Tuberculosis Prevention in Drug-Treatment Centers and Correctional Facilities -- Selected U.S. Sites, 1990-1991

The risk for tuberculosis (TB) is higher among injecting-drug users (IDUs) and correctional facility (CF) inmates than in the general population because a greater proportion are infected with TB and are at higher risk for human immunodeficiency virus (HIV) infection (1,2). Because of this higher risk and because of the potential for transmission of TB in CFs, prevention of TB among persons in these populations is a high priority (1,2). This report summarizes the results of a demonstration project during 1990-1991 to evaluate the feasibility of on-site screening for TB infection among drug-treatment center (DTC) clients and CF inmates and providing preventive therapy to reduce the risk for TB among persons with TB infection.

In 1989, CDC awarded funds to 25 state and city health departments * to support tuberculin skin testing and administration of preventive therapy, in conjunction with HIV counseling and testing, in DTCs and CFs. Health departments collaborated with drug-abuse agencies and CFs to select project sites and to develop plans for implementing project activities. Staff at the DTCs and CFs typically 1) performed Mantoux tuberculin skin tests, 2) performed or arranged for HIV counseling and testing, 3) either referred persons with positive tuberculin reactions for evaluation (DTCs) or performed evaluations on site (CFs), 4) provided directly observed isoniazid (INH) preventive therapy to infected inmates and clients, and 5) monitored inmates and clients for toxicity to INH. Health department TB programs provided overall project planning, staff training in skin testing and preventive therapy at project sites, evaluation of persons with positive skin test reactions for active TB, evaluation of INH preventive therapy, and evaluation of the project. CDC developed a computerized data management system consisting of a standardized data collection workform and data base software.

Data were collected from the time each facility began screening, with most beginning sometime in 1990. Provisional data from 23 areas were available for 40,823 persons enrolled in the target facilities from program initiation through December 1991 (Table 1). Of these, 30,808 (75.5%) were from 114 DTCs and 10,015 (24.5%) were from six CFs. Of the 39,060 (95.7%) persons enrolled and eligible for screening (i.e., all those without a documented history of TB infection), 38,350 (98.2%) received a tuberculin skin test; of these, 36,990 (96.5%) were read. Of those skin tested and who had the tests read in DTCs, 2645 (9.7%) had a reaction of greater than or equal to 5 mm; in CFs, 2214 (22.7%). When persons with previously documented Mantoux reactions were included, 4167 (13.3%) were positive in DTCs, and 2455 (24.6%) in CFs.

HIV serostatus was recorded for 25.5% of all clients, of whom 20.8% were reported as positive. In 34.9%, the HIV-antibody test was completed, but the results have not yet been shared with the TB programs primarily because of confidentiality concerns. For 8.1%, the clients declined the HIV test, and for 31.4%, the HIV test was not offered. Clients whose last HIV test was negative and performed more than 3 months before the TB screening were counted in the "not offered" category. Of the 9750 persons for whom both the HIV and tuberculin skin test status were known, 1765 (22.4%) of 7880 who were HIV seronegative had a greater than or equal to 5 mm reaction to the skin test, compared with 354 (18.9%) of 1516 who were HIV seropositive (Mantel-Haenszel chi-square test=10.7, p<0.002).

Of 6359 persons (3898 in DTCs and 2461 in CFs) with positive skin tests and no prior therapy (i.e., 96.0% of those with positive skin tests), 5812 (91.4%) were referred for follow-up medical evaluation (3576 {91.7%} in DTCs and 2236 {90.9%} in CFs). As of June 1992, 2497 (69.8%) of those from DTCs and 1905 (85.2%) of those from CFs were evaluated.

This project identified 26 previously unreported active TB cases and 145 persons with suspected TB disease. All of the 21 persons with active TB cases and with known HIV status were HIV seropositive. Of the 124 persons with suspected TB for whom HIV status was known, 61 (49.2%) were HIV seropositive.

Excluding persons with medical contraindications, 2859 (88.4%) eligible persons were placed on preventive therapy -- 1386 (84.0%) in DTCs and 1473 (92.9%) in CFs. Of the 1726 persons eligible for completion and for whom a final disposition has been received, 1438 (83.3%) completed a recommended course of preventive therapy: 442 (65.9%) of 671 in DTCs and 996 (94.4%) of 1055 in CFs. Of those eligible for completion in DTCs, 120 (17.9%) were lost to supervision, 90 (13.4%) refused to complete therapy, and 19 (2.8%) did not complete therapy for other reasons.

