

Systematic review registration

https://www.crd.york.ac.uk/prospero/#searchadvanced, identifier (CRD42023428933).

Incarcerated in a Pandemic: How COVID-19 Exacerbated the “Pains of Imprisonment”

Although the exact toll of COVID-19 in U.S. prisons and jails is relatively undetermined, estimates show that deaths due to the virus in the nation's correctional facilities are approximately six times higher than deaths in the general population. During the pandemic, jail and prison structures as well as significant overcrowding made it virtually impossible to institute protective measures against infection in correctional settings. Jail and prison administrators suspended in-person visitation, leaving those incarcerated even further isolated, and their friends and family in fear for the health and safety of their loved ones. The present study examines narratives of individuals who spoke about their experiences while incarcerated during the pandemic. The data for the study were gathered from prison reform advocacy organizations that featured individuals’ stories. The narrative findings provide insight into the traumatic experiences that incarcerated people endured, how institutional failures exacerbated their mistrust of the criminal legal system, and their efforts to cope.

"To Be Honest, You Probably Would Have to Read It 50 Times": Stakeholders Views on Using the Opt-Out Approach for Vaccination in Jails

Background

Despite national guidelines on infectious disease testing and vaccination in prisons, there is heterogeneity on the implementation of these practices in jails. We sought to better understand perspectives on the implementation of opt-out vaccination for infectious diseases in jails by interviewing a broad group of stakeholders involved in infectious diseases vaccination, testing, and treatment in Massachusetts jails.

Methods

The research team conducted semistructured interviews with people incarcerated in Hampden County Jail (Ludlow, Massachusetts), clinicians working in jail and community settings, corrections administrators, and representatives from public health, government, and industry between July 2021 and March 2022.

Results

Forty-eight people were interviewed, including 13 people incarcerated at the time of interview. Themes that emerged included the following: misunderstandings of what opt-out means, indifference to the way vaccines are offered, belief that using the opt-out approach will increase the number of individuals who receive vaccination, and that opt-out provides an easy way for vaccine rejection and reluctance to accept vaccination.

Conclusions

There was a clear divide in stakeholders' support of the opt-out approach, which was more universally supported by those who work outside of jails compared to those who work within or are incarcerated in jails. Compiling the perspectives of stakeholders inside and outside of jail settings on the opt-out approach to vaccination is the first step to develop feasible and effective strategies for implementing new health policies in jail settings.

Conditions of Confinement in U.S. Carceral Facilities During COVID-19: Individuals Speak-Incarcerated During the COVID-19 Epidemic

Objectives

We aimed to describe conditions of confinement among people incarcerated in the United States during the coronavirus disease 2019 (COVID-19) pandemic using a community-science data collection approach.

Methods

We developed a web-based survey with community partners to collect information on confinement conditions (COVID-19 safety, basic needs, support). Formerly incarcerated adults released after March 1, 2020, or nonincarcerated adults in communication with an incarcerated person (proxy) were recruited through social media from July 25, 2020 to March 27, 2021. Descriptive statistics were estimated in aggregate and separately by proxy or formerly incarcerated status. Responses between proxy and formerly incarcerated respondents were compared using Chi-square or Fisher's exact tests based on α=0.05.

Results

Of 378 responses, 94% were by proxy, and 76% reflected state prison conditions. Participants reported inability to physically distance (≥6 ft at all times; 92%), inadequate access to soap (89%), water (46%), toilet paper (49%), and showers (68%) for incarcerated people. Among those receiving prepandemic mental health care, 75% reported reduced care for incarcerated people. Responses were consistent between formerly incarcerated and proxy respondents, although responses by formerly incarcerated people were limited.

Conclusions

Our findings suggest that a web-based community-science data collection approach through nonincarcerated community members is feasible; however, recruitment of recently released individuals may require additional resources. Our data obtained primarily through individuals in communication with an incarcerated person suggest COVID-19 safety and basic needs were not sufficiently addressed within some carceral settings in 2020-2021. The perspectives of incarcerated individuals should be leveraged in assessing crisis-response strategies.

