TB in Prisons and Jails Albuquerque, New Mexico November 28, 2012 Challenges of TB Treatment in Special Populations in Corrections Marcos Burgos, MD November 28, 2012 Marcos Burgos, MD has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1
Challenges of TB Treatment in Special Populations in Corrections TB in Prisons and Jails: Get Out TB Free Albuquerque, New Mexico Marcos Burgos MD Medical Director TB Program New Mexico, Department of Health November 28, 2012 2
Learning Objectives Epidemiology of TB Identify barriers to TB control in prisons Risk factors for TB in Prisons Special medical situations in prisons Illustrative cases of TB and other co morbidities 5 Rationale for Strengthening TB Control and Prevention in Prisons Inmates who have TB disease or LTBI can be treated before they are released into the community The correctional setting can be a primary source of health information, intervention, and management of chronic diseases 3
30,000 Reported TB Cases United States, 1982 2010* 25,000 No. of Cases 20,000 15,000 10,000 5,000 0 Year *Updated as of July 21, 2011 Countries of Birth of Foreign born Persons Reported with TB, United States, 2010 Other Countries 38% Mexico (23%) Philippines (11%) Haiti (3%) Guatemala (3%) China (5%) Vietnam (8%) India (9%) 4
Challenges to TB control in the prisons Logistical and management structures Personal perception, bias, stigma Recognition of basic human rights Revolving door Lack of expertise 9 High Percentage of TB Cases in Incarcerated Persons in the US In 2008, 2.4 million people were incarcerated in United States jails or prisons 25 % of inmates are foreign born 3.2% of all TB cases nationwide occurred among residents of correctional facilities in 2003 BMC Public Health. 2010; 10: 777. 5
Tuberculosis and incarceration TB in corrections is 4 to 5 times greater than outside corrections Inmates at high risk of TB Foreign born, substance abuse, lower socio economical status, other medical conditions Congregate setting Overcrowding poor ventilation Frequent inmate movement 11 Relative Risk for developing TB by various risk factors 6
Prison populations Demographics: Convergence of risk groups Male Young age groups High unemployment rate/low income persons Low education level High rates drug abuse and alcoholism High rates of HIV & STDs High rates of mental illness and homelessness Frequent close contacts and recent exposure to active cases Bureau of Justice Statistics, Special Report, 2008 13 Correctional Population Large numbers incarcerated people now and in the future Chronic illness Mental illness Addiction Incarceration of undocumented immigrants 14 7
Medical problems reported by prison inmates by gender and age, 2004 Medical problem All inmates Male Female Arthritis 15.3 14.6 24.5 Asthma 9.1 8.4 19.2 Cancer 0.9 0.8 2.4 Diabetes 4 3.9 5.5 Heart problems 6.1 5.9 9 Hypertension 13.8 13.6 16.8 Kidney problems 3.2 2.9 6.9 Liver problems 1.1 1.1 1.3 Paralysis 1.4 1.4 1.4 Stroke 2.6 2.5 3.7 Hepatitis 5.3 5 9.5 HIV 1.6 1.6 1.9 STDs 0.8 0.7 2 Tuberculosis 9.4 9.6 6.1 U.S. Department of Justice, Bureau of Justice statistics, 2004. TB & Special Medical Conditions in Corrections 8
36 year old male in Jail for 2 months, history of drug use, ETOH abuse, complaining of weight loss, 30 pounds in 6 months, some productive cough, fever and chills Treated for pneumonia twice Diagnostic studies: AFB smear 3+; LFT elevated X 3 nl TB & Special Medical Conditions in Corrections HIV positive, CD4 46, viral load 800,000 9
HIV in Prisons, 2001 2010 The rate of HIV/AIDS among state and federal prison inmates declined from 194 cases per 10,000 inmates in 2001 to 146 per 10,000 at yearend 2010. AIDS-related deaths among all state and federal prison inmates declined from 24 deaths per 100,000 inmates in 2001 to 5 per 100,000 in 2010. AIDS-related deaths in state prisons declined from 89 in 2009 to 69 in 2010 among males, from 70 to 43 among black non- Hispanics, and from 87 to 60 among all state inmates age 35 or older. California, Florida, New York, and Texas each reported holding more than 1,000 inmates with HIV/AIDS at yearend 2010. These states held 51% (9,492) of all state prisoners with HIV/AIDS. U.S. Department of Justice, Office of Justice Programs. Bureau of Justice Statistics, 2012. 10
