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TUBERCULOSIS TRANSMISSION IN A SOUTH AFRICAN PRISON. Robin Wood Desmond Tutu HIV Centre Institute of Infectious Disease & Molecular Medicine University of Cape Town. NEW YORK 1903

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TUBERCULOSIS TRANSMISSION

IN A SOUTH AFRICAN PRISON

Robin Wood

Desmond Tutu HIV Centre

Institute of Infectious Disease & Molecular Medicine

University of Cape Town

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NEW YORK 1903

The average prison is no less than a tubercular death trap.. from forty to sixty per cent, of all the deaths in prison are due to tuberculosis and autopsies show that nearly all the prisoners have in some degree been infected!”

Dr. J. B. Ransom, of Clinton Prison, New York

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The median estimated annual incidence rate ratio (IRR) for LTBI and TB were26.4(interquartile range [IQR]: 13.0–61.8) and 23.0 (IQR: 11.7–36.1), respectively.

The median estimated fraction (PAF%) of tuberculosis in the general population attributable to the exposure in prisons for TB was 8.5% (IQR: 1.9%–17.9%) and 6.3% (IQR: 2.7%–17.2%) in high- and middle/low-income countries, respectively.

These findings suggest that the risk of LTBI and TB is at least an order of magnitude higher in prisons than in the general population and that the within-prison spread of LTBI and TB is likely to substantially affect the incidence of LTBI and TB in the general population.

December 2010 | Volume 7 | Issue 12 | e1000381

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CURRENT WHO RECOMMENDATIONS

The priority strategy must be the widespread implementation of the Stop TB Strategy, particularly addressing TB/HIV co-infection and MDR-TB, in the incarcerated population. Every prisoner should have unrestricted access to the correct diagnosis and treatment of TB.

Delays in the detection and treatment of TB cases must be minimized to reduce further transmission of infection and pressures to self-treat TB.

Unregulated, erratic treatment of TB in prisons should cease.

Urgent action is needed to integrate prison and civilian TB services to ensure treatment completion for prisoners released during treatment.

Measures to reduce overcrowding and to improve living conditions for all prisoners should be implemented to reduce transmission of TB

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TB TRANSMISSION

Quantity of exhaled air rebreathed

Concentration of TB particles

Infectious TB case Susceptible individual

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TB INFECTION RISK IN PRISONS

Probabilityof TB infection

Quantity of rebreathed air

Concentration of TBorganisms

Cell crowding

Lock-up time

Cell ventilation

No of TB cases

Infectivity

Period of infectivity=Δ

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Pollsmoor prison has 3,200 awaiting trial prisoners

Space allocation: 1,4 m2 per prisoner

Lock-up time 23 hours per day

SAMJ 2011;101(11):809-13

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CROWDING & TB TRANSMISSION

Space allocation: 1,4 m2 per prisoner

Current 1.4m2

RSA 3.4m2

WHO 5.4m2

Fig. 1. The effect of prison cell overcrowding on TB transmission probabilities is plotted against time periods of infectiousness up to 180 days. They are shown for 3 levels of overcrowding; 250% approximates the current level cell occupancy; 100% represents implementation of current South African statutory minimum occupancy of 3.44 m2 of floor space per inmate,7-10 and 50% corresponds to international space recommendations.

SAMJ 2011;101(11):809-13

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LOCK-UP TIME & TB TRANSMISSION

Fig. 2. The effect of length of period of restriction in prison cell per day on TB transmission probabilities is plotted against time periods of infectiousness up to 180 days, shown for 3 time periods of cell occupancy during a 24-hour period; 23 hours per day, 12 hours per day and 8 hours per day. NB: 23 hours per day is the current period of restriction to cells in Pollsmoor prison.

SAMJ 2011;101(11):809-13

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CELL VENTILATION & TB TRANSMISSION

Fig. 3. The effect of increasing levels of cell ventilation on TB transmission probabilities is plotted against time periods of infectiousness up to 180 days. They are shown for 4 values of ventilation air change per hour (ACH): 1 ACH (current estimated cell ventilation), 3 ACH (minimal international recommendation), 8 ACH (moderately increased ventilation) and 12 ACH (the optimal level of ventilation recommended by WHO for health care set- tings).

SAMJ 2011;101(11):809-13

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COMBINED TB CONTROL MEASURES

Fig. 2. The effect of length of period of restriction in prison cell per day on TB transmission probabilities is plotted against time periods of infectiousness up to 180 days, shown for 3 time periods of cell occupancy during a 24-hour period; 23 hours per day, 12 hours per day and 8 hours per day. NB: 23 hours per day is the current period of restriction to cells in Pollsmoor prison.

SAMJ 2011;101(11):809-13

prison cell co 2 levels 5000ppm sabs 1040
PRISON CELL CO2 LEVELS > 5000ppm (SABS 1040)

Regulatory CO2 Exposure Limits

  • ASHRAE Standard 62-1989 1000ppm
    • CO2 concentration in occupied buildings should not exceed 1000ppm
  • Building bulletin 101 (BB101) 1500ppm
    • UK standard for schools, average CO2 during day should not exceed 1500ppm
  • EPA Taiwan 1000ppm and 600ppm
    • Type-1: Stores, theaters, restaurants, & libraries the 8hour average CO2 should not exceed 1000ppm
    • Type 2: Special areas e.g. schools, hospital, day care centers recommend 600ppm
tuberculosis control in prisons
TUBERCULOSIS CONTROL IN PRISONS
  • Decrease TB disease prevalence
    • Effective TB case management
    • Active case finding at entry and subsequently
    • Rapid diagnostics
  • Reduce overcrowding
    • Communal cells are a disaster!
    • Lock up times too long!
  • Ventilation
    • Use appropriate building codes
    • Maintain cross cell air flow
    • Ventilation monitored by CO2