Public Health and Prisons: Priorities in the Age of Mass Incarceration

Mass incarceration is a sociostructural driver of profound health inequalities in the United States. The political and economic forces underpinning mass incarceration are deeply rooted in centuries of the enslavement of people of African descent and the genocide and displacement of Indigenous people and is inextricably connected to labor exploitation, racial discrimination, the criminalization of immigration, and behavioral health problems such as mental illness and substance use disorders. This article focuses on major public health crises and advances in state and federal prisons and discusses a range of practical strategies for health scholars, practitioners, and activists to promote the health and dignity of incarcerated people. It begins by summarizing the historical and sociostructural factors that have led to mass incarceration in the United States. It then describes the ways in which prison conditions create or worsen chronic, communicable, and behavioral health conditions, while highlighting priority areas for public health research and intervention to improve the health of incarcerated people, including decarceral solutions that can profoundly minimize-and perhaps one day help abolish-the use of prisons.

The contingent effect of incarceration on state health outcomes

Introduction

This study examines how growth in the population of former prisoners affects rates of communicable diseases such as tuberculosis, syphilis, chlamydia, and HIV.

Methods

We estimate state-level fixed effects count models showing how the former prisoner population affected communicable disease in U.S. states from 1987 to 2010, a period of dramatic growth in incarceration.

Results

We find contingent effects, based on how specific diseases are recognized, tested, and treated in prisons. The rate of former prisoners increases diseases that are poorly addressed in the prison health care system (e.g., chlamydia), but decreases diseases that are routinely tested and treated (e.g., tuberculosis). For HIV, the relationship has shifted in response to specific treatment mandates and protocols. Data on prison healthcare spending tracks these contingencies.

Discussion

Improving the health of prisoners can improve the health of the communities to which they return. We consider these results in light of the relative quality of detection and treatment available to underserved populations within and outside prisons.

A Case of Previously Undiagnosed Systemic Lupus Erythematosus and Mycobacterium tuberculosis Infection Presenting as Diffuse Alveolar Hemorrhage

Diffuse alveolar hemorrhage (DAH) is described as the collection of blood in alveolar spaces caused by damaged pulmonary vasculature. It often presents as a life-threatening medical emergency that requires urgent medical intervention along with timely diagnosis and management of the underlying cause. We hereby report a 19-year-old female who presented with clinical and radiological characteristics consistent with DAH. Laboratory workup studies revealed a diagnosis of systemic lupus erythematosus (SLE) as well as Mycobacterium tuberculosis (MTB) infection. This report describes an extremely unusual case of undiagnosed SLE and coexistent tuberculosis presenting as DAH. This leads to an interesting possibility of risks in patients with immune-mediated vasculitis towards developing severe pulmonary disease in the setting of pulmonary mycobacterial infection.

Diagnosis, Treatment, and Prevention of HIV Infection among Detainees: A Review of the Literature

Detainees are one of the most vulnerable populations to human immunodeficiency virus (HIV). This is mostly caused by the lack of knowledge on the topic among the inmates; the lack of prophylaxis; the high percentage of risky behaviors in jail, such as sexual abuse, unprotected sexual intercourses, and injective drug use; and the generally low perception of the risk of transmission. It has also been observed that the problem does not cease to exist at the moment of release, but it also may be aggravated by the weak support system or the total absence of programs for people living with HIV/AIDS (PLWHA) to avoid discontinuation of antiretroviral drugs. Difficulty in providing housing and jobs and, therefore, a form of stability for ex-detainees, also contributes to none adherence to antiretroviral therapy. Among the detainees, there are also categories of people more susceptible to discrimination and violence and, therefore, to risky behaviors, such as black people, Hispanics, transgender people, and men who have sex with men (MSM). We reviewed the literature in order to provide a more complete picture on the situation of PLWHA in jail and to also analyze the difficulties of ex-detainees in adhering to HIV therapy.

Molecular surveillance for large outbreaks of tuberculosis in the United States, 2014-2018

OBJECTIVE

This study describes characteristics of large tuberculosis (TB) outbreaks in the United States detected using novel molecular surveillance methods during 2014-2016 and followed for 2 years through 2018.

METHODS

We developed 4 genotype-based detection algorithms to identify large TB outbreaks of ≥10 cases related by recent transmission during a 3-year period. We used whole-genome sequencing and epidemiologic data to assess evidence of recent transmission among cases.

RESULTS

There were 24 large outbreaks involving 518 cases; patients were primarily U.S.-born (85.1%) racial/ethnic minorities (84.1%). Compared with all other TB patients, patients associated with large outbreaks were more likely to report substance use, homelessness, and having been diagnosed while incarcerated. Most large outbreaks primarily occurred within residences among families and nonfamilial social contacts. A source case with a prolonged infectious period and difficulties in eliciting contacts were commonly reported contributors to transmission.

