Mary Foote MD, MPH1
Infectious Disease Fellow
Anne Spaulding MD, MPH1,2
1Emory
University Schools of Medicine and 2Public Health
Atlanta, Georgia
Georgia Department of Public Health, TB Division
TB and Correctional Facilities
 Conditions that facilitate spread of TB infection
 Congregate setting, delayed diagnosis, inadequate
treatment, poor ventilation and repeated transfers
 Populations at increased risk for active TB disease
 Active disease  TB transmission
 Community reservoirs for TB
 Staff, visitors and inadequately treated former inmates
Correctional TB: Epidemiology
 TB in incarcerated persons
 1% of total US population incarcerated
 4.2% TB cases diagnosed in CFs (2011)
 Higher TB incidence rates in prisons
 Prisons = 29.4/100K (fed) and 24.2/100K (state)
 General population = 6.7/100K persons
 Reporting methods limit better estimates …
Bureau of Justice Statistics (2011)/CDC TB report 2011/MacNeil (2005)
Report of Verified Case of TB (CDC)
 Only one question on current incarceration
 No questions on prior incarceration
Prior Studies
Hammett, AJPH, 2002
 Estimate for TB burden in U.S. inmate/releasee population
in 1997
 Of 31,000 persons with TB in U.S. 40% went through CF
Baussano, PLoS Med, 2010
 Systematic review: 14 studies reporting prison TB incidence
in high-income countries (50% U.S.)
 Incidence rate ratio = TB incidence in prisons
=23
incidence in gen population
 % attributable fraction (PAF) = 8.5%
Study Hypotheses
1. Incarceration plays a significant role in TB
transmission
2. A high proportion of TB cases may have had
exposure to a CF
 The longer the exposure greater the TB risk
3. There is an association between adherence to TB
control guidelines and jurisdictional TB rates
Study Setting: Atlanta, GA
 Georgia incarceration rates = 975 per 100K persons
 In 2011, Georgia had:
 11th highest TB incidence in the United States
 3.5 cases/100K persons
 10% of TB cases diagnosed in a CF (31/321 cases)
 53% of the new TB cases reported from the Atlanta
metropolitan area
Specific Aims: Part I
Analysis of TB transmission in Atlanta CF populations
(Fulton/DeKalb counties)
 AIM I:
 To estimate proportion of Atlanta TB cases detained in a
CF in 2011
 Aim II: Among incident TB cases 2009-2012
 Assess proportion that may have acquired and/or
transmitted TB while incarcerated
Methods: Part I
 Identify Atlanta TB cases 2009-2011
 Cross-match with Atlanta CF prisoner databases
 Chart review for incarceration history
 Identify indirect exposure to CF
 Genotype and contact investigation data
Specific Aims: Part II
Facilities evaluation
 AIM 3: For each CF, describe
 TB infection control plans and practices
 Population characteristics
 Incident TB case rate per 100K admission
 AIM 4: For each CF, calculate
 TB case identification rate
 Missed TB case rate
Expected Results
 Anticipate 40-60% of TB cases in Fulton/DeKalb
Counties have been exposed to CF
 All CFs will have a TB infection control plan
 Fair to moderate adherence to guidelines
 Correlation between adherence to guidelines and
community TB rates
 Increased correctional genotypes found in community
Significance
 Better understand true burden of TB in correctional
populations
 Identify problem areas in TB infection control and
practices in Atlanta CFs
 Advocate for more resources
 Improve TB case identification and treatment in hard to
reach populations
 Improve transitional linkages to care
Acknowledgements
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Susan Ray, MD1
Russell Kempker, MD, MSc1
Rose-Marie F. Sales, MD, MPH2
David Maggio, MPH2
Carolyn Martin, RN2
Mille Reeves, RN4
Anne Spaulding, MD, MPH1,3
1Emory
University College of Medicine, Division Infectious Diseases
2Georgia Department of Public health, TB Division
3Emory University, Rollins School of Public health
4Georgia Department of Corrections
Happy World TB Day
Background: TB
 ~1/3 of the world infected with Mycobacterium
tuberculosis (MTB)
 TB is spread by airborne droplets
 Open air and UV light decreases transmission
 10% of persons infected with MTB will develop active
TB disease
 Higher risk of disease in certain conditions
(eg. HIV infection, malnutrition, DM,
substance/EtOH abuse)
Methods: Part II
 CF evaluations: Site visits
 Assess TB infection control plans and adherence to
guidelines
 Analyses
 % TB cases acquired though CF exposure
 Rate of TB cases diagnosed and missed for each CF
 Attributable risk of TB due to correctional exposure

TB Incidence (exposed) – TB Incidence (unexposed)
Next steps
 Scale-up evaluation
 Potential interventions:
 Dedicated correctional TB case managers
 Improving transitional retention in TB care
 Improved TB diagnostics
 Short course LTBI treatment
 Electronic TB management/surveillance program
TB Control in CFs
 CDC Guideline, 2006
 Early identification of TB disease
 Successful treatment of TB disease and latent TB
 Appropriate use of airborne precautions
 Comprehensive discharge planning
 Thorough and efficient contact investigation
 Francis J. Curry National Tuberculosis Center: TB
Infection Control Plan Template for Jails, 2002
Source of Map: Pew Center, 1:100
Prevalence: Selected Conditions
in Prisoners
25
20
Mean %
15
10
5
0
Source: Hammett T. AJPH 2002; 92(11) 1789
Releasees (1997) with Condition as % of US
Population with Condition
Percentage of
US Population
with Condition
100
75
50
25
Other
HCV
0
HIV/AIDS
TB disease
Disease
Source: Hammett T. AJPH 2002; 92(11) 1789
Releasee