Editorial Note

Editorial Note: This report demonstrates that M. tuberculosis can spread rapidly among HIV-infected inmates in congregate living situations and to their visitors; disease developing in a visitor and a parolee may have led to secondary transmission in their household contacts. Containment required efforts of correctional and health department staff at the state and local levels to address the unique medical, custody, public health, and fiscal challenges posed by the outbreaks.

Updated policies and procedures for managing possible TB cases and their contacts are under development and implementation in correctional facilities and the community. The changes are to ensure that HIV-infected inmates with new radiographic abnormalities consistent with TB are placed in respiratory isolation, reported to the local health department and the central public health system of the prisons as having suspected TB, and started on multidrug therapy for TB even when another pulmonary process is diagnosed. These procedures will minimize the likelihood that HIV-infected persons with undiagnosed infectious TB (such as the index case-patient in the prison B outbreak) are transferred from jails, hospitals, or the community into prisons. The clinical course of the index case-patient in the prison A outbreak illustrates the challenge of detecting TB disease that develops in HIV-infected inmates after they have been cleared of having TB disease at entry to prison but develop it later. A TB evaluation should be initiated for HIV-infected inmates with respiratory symptoms who are diagnosed initially with conditions other than TB (1), even if TB has been excluded recently.

A prompt response to infectious TB cases is critical to minimize the transmission of TB and the development of disease among infected persons. All persons suspected to have infectious TB, including any person with a respiratory specimen that is smear-positive for AFB, must be placed immediately in respiratory isolation. A contact investigation must be initiated promptly. All HIV-infected contacts, regardless of TST status, should receive preventive therapy once TB disease is excluded (2,3).

Prevention of community spread (and reintroduction of undiagnosed infectious TB patients into correctional facilities) requires the rapid investigation of contacts in the facility. Inmate contacts should be evaluated and begun on treatment or preventive therapy before release from any facility, including hospitals or high-risk housing units. Joint efforts are under way in California to clarify roles and ensure that the infrastructure of prisons and health departments is adequate to track TB cases and suspected cases and to elicit, notify, and evaluate community contacts promptly (4,5).

The use of preventive therapy may need to be expanded beyond TST-positive inmates to certain HIV-infected persons with a negative TST. HIV-infected persons with a history of untreated or inadequately treated TB that healed should receive TB preventive treatment regardless of their age or results of TSTs (2). Primary prophylaxis for TST-negative HIV-infected persons with an ongoing and unavoidable high risk of exposure to M. tuberculosis should be considered (2,6,7). Following the TB outbreaks described in this report, the California Department of Corrections has recommended routine use of INH preventive therapy for all HIV-infected inmates with CD4 counts less than 100 cells/uL, provided that such therapy is not contraindicated (7). The risks and benefits associated with primary prophylaxis in these settings need to be evaluated.

References

  1. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994:43(no. RR-13).
  2. CDC. Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus: principles of therapy and revised recommendations. MMWR 1998:47(no. RR-20).
  3. CDC. 1997 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. MMWR 1997;46(no. RR-12).
  4. CDC. Prevention and control of tuberculosis in correctional facilities: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1996;45(no. RR-8).
  5. California Department of Health Services, California Tuberculosis Controllers Association, and the California Conference of Local Health Officers. Guidelines for coordination of TB prevention and control by local and state health departments and California Department of Corrections. Berkeley, California: California Department of Health Services, 1998.
  6. CDC. Anergy skin testing and preventive therapy for HIV-infected persons: revised recommendations. MMWR 1997;46(no. RR-15).
  7. California Department of Corrections, Public Health Infectious Disease Advisory Committee. Tuberculosis protocols for human immunodeficiency virus infected inmates. Sacramento, California: California Department of Corrections, 1998.

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