CONCLUSION

Large outbreak surveillance can inform targeted interventions to decrease outbreak-associated TB morbidity.

Influenza Vaccination in Massachusetts Jails: A Mixed-Methods Analysis

OBJECTIVES

Influenza infects millions of people each year and contributes to tens of thousands of deaths annually despite the availability of vaccines. People most at risk of influenza complications are disproportionately represented in people incarcerated in US prisons and jails. The objectives of this study were to survey health administrators in Massachusetts county jails about institutional influenza vaccine policies and practices and estimate influenza vaccination rates in Massachusetts jails from 2013 to 2020.

METHODS

In April 2020, we administered surveys to the health services administrators in Massachusetts' 14 county jails to gather information about influenza vaccination policies and delivery practices. To calculate influenza vaccination rates for each facility, we obtained data on influenza vaccine orders from the Massachusetts Department of Public Health for each county in Massachusetts for influenza seasons 2013-2020. We calculated summary statistics for each reporting facility and each year, conducted a Kruskal-Wallis analysis to compare vaccination rates between years, and used a linear regression model to identify predictors of vaccination rates.

RESULTS

Influenza vaccination rates in Massachusetts jails ranged from 1.9% to 11.8%. We found no significant differences in vaccination rates between years. Influenza vaccine ordering and delivery practices varied by jail, and respondents had high levels of confidence in influenza policies and vaccine delivery practices.

CONCLUSIONS

Influenza vaccination rates in Massachusetts jails are low, and delivery practices in jails vary. Lack of influenza vaccinations in jails is a gap in health care that needs to be prioritized, especially considering the current COVID-19 pandemic. Further investigations for effective and equitable vaccination in this population should involve people who are incarcerated and people who make influenza vaccine policies in jails.

Tuberculosis Outbreaks in State Prisons, United States, 2011-2019

Objectives. To understand the frequency, magnitude, geography, and characteristics of tuberculosis outbreaks in US state prisons. Methods. Using data from the National Tuberculosis Surveillance System, we identified all cases of tuberculosis during 2011 to 2019 that were reported as occurring among individuals incarcerated in a state prison at the time of diagnosis. We used whole-genome sequencing to define 3 or more cases within 2 single nucleotide polymorphisms within 3 years as clustered; we classified clusters with 6 or more cases during a 3-year period as tuberculosis outbreaks. Results. During 2011 to 2019, 566 tuberculosis cases occurred in 41 state prison systems (a median of 3 cases per state). A total of 19 tuberculosis genotype clusters comprising 134 cases were identified in 6 state prison systems; these clusters included a subset of 5 outbreaks in 2 states. Two Alabama outbreaks during 2011 to 2017 totaled 20 cases; 3 Texas outbreaks during 2014 to 2019 totaled 51 cases. Conclusions. Only Alabama and Texas reported outbreaks during the 9-year period; only Texas state prisons had ongoing transmission in 2019. Effective interventions are needed to stop tuberculosis outbreaks in Texas state prisons. (Am J Public Health. 2022;112(8):1170-1179. https://doi.org/10.2105/AJPH.2022.306864).

Care of Justice-Involved Populations

Terminology Incarcerated is a nonspecific term which refers to a person confined to a jail, prison, or other institution. Inmate (preferred term: incarcerated person) refers to a person confined in a correctional facility (jail or prison). Individuals who are classified as being on probation, parole, or supervised release, remain under court supervision and are allowed to serve some or all of their sentence while residing in the community.2 Jails are under municipal or county jurisdictions and house persons awaiting trial, sentencing, or transfer to another facility; those who have violated parole or probation; and some individuals who have been sentenced to less than a year in custody.3 State and federal prisons generally house persons who have been sentenced to greater than one year in custody.3.

A Pilot TB Screening Model in a U.S. Prison Population Using Tuberculin Skin Test and Interferon Gamma Release Assay Based on Country of Origin

The objective of this study was to compare tuberculosis (TB) screening results before and after implementation of a stratified testing strategy screening pilot study, incorporating interferon gamma release assay (IGRA) and tuberculin skin test (TST), based on country of origin. In 2015, the Washington State Department of Corrections began screening people born outside of the United States for TB with IGRA, while U.S.-born people continued screening by TST. Of 405 (75%) foreign-born men screened with IGRA, 403 had valid test results and IGRA screening positivity was 10.4% (N = 42). In contrast, among 5,940 primarily U.S-born men screened with TST, 24 (0.4%) were positive. Overall positivity was 1.05%, similar to TST-only positivity in 2013 (1.05%) and 2014 (0.85%). Incorporating IGRA screening among foreign-born persons was feasible in this state prison system.