Current CDC / IDSA / ATS guidelines duration of therapy for HIV related TB Standard 6 month regimens for most patients Extend therapy to 9 months for patients with + cultures at 2 months and cavitation or delayed clinical response Recommendations: frequency of treatment Always use directly observed therapy for patients with HIV related TB Target patients with advanced HIV disease for more frequent therapy Daily for the first 2 months Thrice weekly or daily during the continuation phase MMWR 2002;51:214 5 11
36 year old male with pulmonary tuberculosis, LFT elevated X 3 nl, Started on RIPE, tolerated treatment well When do we start HIV treatment? CD4 cell count at TB diagnosis and mortality rate 120 Mortality rate (per 100 person-years) 100 80 60 40 20 0 0-99 100-199 200-349 > 350 CD4 cell count Lancet 1999;353:1469 1475 12
CDC Recommendations for use of antiretroviral therapy during TB treatment CD4 cell count at TB diagnosis < 200 < 50 200-350 > 350 ART during TB treatment Start ASAP Monitor, consider starting ART Monitor CD4 & clinical status Management issues: antiretroviral therapy during TB therapy Challenge of adherence to multidrug therapy for both diseases Overlapping drug toxicity profiles Drug interactions Immune reconstitution (paradoxical) reactions Need for coordination between TB and HIV treatment programs 13
36 year old male with pulmonary tuberculosis, Hep C +, LFT elevated X 3 nl, Started on RIPE, tolerated treatment well What ART should we start? Adherence in treatment of TB and HIV DOT program for TB builds strong relationships with patients frequent contact, attention to other aspects of care (housing, etc.) Once-daily ART now possible Provide directly observed ART at the same time as TB medications in prison Educate health providers in prison about ART, side effects 14
Overlapping side effect profiles of first line TB drugs and ART drugs Possible causes Side effect TB drugs ART drugs Skin rash Nausea, vomiting Hepatitis Leukopenia, anemia PZA, RIF, INH PZA, RIF, RBT, INH PZA, RIF, RBT, INH RBT, RIF NVP, EFV, ABC AZT, PIs NVP, PIs, IRIS AZT 46 year old male from Mexico, admitted because intractable diarrhea, weight loss of 60 pound in 6 months, some productive cough, fever and chills Diagnostic studies: AFB smear +; HIV + CD4 18; VL > 800,000 Efavirenz 600 mg/ emtricitabine 200 mg/ tenofovir 300mg 15
Summary: HIV, TB drug interaction Drug interactions in HIV-TB should not prevent HIV-TB treatment Drug interactions should be managed, not avoided Close collaboration with correctional physicians and nurses TB & Special Medical Conditions in Corrections 16
TB Case 44 year old male with history of alcohol abuse and homelessness for 15 years, in prison for about 9 months Productive cough for 3 months and blood tinged sputum The patient has a history of large reaction to a skin test in prison in Arizona The patient has lost 40 pounds in the last year CXR CXR 17
TB case TB case PMH Diabetes (HbA1C 10), Hypertension Chronic depression, Bipolar disorder PSH History of IVDU History of alcoholism for 20 years with most of those years homeless Smoker 1 1/2 packs daily for 30 years 18
TB case The patient is started in 4 drugs AST 64, ALT 61 2 weeks later: AST 286, ALT 287, platelets 160, direct bilirubin 2.5 Treatment stopped, AFB smears 3+ 2 weeks later, AST 568, ALT 638, Platelets 120 TB case HVC + HVC viral load > 3,000,000 2 weeks latter AST 206, ALT 261 Patient started on Amikacin, ETB, Moxifloxacin. 9/16/09 patient develops a generalized maculo papular rash, TB drugs stopped AST 285, ALT 332 19
