1. Rauni Ruohonen FILHA Priorities of TB control in penitentiary care

2. Prevention of transmission Early diagnosis and treatment Isolation of different patient categories Cure of most of TB cases

3. Factors affecting TB transmission 1 Smear positive are highly infectious –Pulmonary cavitary cases are usually smear positive –Immediate isolation is necessary until proven conversion –HIV positive are more often smear negative pulmonary or extrapulmonary cases – should they be isolated ? Transmission is dependent on closeness and time of contact –In penitentiary care contacts are very close and prolonged – culture positive cases can also transmit TB especially to HIV positive population

5. Factors affecting TB transmission 2 Unknown TB cases are major source of transmission

6. Where are the unknown TB cases ? In the civilian society –People entering pre-trial centres –Visitors to detainees and inmates – contact tracing from detected TB cases in penitentiary care must include also civilian contacts In the borders between penitentiary care and civilian society –Police custody – detainees spend prolonged time in custodies during court processes –In civilian health services if detainees or inmates receive care there In the penitentiary care –In pre-trial centres and prisons depending on effectiveness of active case-finding –Special attention should be put on contact tracing and transfers

7. Early diagnosis 1 Interview of inmates and detainees by skilled staff –Sputum smear + cases have mostly symptoms and can be detected by careful interview –HIV positive have more sputum smear negative and extrapulmonary TB. They have the same right for diagnosis and care as HIV negative. –Screening at entry, prior to transfer (also to police custody ) and by symptoms –Identify persons already diagnosed/ on therapy –Careful anamnesis on risk factors, previous contacts and treatments –Refer suspects to examinations and isolation –Careful contact investigations (civilians included) –Continuous training of staff

8. Early diagnosis 2 High quality laboratory services –Sputum smear examinations – rapid classification of species (atypical mycobacteria common in AIDS) –Culture examinations –Rapid drug sensitivity testing Chest x-ray screening –Screening at entry, prior to transfer (?) and by symptoms –In risk groups half yearly during stay in penitentiary care –HIV positive are more often smear negative – early dg needs x-ray –In case of lack of equipment cooperation with other units or civilian society (mobile units?)

9. Problems of infection control 1 More weight is put on engineering controls than on the administrative controls –No ventilation can solve the problems if XDR cases are not detected or are isolated in same room with HIV positive sensitive cases Engineering control focuses usually on TB wards - less in other areas of importance. –Places of special concern: Police custody, transferred-in zones in penitentiary care, wards for TB suspects Ventilation should be improved in all penitentiary care units –Benefits to the prevention of all airborne infections –Decreasing overcrowding is best prevention of airborne infections and can be achieved by criminal system reform –Negative pressure rooms are not needed everywhere

10. Human aspects possibility to open windows,go out, read, watch tv, smoke psychological support needed

11. Problems of infection control 2 With increasing HIV epidemic HIV infection control and hepatitis prevention must be included also in TB infection control and treatment –Needle safety –Prevention of sexual transmission –Prevention of mother to child transmission –Harm reduction programmes –Hepatitis B vaccinations

12. How isolation should be organised Ideal: separate isolation rooms for 1-2 persons If not possible, then: –Establish separate areas. Wards and floors for suspected or confirmed TB patients based on the infectiousness of the patient (cohorts). Hierarchy among prisoners has to be taken into account when two or more inmates are placed in same room – participation of inmates in decision making Discontinuation of isolation as soon as criteria are filled releases more place for needed isolations

13. Isolation in cohorts In present epidemiological situation in North-East Europe at least 7 cohorts need to be isolated separately in male and female wards: –TB suspects HIV - –TB suspects HIV + –MDR TB suspects HIV - –MDR TB suspects HIV + –Sputum smear + sensitive cases –MDR cases –XDR cases In practice only 4-5 cohorts can be managed in one ward. One patient will move possible 3 times from one isolation to another: suspect ss+ MDR isolation

14. Cure most of the TB cases Increasing iv drug use driven HIV epidemic creates more problematic TB patient groups Hepatitis C and B common Opioid substitution therapy (OST) needed Combination of TB treatment with HAART and OST is challenging. Role of CPT ? The Latvian Centre of Excellence should distribute its experiences in this field worldwide

15. Thank you for your attention !