Mitigating outbreaks in congregate settings by decreasing the size of the susceptible population

While many transmission models have been developed for community spread of respiratory pathogens, less attention has been given to modeling the interdependence of disease introduction and spread seen in congregate settings, such as prisons or nursing homes. As demonstrated by the explosive outbreaks of COVID-19 seen in congregate settings, the need for effective outbreak prevention and mitigation strategies for these settings is critical. Here we consider how interventions that decrease the size of the susceptible populations, such as vaccination or depopulation, impact the expected number of infections due to outbreaks. Introduction of disease into the resident population from the community is modeled as a branching process, while spread between residents is modeled via a compartmental model. Control is modeled as a proportional decrease in both the number of susceptible residents and the reproduction number. We find that vaccination or depopulation can have a greater than linear effect on anticipated infections. For example, assuming a reproduction number of 3.0 for density-dependent COVID-19 transmission, we find that reducing the size of the susceptible population by 20% reduced overall disease burden by 47%. We highlight the California state prison system as an example for how these findings provide a quantitative framework for implementing infection control in congregate settings. Additional applications of our modeling framework include optimizing the distribution of residents into independent residential units, and comparison of preemptive versus reactive vaccination strategies.

Is There a Temporal Relationship between COVID-19 Infections among Prison Staff, Incarcerated Persons and the Larger Community in the United States?

Background: Our objective was to examine the temporal relationship between COVID-19 infections among prison staff, incarcerated individuals, and the general population in the county where the prison is located among federal prisons in the United States. Methods: We employed population-standardized regressions with fixed effects for prisons to predict the number of active cases of COVID-19 among incarcerated persons using data from the Federal Bureau of Prisons (BOP) for the months of March to December in 2020 for 63 prisons. Results: There is a significant relationship between the COVID-19 prevalence among staff, and through them, the larger community, and COVID-19 prevalence among incarcerated persons in the US federal prison system. When staff rates are low or at zero, COVID-19 incidence in the larger community continues to have an association with COVID-19 prevalence among incarcerated persons, suggesting possible pre-symptomatic and asymptomatic transmission by staff. Masking policies slightly reduced COVID-19 prevalence among incarcerated persons, though the association between infections among staff, the community, and incarcerated persons remained significant and strong. Conclusion: The relationship between COVID-19 infections among staff and incarcerated persons shows that staff is vital to infection control, and correctional administrators should also focus infection containment efforts on staff, in addition to incarcerated persons.

Risk of COVID-19 infection among prison staff in the United States

BACKGROUND

Multiple large outbreaks of COVID-19 have been documented in prisons and jails across regions of the world, with hazardous environmental conditions amplify the risks of exposure for both incarcerated people and correctional staff. The objectives of this study are to estimate the cumulative prevalence of COVID-19 cases among U.S. prison staff over time and compare it to the prison inmate population and the general U.S. population, overall, and to examine risk of COVID-19 infection among prison staff across jurisdictions.

METHODS

We use publicly available data (April 22, 2020 to January 15, 2021) to estimate COVID-19 crude case rates per 1000 with 95% confidence intervals over the study period for prison staff, incarcerated population, and general population. We also compare COVID-19 case rates between prison staff and the general population within jurisdictions.

RESULTS

Over the study period, prison staff have reported consistently higher rates of COVID-19 compared to the general population, with prison staff case rates more closely mirroring the incarcerated population case rates. The rolling 7-day average case rates for prison staff, prison population, and general population on January 15, 2021 were 196.04 per 1000 (95%CI 194.81, 197.26), 219.16 (95%CI 218.45, 219.86), and 69.80 (95%CI 69.78, 69.83), respectively. There was substantial heterogeneity across jurisdictions, yet in 87% of study jurisdictions, the risk of COVID-19 was significantly greater among prison staff than the general state population.

CONCLUSIONS

Targeting staff for COVID-19 mitigation strategies is essential to protect the health of people who intersect with the correctional system and to flatten the curve in the surrounding communities.

