Opinion

TB Management in the U.S. Prison System: A Societal Microcosm

The Alabama state prison system reported nine cases of tuberculosis (TB) earlier this year—the worst TB outbreak in our country in over five years. The outbreak left many wondering how an ancient disease like TB could affect so many, so easily. A closer look reveals that Alabama, like many U.S. prisons, has long been managing overcrowding due to high admission and low release rates.

More than two-thirds of prisoners in the U.S. are re-arrested for a new crime within three years of release, and more than three-quarters are arrested within five years.1 The rising recidivism rate increases the potential spread of disease, as incarceration is a strong risk factor for acquiring TB.2 Inadequate screening of prisoners on admission, living in close quarters, and interrupted treatment following diagnosis are contributing factors to this dilemma.4 The incidence of inmates infected with TB is much higher than in the general population,4 underscoring that an overcrowded prison system breeds the optimum environment for TB, a contagious, airborne disease that thrives in close-quarters.3

In many ways, healthcare in the U.S. prison system is a microcosm of lessons for our non-prison, free society. For example, when the economy improved in the nineties, inmates felt its rewards firsthand with college courses, organized sports, and fully stocked libraries. The same can hold true for health care. If prisons can reduce or eliminate the spread of communicable disease like TB, then the free world can too. But often inmates are thought of as people who have relinquished their rights by being convicted of crimes.3 This mentality exacerbates the problem and affects healthcare delivery to those in need. It also overlooks the issue that when inmates are not properly treated it results in an increased pool of TB infection in society. The U.S. Federal Bureau of Prisons is critically aware of the need to address TB outbreaks that occur in correctional facilities. The Federal Bureau of Prisons regularly updates its Clinical Practice Guidelines in an attempt to meet the rising need for TB control in prisons.5

Programs aimed at reducing the transmission of TB in prisons can provide healthcare to a group that typically faces poverty, lacks access to medical care, and are at increased risk.6 Suggested programs include screening prisoners for latent TB infection (LTBI), diagnosing and isolating those with TB disease, and providing appropriate medical treatment to those in need. Moreover, prisoners and prison workers need to be made aware and educated about TB and other diseases that thrive inside prison walls.

Fortunately, some aspects of the prison environment provide an optimal setting to implement effective disease management programs.6 The captive audience of prison facilitates direct observation of treatment, complete coverage, and health education.6 If inmates, detainees, and prison staff understand the disease and its risks, then cooperation and participation can be maximized.7 These measures can be instituted in collaboration with local or state health department TB-control programs.7 TB is a misunderstood, yet enduring disease. Its existence spans thousands of years but is often forgotten. And, the disease is closer to home than one would think. In the U.S., it is estimated that up to 13 million people have LTBI, and about five to 10 percent of them will develop TB disease if not treated.9 Alarmingly, if not treated, one person with active TB can infect on average 10 to 15 people.9

Although significant advances have been made in preventing and treating tuberculosis, more needs to be done. Reducing the rate of infection within overcrowded living spaces like prisons is critical to our fight against tuberculosis.

As one of the few companies that continue to invest in solutions for TB, Sanofi has demonstrated sustained dedication to fighting this disease. Since the late 1950’s, Sanofi has been committed to researching, developing and improving strategies to control and prevent TB. Today, our partnerships with groups like the Centers for Disease Control and Prevention provide novel opportunities to treat LTBI, further highlighting the importance of public-private partnerships in addressing unmet public health challenges.

 

Paul Chew is Head of the Sanofi R&D North America Hub and Senior Vice President, Group Chief Medical Officer

 

1 Bureau of Justice Studies Recidivism of Prisoners Released in 30 States in 2005: Patterns from 2005 to 2010. Published April 2014. Available at http://www.bjs.gov/content/pub/pdf/rprts05p0510.pdf. Accessed on August 27, 2015.

2 National Institutes of Health Prisons as Reservoir for Community Transmission of Tuberculosis, Brazil. Published March 2015. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4344267/. Accessed on August 27, 2015.

3 National Institutes of Health Public Health Implications of Substandard Correctional Health Care. Published October 2005. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449420/. Accessed on August 27, 2015.

4 National Institutes of Health Tuberculosis Incidence in Prisons: A Systematic Review. Published December 2010. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3006353/#pmed.1000381-Angie1. Accessed on August 27, 2015.

5 Federal Bureau of Prisons Management of Tuberculosis. Published January 2010. Available at http://www.bop.gov/resources/pdfs/tuberculosis.pdf. Accessed on August 27, 2015.

6 National Institutes of Health Tuberculosis in prisons in countries with high prevalence. Published February 2000. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117551/. Accessed on August 27, 2015.

7 Centers for Disease Control and Prevention TB in Correctional Facilities in the United States. Last updated September 2012. Available at http://www.cdc.gov/tb/topic/populations/correctional/. Accessed on August 27, 2015.

8 Kimberly M. Shea, “Estimated Rate of Reactivation of Latent Tuberculosis Infection in the United States, Overall and by Population Subgroup,” Journal of Epidemiology, