Tuberculosis and Prisons

1. . . Tuberculosis andPrisons Dr. Rodolfo Rodríguez PAHO Regional Advisor San Pedro Sula, Honduras, August 2003

2. Contents • Epidemiology • Diagnosis • Treatment • Situation of TB in the Region • Regional Response to the Current Situation • Groups at High Risk for Tuberculosis (prisoners) San Pedro Sula, Honduras, August 2003

3. Epidemiological Chain of TB Transmission • Causal agent • Reservoir; source of infection • Mechanism of transmission • Susceptible host San Pedro Sula, Honduras, August 2003

4. Tuberculosis and the Bacillus Causing It • Bacillus is thin, somewhat curved, from 1 to 4 microns in length, with a complex cellular wall (lipid core) responsible for its characteristic coloration (acid-alcohol-resistant). • Susceptible to sunlight, heat and dryness. • Strictly parasitic and airborne; slow multiplier. San Pedro Sula, Honduras, August 2003

5. Natural History • Exposure to a potentially contagious case is a prerequisite to infection. • Once an individual is exposed, then • Risk factors will determine the infection. • Risk factors will determine the infected person’s chances of developing TB. • Risk factors will determine the TB patient’s odds of dying from TB. San Pedro Sula, Honduras, August 2003

6. San Pedro Sula, Honduras, August 2003

7. Transmission of the Koch Bacillus Transmission is a mechanical phenomenon that takes place the moment that the bacilli implant themselves in the new host and start multiplying. This depends on several factors: • Bacterial status of the patient (BK+) (C+) (C-) • Closeness of contact (intimate) (occasional) • Density of the bacilli in the air. San Pedro Sula, Honduras, August 2003

8. Transmission of the Bacillus Closeness of Contact Risk of Infection • Risk greater with intimate contact. • Risk less with occasional contact. • In both cases, the risk increases with the age of the contact. San Pedro Sula, Honduras, August 2003

9. Who Transmits TB the Most? • People who cough the most. • People with SS+ in their sputum. • Patients who go untreated. • Patients who just began treatment. • Cases responding poorly to treatment. San Pedro Sula, Honduras, August 2003

10. At Risk for Illness • Subjects infected by cases with a positive sputum exam (SS+) become ill more frequently than do those subjects infected by other types of patients with tuberculosis. San Pedro Sula, Honduras, August 2003

11. Greatest Risk of Developing TB • During the first two years after initial TB infection. • Age: First months/years of life • Drug addicts • People with immunodeficiency • HIV infection, level CD4 • Treatment with steroids • Lymphoma, etc. San Pedro Sula, Honduras, August 2003

12. Epidemiology of TB Important Concepts 1. Infection: infected person 2. Illness: patient 3. Re-infection a) Endogenous b) Exogenous San Pedro Sula, Honduras, August 2003

13. Diagnosing Tuberculosis San Pedro Sula, Honduras, August 2003

14. Why is it necessary to correctly diagnose TB cases? • To offer early treatment and break the epidemiological chain of transmission. • To appropriately register the patient and report the case. • To adequately indicate a patient-specific anti-TB treatment program. San Pedro Sula, Honduras, August 2003

15. Diagnosing TB • Clinical Evaluation • Microbiology • Radiology • Tuberculine (PPD) test • Anatomical pathology • Unconventional methods San Pedro Sula, Honduras, August 2003

16. Clinical Traits of TB • Depends on where disease is located • Pulmonary • Pleural, lymphatic, urogenital, osteoarticular, meningeal … • Any organ or tissue can be affected. • Disseminated or miliary TB: More frequent with AIDS and other immunodeficiency disorders. San Pedro Sula, Honduras, August 2003

17. When should you think that a patient might be suffering from TB? • Cough and/or expectoration for more than 2–3 weeks: Respiratory Symptomatic • Other symptoms • Respiratory • Blood in sputum, difficulty breathing, pain in thorax … • General • Weakness, loss of appetite, weight loss • Low-grade fever, profuse sweating … • Other organs: Depends on location San Pedro Sula, Honduras, August 2003

18. Microbiological Diagnosis of Tuberculosis San Pedro Sula, Honduras, August 2003

19. TB Microbiology • Check-up, exam: BAAR • Culture • Tests to categorize species • Sensitivity test • Other diagnostic techniques San Pedro Sula, Honduras, August 2003

20. Radiology of Tuberculosis San Pedro Sula, Honduras, August 2003

21. Radiology and Tuberculosis • For diagnosis • Valuable for clarifying a suspected case. • Non-specific: The same radiological pattern can exist with other diseases. • For prognosis and response to treatment • This can be indicated providing resources exist. San Pedro Sula, Honduras, August 2003

22. Use of PPD • Used as a diagnostic complement, though positive test results does not always means TB infection, much less illness. • For HIV-positive and pediatric patients, usually means prophylactic treatment. • Epidemiological studies indicating Annual Risk of Infection. San Pedro Sula, Honduras, August 2003

23. San Pedro Sula, Honduras, August 2003

24. Treating Tuberculosis Basics San Pedro Sula, Honduras, August 2003

25. Background New patient who received no prior anti-TB treatment Never treated • Relapse • Recovered patient who abandoned treatment previously • Failure of initial primary care Previously treated Chronic SS (+) patient treated again with supervision San Pedro Sula, Honduras, August 2003

26. Bacteriological Basis for TB Treatment 1. Drug combination 2. Prolonged treatment 3. Intermittent treatment in 2 phases 4. Single-dose administration. San Pedro Sula, Honduras, August 2003

27. Characteristics of an Ideal Anti-TB Treatment Program • Simplified drug therapy • Low cost • Whatever the patient best accepts • Health services that are easy to get and use San Pedro Sula, Honduras, August 2003

28. Recipe for Good Compliance with a Treatment Program • Free treatment • Treatment supervised 100% • Optimal relationship between health-care personnel and patient • Improved access to treatment San Pedro Sula, Honduras, August 2003

29. Status of Tuberculosis in the Region San Pedro Sula, Honduras, August 2003

30. Trends in Total Number of Reported TB & SS+ Cases(Region of the Americas, 1990– 2001) San Pedro Sula, Honduras, August 2003

31. Estimated Incidence Rates for TB (Region of the Americas, 2001, per 100,000) San Pedro Sula, Honduras, August 2003

32. TB Priority Countries Brasil Peru Mexico Bolivia Haiti Ecuador Dominican Republic Honduras Nicaragua Guyana Canada USA 8% 6.8% 75% Total Cases: 230,203 Peru Brazil 50% San Pedro Sula, Honduras, August 2003

33. Priority Countries • Criteria • High TB burden • Weak National TB Programs • Low- and middle-income countries • Critical for reaching 2005 goals • Brazil, Bolivia, Dominican Republic, Ecuador, Guyana, Haiti, Honduras, Mexico, Nicaragua and Peru. San Pedro Sula, Honduras, August 2003

34. Anti-TB Drug Resistance Studies (Region of the Americas, 2002) Studies completed Studies in progress No studies San Pedro Sula, Honduras, August 2003

35. Preliminary MDR (Region of the Americas, 1994–2002) CAN 1.2% - USA 1.2% DOR 6.6% Puerto Rico 2.5% CUB 0.3% MEX: 3 states, 2.4% HON 1.8% GUT 0.7% ELS 0.3% VEN 0.3% NIC 1.2% COL 1.47% ECU 6.6% BRA 0.9% PER BOL 3.0% 1.2% No data - >= 3% CHI ARG 0.6% - < 3% 0.9% URU - =< 1% 0.01% San Pedro Sula, Honduras, August 2003

36. Priorities for TB-HIV Control in the Americas Priority to Control HIV Low Intermediate High Low Intermediate High Priority to Control TB San Pedro Sula, Honduras, August 2003

37. Implementation Status of the DOTS Strategy(Region of the Americas, 2001) DOTS: 73% pop. June 2003: 80% pop. (estimate) < 10% coverage < 10% -<49% >50-90% Total coverage No DOTS San Pedro Sula, Honduras, August 2003

38. DOTS/TAES Coverage (Region of the Americas, 2002) San Pedro Sula, Honduras, August 2003

39. DOTS Coverage (% pop.)Trends and Forecast for 2005 San Pedro Sula, Honduras, August 2003

40. DOTS/TAES Status in Priority Countries 2001 Detection Rate, 2000 Treatment Success Rate PER BOL HON NIC GUY HAI DOR MEX BRA San Pedro Sula, Honduras, August 2003

41. Regional Response to the Current Situation San Pedro Sula, Honduras, August 2003

42. Main Challenges • Expanding DOTS coverage (goals for 2005). • Coordinating with HIV/AIDS Programs. • Starting resource mobilization (partners, donors, GFATM) • Improving DOTS/TAES access and coverage to high-risk groups and neglected populations (prisoners, indigenous population, marginalized groups, people with TB-HIV) • Starting community participation in DOTS. San Pedro Sula, Honduras, August 2003

43. Groups at High Risk for Tuberculosis (prisoners) San Pedro Sula, Honduras, August 2003

44. San Pedro Sula, Honduras, August 2003

45. Main Challenges • Prisons present a challenge to control TB. The prisoner population (persons deprived of liberty/PDL) is on the increase, and overcrowding is creating conditions ripe for outbreaks with serious consequences for both this populations as well as the population at large. • Remember that • TB is transmitted through the air. High-risk conditions are thus created. • A single highly contagious person can infect many others who share the same environment. San Pedro Sula, Honduras, August 2003

46. Main Challenges • Persons infected with HIV, if also infected by M. tuberculosis, are at a greater risk of developing tuberculosis. • Late detection and not starting supervised treatment early enough constitute the greatest risks to TB control both in prisons and in communities. San Pedro Sula, Honduras, August 2003

47. Main Challenges • Controlling contacts and preventive therapy also present challenges for TB control. • Prison time and later follow-up offer a unique opportunity to control tuberculosis among a very high-risk population. San Pedro Sula, Honduras, August 2003