Rational laboratory testing in uveitis: A Bayesian analysis

Uveitis encompasses a heterogeneous group of clinical entities with the common feature of intraocular inflammation. In addition to patient history and examination, a focused set of laboratory investigations is frequently necessary to establish a specific diagnosis. There is limited consensus among uveitis specialists regarding appropriate laboratory evaluation for many distinct patient presentations. The appropriateness of a laboratory test for a given case of uveitis will depend on patient-specific as well as epidemiologic factors. Bayesian analysis is a widely used framework for the interpretation of laboratory testing, but is seldom adhered to in clinical practice. Bayes theorem states that the predictive value of a particular laboratory test depends on the sensitivity and specificity of that test, as well as the prevalence of disease in the population being tested. In this review we will summarize the performance of commonly-utilized laboratory tests for uveitis, as well as the prevalence of uveitic diagnoses in different geographic practice settings. We will propose a logical framework for effective laboratory testing in uveitic disease through rigorous application of Bayesian analysis. Finally, we will demonstrate that while many highly sensitive laboratory tests offer an effective means to rule out associated systemic disease, limited test specificity and low pretest probability often preclude the diagnosis of systemic disease association with any high degree of certainty, even in the face of positive testing.

Occupational Respiratory Infections

Occupational respiratory infections can be caused by bacterial, viral, and fungal pathogens. Transmission in occupational settings can occur from other humans, animals, or the environment, and occur in various occupations and industries. In this article, we describe 4 occupationally acquired respiratory infections at the focus of NIOSH investigations over the last decade: tuberculosis (TB), influenza, psittacosis, and coccidioidomycosis. We highlight the epidemiology, clinical manifestations, occupational risk factors, and prevention measures.

The seedbeds of Tuberculosis: is it time to target congregate settings and workplaces?

Countries where the incidence of Tuberculosis (TB) is low display a low transmission rate in the general population, and this rate has progressively declined in recent decades; however, TB epidemiology has shown a shift of the disease burden from the general population to specific populations at higher risk, such as vulnerable individuals and hard-to-reach groups. In low-incidence countries, preventive and therapeutic strategies must therefore be geared towards targeted interventions in these populations, with the priority being to promptly identify and treat latent tuberculosis infection (LTBI) rather than manage infectious cases. One of the most complex challenges in this area is to identify population subgroups with increased incidence/prevalence of LTBI/TB. The aim of this study was to provide a concise overview of the main studies and available evidence concerning the epidemiology of TB and LTBI in non-healthcare congregate settings, with specific emphasis on studies conducted in occupational settings and workplaces. Recognizing settings at increased risk might contribute to eliminating TB in low-incidence countries, a challenge which requires tailored responses. Occupational and preventive medicine has a major role to play in directing ad hoc policies and programs of LTBI surveillance. If TB is to be eradicated, it is essential to contain the seedbeds of infection: indeed, as long as a large reservoir of infected subjects exists, new active TB cases may arise at any time.

Tuberculosis active case-finding interventions and approaches for prisoners in sub-Saharan Africa: a systematic scoping review

BACKGROUND

In sub-Saharan Africa (SSA), most prisons are overcrowded with poor ventilation and put prisoners disproportionally at risk of exposure to Mycobacterium tuberculosis (TB) and developing TB infection but are mostly missed due to poor access to healthcare. Active case-finding (ACF) of TB in prisons facilitates early diagnosis and treatment of inmates and prevent the spread. We explored literature and described evidence on TB ACF interventions and approaches for prisoners in SSA prisons.

METHODS

Guided by the Arksey and O'Malley framework, we searched PubMed, Google Scholar, SCOPUS, Academic search complete, CINAHL and MEDLINE with full text via EBSCOhost for articles on prisoners and ACF from 2000 to May 2019 with no language restriction. Two investigators independently screened the articles at the abstract and full-text stages in parallel guided by the eligibility criteria as well as performed the methodological quality appraisal of the included studies using the latest mixed-method appraisal tool. We extracted all relevant data, organized them into themes and sub-themes, and presented a narrative summary of the results.

RESULTS

Of the 391 eligible articles found, 31 met the inclusion criteria. All 31 articles were published between 2006 and 2019 with the highest six (19.4%) in 2015. We found evidence in 11 countries. That is, Burkina Faso, Cameroon, Coˆte d'Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Malawi, Nigeria, South Africa, Uganda, and Zambia with most 41.9% (13/31) recorded in Ethiopia. These intervention studies were conducted in 134 prisons between 2001 and 2018 using either a single or combination of mass, facility-led, entry, peer educators for routine screening, and exit ACF approaches. The majority (74%) of the studies utilized only a mass screening approach. The most (68%) reported study outcome was smear-positive TB cases only (68%). We found no evidence in 16 SSA countries although they are classified among the three high-burden country lists for TB TB/HIV and Multidrug resistant-TB group.