Reported by: Div of Tuberculosis Elimination, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Approximately 540,000 inmates are discharged each year from federal and state correctional institutions (3), and an estimated 645,000 clients (including approximately 265,000 IDUs) are discharged from DTCs (4). Although the facilities in this project may not be representative of DTCs and CFs nationwide, the tuberculin skin testing results suggest that approximately 87,000 (13.3%) of the DTC clients and 133,000 (24.6%) of federal and state correctional institution inmates may be discharged annually with latent TB infection. Many of these persons have a history of injecting-drug use and either have or are at risk for HIV infection. These persons are at increased risk for developing active TB and transmitting the disease to others (5).

In this report, the prevalence of skin-test positivity was higher among HIV- seronegative persons, suggesting that HIV-induced anergy might be obscuring the true prevalence of tuberculin positivity among those clients tested -- especially among IDUs in the northeastern United States, among whom HIV-seroprevalence levels of up to 49% have been reported in DTCs (6). Anergy status was not collected in this project; however, CDC recommends that persons with known or suspected HIV infection be evaluated for anergy by testing with at least two companion antigens (e.g., tetanus toxoid, mumps, or Candida). Anergic, tuberculin-negative persons from populations with a high prevalence of TB also should be considered for preventive therapy (7). Since 1989, CDC has recommended 12 months of INH preventive therapy for all HIV-positive or HIV-status-unknown IDUs with greater than or equal to 5 mm of induration to the Mantoux tuberculin skin test and 6-12 months for all HIV-negative IDUs with greater than or equal to 10 mm of induration (8).

In a high proportion of clients, the HIV test either was not offered or was completed but the results not shared with the TB program. All of the new active TB cases and nearly half of the TB suspects identified with known HIV status were HIV seropositive, reinforcing the importance of HIV infection as a risk factor for the development of TB. Because of the high risk for HIV infection in persons in DTCs and CFs, and the need for longer preventive therapy among HIV-infected persons, HIV counseling and testing should be offered to all persons in these settings. Procedures are being considered to enable sharing of HIV results with TB programs while protecting client confidentiality.

The highest priority in TB control and elimination is the identification and effective treatment of cases of active TB and the follow-up of persons exposed to infectious persons. The next priority is providing screening and preventive therapy for persons at high risk for TB. Efforts to screen populations at high risk for TB and ensure adherence to preventive therapy -- especially if such persons are not in a supervised setting -- are subject to substantial logistical impediments. This project demonstrated that both DTCs and CFs succeeded in ensuring persons received skin testing and had the tests read. However, efforts in CFs were more successful than DTCs in ensuring that persons with tuberculin reactions were evaluated. Some project areas reported difficulty in scheduling appointments for DTC clients in health department TB clinics because of heavy existing caseloads. Because of the extensive length of preventive therapy, substantial data on completion rates are not yet available, especially for DTCs. Nonetheless, data indicate that CFs were especially successful in ensuring persons completed preventive therapy. Although lower, the completion rate for DTCs was similar to the 68.8% rate that U.S. health departments have reported achieving among close contacts of active TB cases (CDC, unpublished data, 1991). For evaluation of this program, future analysis should include assessment of the proportion of persons with tuberculous infection who develop active TB after preventive therapy in relation to HIV serostatus and characterization of the facilities that were most successful in ensuring high-risk persons completed preventive therapy.

References

1. CDC. The use of preventive therapy for tuberculous infection in the United States: recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR 1990;39(no. RR-8):9-12.

2. CDC. Prevention and control of tuberculosis in correctional institutions: recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR 1989;38:313-20,325.

3. American Correctional Association. Juvenile and adult correctional departments, institutions, agencies, and paroling authorities. Laurel, Maryland: American Correctional Association, 1992:XXII.

4. National Institute on Drug Abuse. National Drug and Alcoholism Treatment Unit Survey (NDATUS), 1989 main findings report. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1990; DHHS publication no. (ADM)91-1729.

5. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med 1989;320:545-50.

6. CDC. National HIV serosurveillance summary -- results through 1990. Vol 2. Atlanta: US Department of Health and Human Services, Public Health Service, 1992:13-5; publication no. HIV/NCID/11-91/011.

7. CDC. Purified protein derivative (PPD)-tuberculin anergy and HIV infection: guidelines for anergy testing and management of anergic persons at risk of tuberculosis. MMWR 1991;40(no. RR-5):27-33.

8. CDC. Tuberculosis and human immunodeficiency virus infection: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR 1989;38:236-8,243-50.

• Selection of these 25 sites was based on high levels of reported acquired immunodeficiency syndrome and TB cases. The sites included Baltimore, California, Chicago, Connecticut, Detroit, District of Columbia, Florida, Georgia, Houston/Harris County, Los Angeles County, Louisiana, Maryland, Massachusetts, Missouri, New Jersey, New York, New York City, Ohio, Pennsylvania, Philadelphia, Puerto Rico, San Francisco, Texas, Virginia, and Washington.

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