Rauni Ruohonen

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Priorities of TB control in penitentiary care

• Rauni Ruohonen
• FILHA

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Prevention of transmission

• Early diagnosis and treatment
• Isolation of different patient categories
• Cure of most of TB cases

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Factors affecting TB transmission 1

• Smear positive are highly infectious
• Pulmonary cavitary cases are usually smear
  positive
• Immediate isolation is necessary until proven
  conversion
• HIV positive are more often smear negative
  pulmonary or extrapulmonary cases should they
  be isolated ?
• Transmission is dependent on closeness and time
  of contact
• In penitentiary care contacts are very close and
  prolonged culture positive cases can also
  transmit TB especially to HIV positive population

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Factors affecting TB transmission 2

• Unknown TB cases are major source of transmission

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Where are the unknown TB cases ?

• In the civilian society
• People entering pre-trial centres
• Visitors to detainees and inmates contact
  tracing from detected TB cases in penitentiary
  care must include also civilian contacts
• In the borders between penitentiary care and
  civilian society
• Police custody detainees spend prolonged time
  in custodies during court processes
• In civilian health services if detainees or
  inmates receive care there
• In the penitentiary care
• In pre-trial centres and prisons depending on
  effectiveness of active case-finding
• Special attention should be put on contact
  tracing and transfers

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Early diagnosis 1

• Interview of inmates and detainees by skilled
  staff
• Sputum smear cases have mostly symptoms and can
  be detected by careful interview
• HIV positive have more sputum smear negative and
  extrapulmonary TB. They have the same right for
  diagnosis and care as HIV negative.
• Screening at entry, prior to transfer (also to
  police custody ) and by symptoms
• Identify persons already diagnosed/ on therapy
• Careful anamnesis on risk factors, previous
  contacts and treatments
• Refer suspects to examinations and isolation
• Careful contact investigations (civilians
  included)
• Continuous training of staff

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Early diagnosis 2

• High quality laboratory services
• Sputum smear examinations rapid classification
  of species (atypical mycobacteria common in AIDS)
• Culture examinations
• Rapid drug sensitivity testing
• Chest x-ray screening
• Screening at entry, prior to transfer (?) and by
  symptoms
• In risk groups half yearly during stay in
  penitentiary care
• HIV positive are more often smear negative
  early dg needs x-ray
• In case of lack of equipment cooperation with
  other units or civilian society (mobile units?)

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Problems of infection control 1

• More weight is put on engineering controls than
  on the administrative controls
• No ventilation can solve the problems if XDR
  cases are not detected or are isolated in same
  room with HIV positive sensitive cases
• Engineering control focuses usually on TB wards -
  less in other areas of importance.
• Places of special concern Police custody,
  transferred-in zones in penitentiary care, wards
  for TB suspects
• Ventilation should be improved in all
  penitentiary care units
• Benefits to the prevention of all airborne
  infections
• Decreasing overcrowding is best prevention of
  airborne infections and can be achieved by
  criminal system reform
• Negative pressure rooms are not needed everywhere

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Human aspects possibility to open windows,go
out, read, watch tv, smokepsychological support
needed
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Problems of infection control 2

• With increasing HIV epidemic HIV infection
  control and hepatitis prevention must be included
  also in TB infection control and treatment
• Needle safety
• Prevention of sexual transmission
• Prevention of mother to child transmission
• Harm reduction programmes
• Hepatitis B vaccinations

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How isolation should be organised

• Ideal separate isolation rooms for 1-2 persons
• If not possible, then
• Establish separate areas. Wards and floors for
  suspected or confirmed TB patients based on the
  infectiousness of the patient (cohorts).
• Hierarchy among prisoners has to be taken into
  account when two or more inmates are placed in
  same room participation of inmates in decision
  making
• Discontinuation of isolation as soon as criteria
  are filled releases more place for needed
  isolations

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Isolation in cohorts

• In present epidemiological situation in
  North-East Europe at least 7 cohorts
  need to be isolated separately in male and female
  wards
• TB suspects HIV -
• TB suspects HIV
• MDR TB suspects HIV -
• MDR TB suspects HIV
• Sputum smear sensitive cases
• MDR cases
• XDR cases
• In practice only 4-5 cohorts can be managed in
  one ward.
• One patient will move possible 3 times from one
  isolation to another suspect ss
  MDR isolation

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Cure most of the TB cases

• Increasing iv drug use driven HIV epidemic
  creates more problematic TB patient groups
• Hepatitis C and B common
• Opioid substitution therapy (OST) needed
• Combination of TB treatment with HAART and OST is
  challenging. Role of CPT ?
• The Latvian Centre of Excellence should
  distribute its experiences in this field
  worldwide

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Thank you for your attention !