CONCLUSION

Our review highlights a dearth of evidence on TB ACF interventions in most SSA countries prisons. Hence, there is the need to scaling-up ACF interventions in SSA prisons, particularly countries included in the three high-burden country lists for TB, TB/HIV, and MDR-TB.

The diagnosis of latent tuberculosis infection (LTBI): currently available tests, future developments, and perspectives to eliminate tuberculosis (TB)

INTRODUCTION

Despite great efforts, tuberculosis (TB) is still a major public health threat worldwide. For decades, TB control programs have focused almost exclusively on infectious TB active cases.  However, it is evident that this strategy alone cannot achieve TB elimination. To achieve this objective a comprehensive strategy directed toward integrated latent tuberculosis infection (LTBI) management is needed. Recently it has been recognized that LTBI is not a stable condition but rather a spectrum of infections (e.g., intermittent, transient or progressive) which may lead to incipient, then subclinical, and finally active TB disease.

AIM

Provide an overview of current available LTBI diagnostic test including updates, future developments and perspectives.

RESULTS

There is currently no test for the direct identification of live MT infection in humans. The diagnosis of LTBI is indirect and relies on the detection of an immune response against MT antigens, assuming that the immune response has developed after a contact with the biological agent. Tuberculin skin test (TST) and interferon gamma release assays (IGRAs) are the main diagnostic tools for LTBI, however, both present strengths and limitations. The most ancient diagnostic test (TST) can be associated with several technical errors, has limited positive predictive value, is being influenced by BCG vaccination and several conditions can reduce the skin reactivity. Notwithstanding these limitations, prompt identification of TST conversion, should orientate indications for preventive therapy of LTBI. IGRAs have superior specificity, are not affected by M. bovis, BCG vaccination and other environmental mycobacteria. However, they present some logistical and organisational constraints and are more expensive. Currently, the WHO guidelines recommend that either a TST or an IGRA can be used to detect LTBI in high-income and upper middle-income countries with estimated TB incidences less than 100 per 100,000 population. Two skin tests (C-TB and Diaskintest), using only two specific M. tuberculosis antigens (ESAT-6 and CFP-10) instead of the tuberculin solution, have recently been developed but, to date, none of these tests is available on the European market.

CONCLUSION

Early identification and treatment of individuals with LTBI is an important priority for TB control in specific groups at risk within the population: this is of crucial meaning in recently infected cases both at the community level and in some occupational settings. Currently there is no gold standard test for LTBI: an improved understanding of the available tests is needed to develop better tools for diagnosing LTBI and predicting progression to clinical active disease.

High Completion Rate for 12 Weekly Doses of Isoniazid and Rifapentine as Treatment for Latent Mycobacterium tuberculosis Infection in the Federal Bureau of Prisons

CONTEXT

Correctional facilities provide unique opportunities to diagnose and treat persons with latent tuberculosis infection (LTBI). Studies have shown that 12 weekly doses of isoniazid and rifapentine (INH-RPT) to treat LTBI resulted in high completion rates with good tolerability.

OBJECTIVE

To evaluate completion rates and clinical signs or reported symptoms associated with discontinuation of 12 weekly doses of INH-RPT for LTBI treatment.

SETTING/PARTICIPANTS

During July 2012 to February 2015, 7 Federal Bureau of Prisons facilities participated in an assessment of 12 weekly doses of INH-RPT for LTBI treatment among 463 inmates.

MAIN OUTCOME MEASURES

Fisher exact test was used to assess the associations between patient sociodemographic characteristics and clinical signs or symptoms with discontinuation of treatment.

RESULTS

Of 463 inmates treated with INH-RPT, 424 (92%) completed treatment. Reasons for discontinuation of treatment for 39 (8%) inmates included the following: 17 (44%) signs/symptoms, 9 (23%) transfer or release, 8 (21%) treatment refusal, and 5 (13%) provider error. A total of 229 (49.5%) inmates reported experiencing at least 1 sign or symptom during treatment; most frequently reported were fatigue (16%), nausea (13%), and abdominal pain (7%). Among these 229 inmates, signs/symptoms significantly associated with discontinuation of treatment included abdominal pain (P < .001), appetite loss (P = .02), fever/chills (P = .01), nausea (P = .03), sore muscles (P = .002), and elevation of liver transaminases 5× upper limits of normal or greater (P = .03).

