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| TB prevention and control |
| By Jim Montalto, News Editor |
| Published: 07/17/2006 |
 Tuberculosis continues to be a public health challenge around the world, especially in settings where people from diverse backgrounds and communities are closely housed. Efforts to improve TB control measures in correctional and detention facilities have been increased, but outbreaks continue, and it has been found that TB has been transmitted to residents in nearby communities. Consequently, corrections serves as a critical setting for detecting and treating TB.In an effort to provide a more current strategy for managing this prevalent problem, the Centers for Disease Control, with assistance from the Advisory Council for the Elimination of TB, assembled the Tuberculosis in Corrections Working Group. TCWG consists of experts in both public health and correctional health care including the National Commission on Correctional Health Care, the American Correctional Association, the American Jail Association, and the Society of Correctional Physicians. The CDC presented the group's counsel in a report called the Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC, in a recent issue of Mortality and Morbidity Weekly Report. It expands upon 1996 ACET recommendations and provides guidelines for effective TB prevention and control in jails, prisons and other correctional and detention facilities. MMWR also defines the necessary activities for preventing the disease's transmission, which include: “screening (finding persons with TB disease and latent TB infection (LTBI); containment (preventing transmission of TB and treating patients with TB disease and LTBI); assessment (monitoring and evaluating screening and containment efforts); and collaboration between correctional facilities and public health departments in TB control. These overarching activities are best achieved when correctional facility and public health department staff are provided with clear roles of shared responsibility.” According to the CDC at least three factors contribute to the high rate of TB in correctional and detention facilities. “First, disparate numbers of incarcerated persons are at high risk for TB (i.e., users of illicit substances, like injection drugs, persons of low socioeconomic status, and persons with human immunodeficiency virus [HIV] infection). These persons often have not received standard public health interventions or non-emergency medical care before incarceration. “Second, the physical structure of the facilities contributes to disease transmission, as facilities often provide close living quarters, might have inadequate ventilation, and can be overcrowded. “Third, movement of inmates into and out of overcrowded and inadequately ventilated facilities, coupled with existing TB-related risk factors of the inmates, combine to make correctional and detention facilities a high-risk environment for the transmission of tuberculosis and make implementation of TB-control measures particularly difficult.” As a result, the CDC recommends aggressive TB testing strategies and emphasizes the importance of collaboration between corrections and public health officials with respect to discharge planning and contact investigation. Since early identification remains the most effective means of preventing TB transmission, the report encourages testing and treating inmates before being integrated into the general correctional facility population. If possible, new inmates should be housed separately until they have been screened. In addition to finding those inmates with TB, screening also helps with detecting latent TB infection, which has a high risk of developing into TB. Screening methods include chest radiograph, Mantoux Tuberculin skin testing (TST), and a newer diagnostic test measure known as the QuantiFERON®-TB Gold Test. This test was approved by the FDA in 2005 and, according to the report, measures “the number of interferon-gamma produced by cells in whole blood that have been stimulated by mycobacterial peptides. The peptides used in the test mimic proteins known as ESAT-6 and CFP-10, which are present in M. tuberculosis but absent from all BCG strains and from the majority of commonly encountered non-TB mycobacteria.” Like TST, QFT-G cannot distinguish between LTBI and TB disease, so the CDC recommends using this test in conjunction with risk assessment, radiography and other diagnostic evaluations. Benefits of using the QFT-G test include obtaining results in a single patient visit, and reducing the variability of a skin-testing reading because observation is performed in a qualified laboratory. Drawbacks, however, include the need to draw blood, the 12 hour time span within which processing of the blood specimens must be taken, the limited laboratories that can process the test, and a lack of clinical experience in interpreting test results. The CDC seems to feel that eliminating the required second visit to read other tests, like TST, is an advantage that will make QFT-G more popular. The report goes on to discuss case reporting, isolation, environmental controls, respiratory protection, diagnosis and discharge planning, all of which can be read more in depth in the MMWR report. Next week Corrections.com will cover how one facility has adopted these recommendations, including the QFT-G Gold test. |
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