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TUBERCULOSIS IN PRISONS Elizabeth Haworth Consultant RE HPA SE TUBERCULOSIS IN PRISON The Facts • • • • • • • • • Consistently higher rates of TB in prisoners Reasons: - social exclusion risk factors/behaviour (90 % mentally ill or substance abuse) - co-factors eg HIV - environmental factors eg overcrowding, poor ventilation 72,000 (150,000/yr ~ 1.5m family/friends) held in 137 prisons in E & W Transmission - inmates and staff Length of stay correlated with TB infection risk Transmission in prison, to visitors and community contacts MDR TB Control in prison -WHO guidelines, Dx, tmt, DOTS Management challenge worldwide - seamless integration of prison and community health care/PH Maher D, Grzemska M, Coninx R, Reyes H. Guidelines for the control of tuberculosis in prisons. WHO/TB/98.250. World Health Organization, 1998 and other WHO publications TUBERCULOSIS IN PRISON Problems • • • • • • • Institution Security/offenders Staff Health care - transfer from prison service to DH/NHS Occupational health Close contact Transient/mobile population TUBERCULOSIS IN PRISON Support • • • • • • WHO guidance WHO HIPP Experience from other countries eg USA HPA surveillance project Local projects The Prison Health Handbook - Transfer of health care responsibilities to NHS TUBERCULOSIS IN PRISON Incidents • No ?? Less than 10/year reported to CDSC • London - Isoniacid resistant TB outbreak in local prison • SE - Cat C prison - YOI • Cases in most prisons including Cat A and secure units for asylum seekers TUBERCULOSIS IN PRISON London incident Local prison No inmates: 1200 Index case - delayed dx and effective tmt 28% cases associated with prison Total cases 209 (confirmed or probable Jan 05) ~178 London, 31 out of London (48 % completed tmt, 2 deaths, 7 MDR TB No tuberculin tested: more than 1000 Case/treated Chemoprophylaxed Completed tmt Outcome: 80 90 64% TUBERCULOSIS IN PRISON SE incident Cat C (training) prison No inmates: 580 Single rooms: 40 Index case ill April 2004 ( 6/12 in prison and cough for 3/12) Delayed dx – cavitating smear + ve TB INH resistant Many contacts and xs anxiety Hospital contacts (MAU) No Heafed Many Case/treated Chemoprophylaxed Completed tmt Outcome 1 Many Possible case transferred in ?100% Exposure algorithm Does the prisoner have either of the following symptoms? cough > 3 weeks coughing blood Yes Prisoner should be immediately placed in isolation in E3 in Parkhurst. CXR and sputum-smear results should be reported on within 24 hours - 2 further sputum specimens should be collected No Does the prisoner have two or more of the following symptoms? night sweats fever weight loss excessive fatigue loss of appetite chest pain Yes Is the prisoner formerly homeless and / or a hard drug user? Yes Prisoner should remain in single occupancy cell. CXR and sputum-smear results (if obtainable) should be reported on within 24 hours in which time normal movements should be restricted. No No Does the prisoner have one or more of the following symptoms? night sweats fever weight loss excessive fatigue loss of appetite chest pain No No further action Yes Prisoner should be subject to normal movements. CXR and early morning sputum specimens should be considered. If requested, a CXR and report should be obtained within 3 working days. Exposure algorithm c’td Does the prisoner have either of the following symptom s? No cough > 3 weeks coughing blood Yes Prisoner should be immediately placed in isolation in E3 in Parkhurst. CXR and sputum-smear results should be reported on within 24 hours - 2 further sputum specimens should be collected Does the prisoner have two or more of the following symptom s? No night sweats fever weight loss excessive fatigue loss of appetite chest pain Yes Is the prisoner formerly homeless and / or a hard drug user? Yes Prisoner should remain in single occupancy cell. CXR and sputum-smear results (if obtainable) should be reported on within 24 hours in which time normal movements should be restricted. No Does the prisoner have one or more of the following symptom s? No night sweats fever weight loss excessive fatigue loss of appetite chest pain No further action Yes Prisoner should be subject to normal movements. CXR and early morning sputum specimens should be considered. If requested, a CXR and report should be obtained within 3 working days. TUBERCULOSIS IN PRISON SE incident YOI No inmates: 350 (age 14 to 18) Index case - delayed diagnosis following haemoptysis - smear positive cavitating lesion - hospitalised until established on tmt and non-infectious Contact tracing No tuberculin tested – 148 (119 trainees, 29 staff) Outcome Case/treated Chemoprophylaxed 1 5 TUBERCULOSIS IN PRISON Organisational and treatment challenges • • • • • • Prison regime/schedules Security Authority Surveillance and information holes Therapy - appropriate drugs, monitoring, DOT Contact tracing ∞ exposure - needs skilled and knowledgeable staff - staff anxiety - lack of OH service (info/confidence, health checks, immunisation) • Single rooms • Negative pressure TUBERCULOSIS IN PRISON Responsibility of PCTs to create network for commissioning and providing prison health care • New PCT led networks for the commissioning and provision of healthcare in prisons (PCT, NHST, HPA, SHA) - preparation for transfer of responsibilities from April 2005 - PCTs responsible for commissioning prison health care April 2006 - Network joint PCT & Prison - Same standards and range of health care as general public (Health Services for Prisoners, DoH 2004) • • • • • • • Opportunity for improvement but: Transitory population with high turnover High infection rates (BBV, TV, STIs) Education/training needs Audit & evaluation EBP Staff safety & security TUBERCULOSIS IN PRISON Action • TB Action Plan - Stopping Tuberculosis in England Oct 04 TB Programme Reduce risk of new infection Quality tmt & care Low levels of drug resistance • Implementation Public health effort better organised better targeted Early accurate dx Better surveillance Resource R&D • British Thoracic Society • WHO Guidance/expert advice • DH (The Prison Health Handbook) • SOPs • Education/training TUBERCULOSIS IN PRISON Lessons • • • • Other regions National surveillance Other countries – NY and MDR TB Co-infections - particularly HIV TUBERCULOSIS IN PRISON Diagnostic developments • • • • Rapid automated culture Rapid molecular tests for drug resistance DNA fingerprinting IFN assays (eg Tspot-TB, Quantiferon) for active and latent infection - blood test - no second reading - guides chemoprophylaxis TUBERCULOSIS IN PRISON Issues • • • • • • Information/knowledge Staff capacity and accountability EBP Stakeholder agreement Outcome/performance monitoring/audit Funding ? TUBERCULOSIS IN PRISON Acknowledgements Dr Paul Bingham DPH and CCDC IoW Dr Kyle Knox CCDC Ox Dr Marie Claire Lobo SpR Portsmouth Dr Mary Piper DH Dr Helen Maguire HPA London Dr Jane Jones CDSC Alistair Storey CDSC THANK YOU