CONCLUSIONS

The LTBI completion rates were high for the INH-RPT regimen, with few inmates discontinuing because of signs or symptoms related to treatment. This regimen also has practical advantages to aid in treatment completion in the correctional setting and can be considered a viable alternative to standard LTBI regimens.

Epidemiology of Tuberculosis in the United States

Although considerable progress has been made in reducing US tuberculosis incidence, the goal of eliminating the disease from the United States remains elusive. A continued focus on preventing new tuberculosis infections while also identifying and treating persons with existing tuberculosis infection is needed. Continued vigilance to ensure ongoing control of tuberculosis transmission remains key.

Framing the discussion of microorganisms as a facet of social equity in human health

What do “microbes” have to do with social equity? These microorganisms are integral to our health, that of our natural environment, and even the “health” of the environments we build. The loss, gain, and retention of microorganisms—their flow between humans and the environment—can greatly impact our health. It is well-known that inequalities in access to perinatal care, healthy foods, quality housing, and the natural environment can create and arise from social inequality. Here, we focus on the argument that access to beneficial microorganisms is a facet of public health, and health inequality may be compounded by inequitable microbial exposure.

What do microbes have to do with social equity? This Essay explores the argument that access to beneficial microorganisms is a facet of public health, and that health inequality may be compounded by inequitable microbial exposure.

Changes in Tuberculosis Disparities at a Time of Decreasing Tuberculosis Incidence in the United States, 1994-2016

OBJECTIVES

To assess national progress in reducing disparities in rates of tuberculosis (TB) disease, which disproportionately affects minorities.

METHODS

We used Centers for Disease Control and Prevention (CDC) surveillance data and US Census data to calculate TB rates for 1994 through 2016 by race/ethnicity, national origin, and other TB risk factors. We assessed progress in reducing disparities with rate ratios (RRs) and indexes of disparity, defined as the average of the differences between subpopulation and all-population TB rates divided by the all-population rate.

RESULTS

Although TB rates decreased for all subpopulations, RRs increased or stayed the same for all minorities compared with Whites. For racial/ethnic groups, indexes of disparity decreased from 1998 to 2008 (P < .001) but increased thereafter (P = .33). The index of disparity by national origin increased an average of 1.5% per year.

CONCLUSIONS

Although TB rates have decreased, disparities have persisted and even increased for some populations. To address the problem, the CDC's Division of TB Elimination has focused on screening and treating latent TB infection, which is concentrated among minorities and is the precursor for more than 85% of TB cases in the United States.

High prevalence of self-reported tuberculosis and associated factors in a nation-wide census among prison inmates in Peru

OBJECTIVE

To estimate the prevalence of self-reported tuberculosis TB diagnosed at Peruvian correctional facilities (CFs), and their associated factors.

METHODS

Cross-sectional study based on secondary analysis of the National Census held in all Peruvian CFs in 2016. Outcome was defined as self-reported TB diagnosed by a healthcare professional intra-penitentiary. A descriptive bivariate analysis was carried out, followed by multivariate analysis using Poisson regression in order to calculate the adjusted prevalence ratios (PRa). Additionally, a mixed effects multilevel model adjusted by CFs as clusters was performed.

RESULTS

Of 77 086 prison inmates in 66 CFs participated in the original census, of which 69 890 were included. Of these, 1754 self-reported TB diagnosed intra-penitentiary, yielding a prevalence of 2510/100 000 PDL. In the final model, self-reported TB was associated with younger age, male gender, lower educational level, not having a stable partner, having prison readmissions and having relatives in prison. There was also strong association with HIV/AIDS (PRa 2.77; 1.84-4.18), STIs (PRa 2.13; 1.46-3.10), DM (PRa 1.99; 1.59-2.50) and recreational drugs use (PRa 1.41; 1.23-1.61). The mixed model showed significant variance for belonging to different CFs (2.13; 1.02-4.44) and CF overcrowding (3.25; 1.37-7.71).

CONCLUSIONS

Self-reported TB prevalence found was higher than reported by other lower/lower-middle income countries. Demographic factors, individual clinical features and overcrowding increases the likelihood of self-reported TB.

Tuberculosis among correctional facility workers: A systematic review and meta-analysis

INTRODUCTION

Prison inmates can transmit tuberculosis, including drug-resistant strains, to correctional facility workers and the community. In this systematic literature review, we investigated the magnitude of active and latent tuberculosis infection (LTBI) and associated risk factors among correctional facility workers.

