One might think that it would be easier to complete a long course of treatment in patients who are literally captive than among free-roaming people in the community, but that apparently is not the case -- at least when it comes to treating tuberculosis.
TB patients diagnosed in U.S. prisons, especially those who were foreign-born, had significantly lower rates of documented treatment completion than community-dwelling TB patients, according to Kiren Mitruka, MD, and colleagues, of the CDC's Division of Tuberculosis Elimination in the April issue of the American Journal of Preventive Medicine.
The TB treatment completion rate among patients diagnosed while incarcerated was 75.6%, compared to 93.7% among non-incarcerated patients. A higher proportion of those diagnosed during stays in prisons, jails or other detention facilities were also lost to follow up (1.7% versus 2.2%) or moved (9.4% versus 2.3%) during treatment (P<0.001 for all).
A review of treatment outcomes and trends by incarceration status, using data from the U.S. National TB Surveillance System, showed an increase in suspected treatment non-completion, based on lack of completion documentation, in U.S. jails and prisons, between 1999 and 2011.
Moreover, compared to U.S.-born prisoners with TB, those of foreign-birth were three times as likely to have no documented treatment completion.
The researchers noted that early TB case detection and treatment completion are the cornerstones of tuberculosis control efforts and that most forms of TB require at leas six months of treatment.
For inmates released or transferred before treatment completion, continuity of care plans are required, but they are not always implemented, they wrote.
"Socioeconomic challenges, high mobility and behavioral factors can increase the risk of loss to follow-up of inmates, challenging U.S. local public health programs in documenting whether or not they completed their TB treatment," the researchers wrote.
Incomplete treatment increases the risk for drug resistance and relapsed active disease, presenting a public health risk.
Jails and prisons are high-risk settings for TB outbreaks and lapses in TB prevention and control at correctional facilities. From 9% to 43% of TB cases in the community were associated with incarceration in various studies.
In a 2015 CDC review of source cases that started TB outbreaks in the U.S., 50% had a history of incarceration.
"Thus, correctional facilities represent a key opportunity to promote TB control efforts by promptly diagnosing TB and ensuring that continuity of care is established for inmates released before treatment completion," the researchers wrote.
In the newly published study, Mitruka and colleagues examined 163,150 TB cases eligible to complete TB treatment in the U.S. between 1999 and 2011, including 6,093 (3.7%) cases diagnosed during incarceration, 156,770 (96.1%) who were community dwelling and 287 (0.2%) with unknown incarceration status.
The analysis revealed that:
"Although social TB risk factors (e.g., homelessness and substance abuse) are common among incarcerated people, these factors were not associated with their lack of documented TB treatment completion," the researchers wrote. "Rather, being foreign born was the strongest correlated, after adjustment for demographic and clinical factors."
The highest proportion of incarcerated TB patients with no documented completion were those being held in federal, rather than state and local facilities, including Immigration and Customs Enforcement (ICE) detention facilities (U.S. born, 14.8%; foreign born, 48.1%).
Given that ICE detainees undergoing treatment for TB are routinely deported before their treatment is complete, "establishing continuity of care and documenting treatment completion is critical, as instances of re-importation and spread of TB in U.S. communities, including a drug-resistant strain, have been previously documented," the researchers noted.
The research was supported by the U.S. Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services.
Primary Source
American Journal of Preventive Medicine
Source Reference: Mitruka K, et al. "Disparities in tuberculosis treatment completion by incarceration status, U.S., 1999-2011" Am J Prevent Med 2017; April; DOI: 10.1016/j.amepre.2016.10.035.
Source: MedPage Today