Implementing a TB-Control Program in Prisons: The Basics Dr. Mayra Arias

Elements Needed before a TB-Control Program in Prisons Is Considered Political will: - Prison authorities. - Public-health authorities. Civilian TB-Control Program (NTP) in place. Acknowledgement of TB as a problem in prisons in the country. Access of health officials to all detention centers. Financial and institutional support.

Step One: Step One: Defining the problem Situation Analysis Epidemiological TB data from representative prisons. Structural and administrative aspects.

Step Two: Step Two: The Proposal Development of a written plan or proposal, signed and endorsed by the highest responsible levels within the civilian (public-health) and penal sectors.

An Effective TB-Control Program in prisons Goals 1-Reduce morbidity and mortality. 2-Prevent the development of drug-resistant TB. 3-Reduce and ultimately stop the transmission of TB infection.Strategies 1-Early diagnosis of TB. 2-Effective treatment, cure.

Early Diagnosis Focuses on early diagnosis of infectious cases to achieve greater impact on infection control. May be used to detect cases during screening at entry and those cases that occur while in prison. Is followed by prompt and effective treatment. Is cheap and accessible.

Effective Treatment Requires: Continuous supply of correct drugs, correct quantities, good quality. Correct prescription, correct doses, proper duration. Directly observed therapy (DOT) and support to the patient. Follow-up of treatment efficacy through clinical and lab assessment. Guarantee that the patient completes therapy and that treatment results are recorded and reported.

Organizational Models for TB-Control Programs Centralized: Prisoners with suspected TB sent to a facility specifically for diagnosis and treatment of TB. Decentralized: Prisoners are diagnosed and treated in their prisons of origin. Accessibility of services to all categories of prisoners. Existing infrastructure. Operational requirements. Integrated prison-civilian program.

Why an integrated TB control program? Definition: Definition: Health services in prisons are linked throughout the system to the health services of the public health system (NTP).

Challenges Provision of health services in prisons - Responsibility of health services in prisons (whose?). - Cases management (diagnosis, treatment, follow-up). - Funding. - Untrained and unmotivated staff. - Exclusion of some groups of prisoners. Conflict of interests - Monetary. - Legal and security requirements. - Patient-doctor relationship. Prison-population mobility Corruption

Integrated Programs: Why? Ensures the correct case follow-up during and after incarceration (released, transferred). Promotes the access to health care for all prisoners in every prison. Guarantees cohesive guidelines and equal quality of services for prisoners (diagnostics and treatment). Ensures that the TB statistics in prisons are included in the NTP data, and are distinguished as such. Maximizes resources and promotes the sharing of experiences.

Case-Finding Strategies Self-referral (passive) RS Screening at entry (active) Mass screening (active) Contact investigation (active)

Case-Finding through Self-Referral Patients must be willing to seek medical assistance. Health staff must be alert to recognize symptoms, diagnose and treat TB. TB care must be accessible. Fear of effects of a TB diagnosis. Need for trained personnel. Weak TB services, corruption. Education & close supervision

Case-Finding through Contact Investigation Standardized by NTP guidelines Should be implemented promptly after diagnosing a case (*smear positive) What is a close contact? What protocol should be followed? Time-consuming Establishment of protocols, Training of health staff

Case-Finding during Entry Screening Recommended by UN and Council of Europe. Inmates usually from a background where the prevalence of TB is already high. Allows for the containment of infection Inconvenience to prison authorities. Lack of medical staff in prisons In many cases, entry of inmates occurs at all times. Lack of isolation facilities. Close communication between prison administrative and health staff and between civilian and prison health staff

Case-Finding through Mass Screening Detects pool of prevalent cases. All prisoners must be screened. May be done once and followed-up by other strategies. Resource-consuming. Should prioritize prisons with higher risk for TB.

Screening Methods Symptom Assessment Simple to implement. Inexpensive. Radiography Low positive predictive value. Must be administered by trained personnel. Recommended where resources are limited. Sensitivity and specificity: broad spectrum. High capital and running cost. High degree of training required.

Case Identification Collection of sputum specimen. Transporting specimen to lab. Lab services available. Reporting of results.

Case Management: DOTS Implementation Categorizing cases using standardized classification and assigning them standardized treatment regimens. Ensuring treatment adherence (in prison, transferred, released cases). Tracing managing cases who default from treatment. Documenting treatment follow-up and outcomes. Supervising and evaluating the program.

Case Management: Prison-Civilian Integrated Programs Compare treatment outcomes between each group and the trends in outcomes over time. Improve knowledge of what drugs and laboratory materials are acquired. Make the best use of the resources available.

Protection from TB in Prisons 3 levels of Infection Control Administrative Environmental Personal respiratory

Administrative Measures Reduce the risk of exposure of persons that are not infected to other persons with infectious TB (smear- positive cases)Strategy Development of effective policies and protocols that guarantee prompt Identification, isolation, diagnostic evaluation & treatment. Education, training, counseling of health staff about TB.

Administrative Measures, cont. Infection risk assessment in different prisons, infection risk assessment of different areas (rooms) in each prison. Organization of isolation rooms, separate from other rooms. ** Early diagnosis (smear-positive cases) Active and passive finding. Use of cough registers (RS). Training of prison staff and visitors. Efficient communication between of lab staff and prison health staff.

Administrative Measures, contd Collection of sputum in well-ventilated spaces. Early initiation of treatment. Proper protocols for prisoners who are transferred or released. Evaluation of the implementation of TB infection control measures. Continuous training to staff regarding infection control measures.

Environmental Measures Reduce the concentration of infectious droplet nuclei in the air, prevent their dissemination.Strategies Mechanical and/or natural ventilation: maximize ventilation and control air flow. HEPA filtration (high-risk areas). Ultraviolet germicidal irradiation (UVGI) (high risk areas).

Personal Respiratory Protection Measures Complement the administrative and environmental measures. Areas of higher risk of exposure to M. tuberculosis (isolation wards, procedures that produce aerosols): Particle respirators (N95). Training to personnel.

Opportunities Captive population: Better case follow-up. Benefit for the community (civilian). Promotes prisoners self-worth and their reintegration into society. Potential for attaining funds and creating awareness for prisoners health and for penal reform. Improves staffs performance.

Reference Tuberculosis Control in Prisons – A Manual for Programme Managers WHO/CDS/2000