Tuberculosis: Behind Bars and Beyond Assessing the burden of correctional TB and its role as a driver of community risk

1. Tuberculosis: Behind Bars and BeyondAssessing 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

2. TB and Correctional Facilities • Conditions that facilitate spread of TB infection • Congregate setting, delayed diagnosis, inadequate treatment, poor ventilation and repeated transfers   • Populations at increased risk for active TB disease • Active disease  TB transmission • Community reservoirs for TB • Staff, visitors and inadequately treated former inmates

3. Correctional TB: Epidemiology • TB in incarcerated persons • 1% of total US population incarcerated • 4.2% 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)

4. Report of Verified Case of TB (CDC) • Only one question on current incarceration • No questions on prior incarceration

5. Prior Studies Hammett, AJPH, 2002 • Estimate for TB burden in U.S. inmate/releasee population in 1997 • Of 31,000 persons with TB in U.S. 40% went through CF Baussano, PLoS Med, 2010 • Systematic 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%

6. Study Hypotheses • Incarceration plays a significant role in TB transmission • A high proportion of TB cases may have had exposure to a CF • The longer the exposure greater the TB risk • There is an association between adherence to TB control guidelines and jurisdictional TB rates

7. Study Setting: Atlanta, GA • Georgia incarceration rates = 975 per 100K persons • In 2011, Georgia had: • 11th highest TB incidence in the United States • 3.5 cases/100K persons • 10% of TB cases diagnosed in a CF (31/321 cases) • 53% of the new TB cases reported from the Atlanta metropolitan area

8. Specific Aims: Part I Analysis of TB transmission in Atlanta CF populations (Fulton/DeKalb counties) • AIM I: • To estimate proportion of Atlanta TB cases detained in a CF in 2011 • Aim II: Among incident TB cases 2009-2012 • Assess proportion that may have acquired and/or transmitted TB while incarcerated

9. Methods: Part I • Identify Atlanta TB cases 2009-2011 • Cross-match with Atlanta CF prisoner databases • Chart review for incarceration history • Identify indirect exposure to CF • Genotype and contact investigation data

10. Specific Aims: Part II Facilities evaluation • AIM 3: For each CF, describe • TB infection control plans and practices • Population characteristics • Incident TB case rate per 100K admission • AIM 4: For each CF, calculate • TB case identification rate • Missed TB case rate

11. Expected Results • Anticipate 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 rates • Increased correctional genotypes found in community

12. Significance • Better 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

13. Acknowledgements • Susan 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 Diseases 2Georgia Department of Public health, TB Division 3Emory University, Rollins School of Public health 4Georgia Department of Corrections

14. Thank You!!! Happy World TB Day

15. Extra Slides

16. Background: TB • ~1/3 of the world infected with Mycobacterium tuberculosis (MTB) • TB is spread by airborne droplets • Open air and UV light decreases transmission • 10% of persons infected with MTB will develop active TB disease • Higher risk of disease in certain conditions (eg. HIV infection, malnutrition, DM, substance/EtOH abuse)

17. Methods: Part II • CF evaluations: Site visits • Assess TB infection control plans and adherence to guidelines • Analyses • % TB cases acquired though CF exposure • Rate of TB cases diagnosed and missed for each CF • Attributable risk of TB due to correctional exposure • TB Incidence (exposed) – TB Incidence (unexposed)

18. Next steps • Scale-up evaluation • Potential interventions: • Dedicated correctional TB case managers • Improving transitional retention in TB care • Improved TB diagnostics • Short course LTBI treatment • Electronic TB management/surveillance program

19. TB Control in CFs • CDC Guideline, 2006 • Early identification of TB disease • Successful treatment of TB disease and latent TB • Appropriate use of airborne precautions • Comprehensive discharge planning • Thorough and efficient contact investigation • Francis J. Curry National Tuberculosis Center: TB Infection Control Plan Template for Jails, 2002

20. Source of Map: Pew Center, 1:100

21. Prevalence: Selected Conditions in Prisoners Mean % Source: Hammett T. AJPH 2002; 92(11) 1789

22. HCV = Approx. 150,000 cases Source: Hammett T. AJPH 2002; 92(11) 1789