METHODS

We searched MEDLINE, EMBASE, LILACS, Cochrane CENTRAL, ISI Web of Science, CINAHL, and SCOPUS databases (January 1, 1989-December 31, 2017) for studies with the MeSH terms "prison" (and similar) AND "tuberculosis", without language restriction. We searched for gray literature in Google Scholar and conference proceedings. Stratified analyses according to tuberculosis burden were performed.

RESULTS

Of the 974 titles identified, 15 (nine good, six fair quality) fulfilled the inclusion criteria (110,393 correctional facility workers; six countries; 82,668 active tuberculosis; 110,192 LTBI). Pooled LTBI prevalence and incidence rates were 26% (12-42, I2 = 99.0%) and 2% (1-3, I2 = 98.6%), respectively. LTBI prevalence reached 44% (12-79, I2 = 99.0%) in high-burden countries. Active tuberculosis was reported only in low-burden countries (incidence range, 0.61-450/10,000 correctional facility workers/year). LTBI-associated risk factors included job duration, older age, country of birth, current tobacco smoking, reported contact with prisoners, and BCG vaccination.

CONCLUSION

Despite the risk of bias and high heterogeneity, LTBI was found to be prevalent in correctional facility workers, mainly in high-burden countries. LTBI risk factors suggest both occupational and community exposure. Active tuberculosis occurrence in low-burden countries suggests higher vulnerability from recent infection among correctional facility workers in these countries. Systematic surveillance and infection control measures are necessary to protect these highly vulnerable workers.

'Know Your Epidemic': Are Prisons a Potential Barrier to TB Elimination in an Australian Context?

Globally, rates of tuberculosis (TB) cases in prisons are substantially higher than in the general population. The goal of this study was to review TB notifications in Victorian correctional facilities, and consider whether additional interventions towards TB elimination may be useful in this setting. All patients who were notified with or treated for TB in the Australian state of Victoria from 1 January 2003 to 1 December 2017 were included in this study. Descriptive analysis was performed. Demographic and treatment outcome data for individuals with and without a history of incarceration were reviewed and compared. Of the 5645 TB cases notified during the study period, 26 (0.5%) had a history of being incarcerated in correctional facilities while receiving treatment for TB. There were 73,238 inmates in Victorian correctional facilities over the same study period, meaning that approximately 0.04% of inmates were diagnosed or treated with TB disease in correctional facilities. Incarcerated individuals were more likely to have positive sputum smears and cavitation compared with nonincarcerated people with TB. There was no significant difference in treatment outcomes between the general TB population and those who had a history of incarceration during their treatment. There is a low apparent rate of TB in Victorian prisoners, and prisons do not contribute significantly to TB incidence in Victoria. Overall, TB outcomes do not differ between prisoners and nonprisoners. Ongoing efforts to sustain these lower rates and comparable outcomes in this vulnerable cohort are important for continued progress towards TB elimination.

Tuberculosis trends in California correctional facilities, 1993-2013

BACKGROUND

Incarcerated persons are disproportionately diagnosed with tuberculosis (TB). California has the second highest inmate population in the United States, but reports the highest number of cases.

OBJECTIVE

To describe the TB epidemiology among incarcerated patients in California.

METHODS

Trends in incidence were assessed using Poisson regression, and trends in percentage were assessed using weighted linear regression. Demographic and clinical characteristics were compared using χ2 or Mann-Whitney U tests.

RESULTS

During 1993-2013, of the 64 090 TB cases reported, 2323 (4%) were correctional facility residents. Incidence in correctional facilities decreased until 2006 (annual per cent change [APC] -12.3%, 95%CI -14.4 to -10.1), but has since stabilized (APC 4.4%, 95%CI -2.1 to 11.4). Compared with state prisoners, federal prisoners were more likely to be male (98%, P = 0.03), persons arriving in the United States within 5 years of diagnosis (62%, P < 0.001), and born in Mexico (88%, P = 0.02), whereas local jail inmates were more likely to have a history of substance use (75%, P < 0.001) and homelessness (35%, P < 0.001).

CONCLUSIONS

TB incidence in correctional facilities had steadily declined over the last two decades, but has recently leveled out. To promote further reduction in incidence among diverse incarcerated populations, health departments and correctional facilities should strengthen collaboration by conducting TB risk-based assessments.