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 Department of Public Health, TB Division

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

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)

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

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%

Study Hypotheses 1. 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, GA Georgia incarceration rates = 975 per 100K persons In 2011, Georgia had: 11 th 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

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 Assess proportion that may have acquired and/or transmitted TB while incarcerated

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

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

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

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

Acknowledgements Susan Ray, MD 1 Russell Kempker, MD, MSc 1 Rose-Marie F. Sales, MD, MPH 2 David Maggio, MPH 2 Carolyn Martin, RN 2 Mille Reeves, RN 4 Anne Spaulding, MD, MPH 1,3 1 Emory University College of Medicine, Division Infectious Diseases 2 Georgia Department of Public health, TB Division 3 Emory University, Rollins School of Public health 4 Georgia Department of Corrections

Happy World TB Day

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)

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)

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

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

Source of Map: Pew Center, 1:100

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

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