TB Case rash resolved, patient developed rash when amikacin is introduced AST 315, ALT 346, Platelets 132 TB case 1 week latter AST 228, ALT 261, rash resolved The patient started on, rifabutin, ETB and levofloxacin sequentially Two weeks latter AST 252, ALT 255, Platelets 91 and patient seems to be tolerating treatment well 20
Hepatic C The hepatitis C virus is the leading cause of liver cancer and the most common bloodborne infection in the US, affecting approximately 3.2 million people. About 25% of persons living with HIV and about 30% of those living with Hepatitis C spent time in correctional facilities. Among prisoners, 12% and 30% are infected with the virus in the U.S. HVC and TB treatment Few studies have evaluated the impact of HCV infection during treatment for TB In Florida among 128 patients, 30% of hepatitis C infected individuals developed hepatotoxicity compared with 11% among uninfected individuals Hepatitis C was an independent risk factor for the development of hepatotoxicity, elevating the risk fivefold The risk of hepatotoxicity more than 14 fold in HVC/HIV coinfection An Official ATS Statement: Hepatotoxicity of Antituberculosis Therapy, 2006 21
Evaluation and treatment of Hep C Antiviral therapy is generally indicated for inmates with chronic hepatitis C if they have no contraindications to treatment and present with at least one of the following: Genotype 1 and liver biopsy result with evidence of progressive fibrosis Genotype 2 or 3 (with no biopsy performed) Genotypes 4, 5, or 6: The best approach to management of these cases is not clearly defined by the medical literature. HCV should be the same as for genotype 1 as noted above. Various co infections or co morbidities, such as cirrhosis and renal disease, may affect treatment decisions Expert advice and guidance should be obtained Federal Bureau of Prisons Clinical Practice Guidelines, Clinical Guidelines, March 2012. Mode of transmission of Hep C Percutaneous Exposure to Infectious Blood (primary mode) Injection drug use Transmission of contaminated blood products (prior to July 1992) Tattooing with shared sharps in jails or prisons (potential mode) Other Modes of Transmission (inefficient) Sexual contact (increased risk for inmates with history of STD or multiple sexual partners) Congenital transmission (risk of 5 6%) Ways HCV is not transmitted Breast feeding Kissing, sneezing, hugging, coughing Food or water Casual contact, including sharing eating utensils or drinking glasses 22
TB & Special Medical Conditions in Corrections HIV HVC DM Renal insufficiency Diabetes and TB 80,000 of prisoners have diabetes, a prevalence of 4.8% Diabetes accelerates latent TB active TB (3x) Diabetes makes TB harder to diagnose and treat Diabetes leads to poor TB outcomes Diabetes Management in Correctional Institutions, American Diabetes Association, 2012, care.diabetesjournals.org 23
TB and Diabetes Harder to Find More likely to have exclusively lower lobe disease Harder to Treat More likely to have cavitary disease More likely to remain smear positive at 8 weeks of treatment Relapse Rates? Death during TB treatment? Dooley KE, Am J Trop Med Hyg. 2009 Apr;80(4):634 9, Impact of diabetes mellitus on treatment outcomes of patients with active tuberculosis TB infection and renal insufficiency TB infection among US chronic dialysis patients, is not infrequent Patients with renal insufficiency should be screen for LTBI Ethic minority groups have a higher prevalence of renal insufficiency and risk of infection with tuberculosis Patients with renal insufficiency are at increase risk of developing tuberculosis 24
Treatment of Active TB in patients with reduced renal function In general INH, RIF can be used at normal doses in renal impairment Pyridoxine should be give to prevent peripheral neuropathy PZA and ETB 3X weekly Give treatment after hemodyalsis to avoid premature drug removal TB & Special Medical Conditions in Corrections HIV HVC DM Renal insufficiency 25