An Unanswered Health Disparity: Tuberculosis Among Correctional Inmates,1993 Through 2003

Jessica R. MacNeil; Mark N. Lobato, MD; Marisa Moore, MD, MPH

Disclosures

Am J Public Health. 2005;95(10):1800-1805. 

In This Article

Discussion

The success of TB control in the United States is evident by the steady decline in cases among incarcerated populations along with declining rates in the communities from which inmates are drawn. Yet, our findings call attention to the epidemiology and health-related outcomes in correctional inmates that demonstrate marked disparities in TB rates, measures of risk including HIV infection, and TB treatment outcomes.

Substantially greater case rates in correctional systems are indicative of this disparity, especially in the federal prison system. In 2003, the TB case rate for federal prisons was 6.9 times the case rate in the general US population (5.1 cases per 100000 population).[1] Paradoxically, enhanced screening in federal prisons may have resulted in better case detection and thus an apparent rise in the number of TB cases.[18] The increasing proportion of inmates who are born in countries other than the United States also may be partly responsible for the increase in TB cases in federal prisons.[19] Although we did not calculate the case rate among jail inmates because of unreliable population estimates, local studies indicate that case rates in jail populations are also greater than in the general population. In San Francisco, for example, jail inmates had a case rate of 72.1 cases per 100000 inmates compared with a rate of 26.2 cases per 100000 persons in the local population.[5]

Inmates, in contrast to noninmates, are more likely to have multiple risk factors for infection with M tuberculosis and for progression to TB disease. Inmates are also more likely to have drug-resistant TB. Special efforts are needed to mitigate the personal and public health toll created by these risk factors.[20,21] The concentration of these factors in a congregate population has resulted in explosive outbreaks of TB, as demonstrated in a North Carolina outbreak involving 25 homeless patients, 72% of whom had a history of incarceration in the local county jail.[22] Tuberculosis outbreaks and ongoing transmission have occurred even after inmates were screened for TB[23,24,25] and also have been attributed to failure to complete treatment by inmates known to have LTBI.[26,27]

Despite elevated rates of HIV infection-the strongest risk factor for developing TB among adults who have LTBI[28]-the HIV status of more than one third of inmates with TB is unknown. In a study of 20 large city and county jails, a review of inmate medical records found that only 48% of 376 inmates with LTBI had a known HIV status.[29] Although the CDC recommends routine HIV counseling and testing at intake to the correctional facility,[30] the majority of correctional systems currently do not offer universal HIV testing, a critical limitation for effective TB prevention and control and for the medical management of individual patients.[31] Moreover, in HIV-infected persons infected with M tuberculosis, the progression to TB disease is often rapid and can cause difficult-to-control outbreaks.[27]

Outbreaks of both multidrug-resistant and drug-susceptible TB related to HIV coinfection have been documented in correctional facilities.[3,4,27,32,33] These outbreaks are often attributed to the failure to detect TB disease early after entry into the facility or failure to complete treatment for LTBI resulting in TB transmission to other inmates, correctional facility employees,[3,34,35] and community members.[36]

Epidemiologic and operational studies have helped elucidate problem areas for TB prevention and control in correctional systems and the surrounding community.[5,7,10,14,25,34,35,36,37] One such study in Memphis, Tenn, showed that 43% of community residents with TB had been incarcerated in the same jail at some time before their diagnosis, and this jail had experienced a TB outbreak lasting several years.[14] A subsequent study revealed the strain in question was more prevalent in the surrounding community than it was prior to the jail outbreak.[35] In Maricopa County, Ariz, 24% of persons reported with TB during 1999 and 2000 had been incarcerated in the county jail prior to their TB diagnosis.[37] Additionally, it was discovered that the majority of persons (83%) who later had TB had not received any TB screening while in jail. These and other reports have highlighted the need for implementing infection control measures in correctional facilities.[24]

Our data confirmed that health disparities in treatment outcomes exist for inmates with TB. Inmates have lower treatment completion rates; even when individual risk groups are compared, the discrepancy in treatment completion for inmates persists ( Table 4 ). Tuberculosis screening at entry to a correctional facility provides a unique opportunity for identifying individuals at risk for TB who might not otherwise have access to medical care and prevention services.[37] Correctional systems, especially jails, offer distinct logistical obstacles to screening and treatment; inmates are moved frequently or are released, making evaluation and completion of therapy difficult at best.[14] Inmates are more likely to have treatment outcomes classified as "incomplete" owing to their moving out of the jurisdiction or being lost to treatment supervision.[38] Failure to complete treatment for TB is a cause for concern for the health of those individuals who did not receive a full course of curative therapy and for the communities in which they live.

One limitation of our study is that the national surveillance data identified only case-patients diagnosed during incarceration. Those with TB who may have progressed to disease before or after incarceration are not separately defined in our analysis. Standard TB-control activities and investigations may not elicit information about incarceration, resulting in possible underreporting of cases that are epidemiologically linked with incarceration.[34,36] Failures to establish these connections hamper the effectiveness of public health interventions.[22,35,36] Another limitation of the study is the difficulty of tracking outcomes when inmates are transferred within or between correctional systems. For that reason, our data may underestimate completion rates for some prison inmates.

Poor access to TB services and socioeconomic status play a role in the elevated TB rates among correctional inmates.[39] However, inmates are more likely to receive treatment by directly observed therapy, a patient-management practice that generally improves the success of treatment completion. Our finding of unacceptably low rates for the therapy completion among inmates is disturbing because of the possibility that these individuals may be the cause of future TB outbreaks in a given community.[40] To better ascertain and improve treatment completion rates among inmates, health departments should enhance their capacity for tracking TB patients diagnosed or treated in correctional systems. To ensure that TB medical evaluations and therapy are completed for inmates, public health and corrections officials are obliged to develop policies that optimize discharge planning and case management for inmates released during TB evaluation or treatment.[38,40] These policies should be reevaluated periodically to determine whether such practices should be modified to improve outcomes.[2,41]

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