Mary Foote MD, MPH 1 Infectious Disease Fellow Anne Spaulding MD, MPH 1,2 1 Emory University Schools of Medicine and 2 Public Health Atlanta, Georgia Georgia.
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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
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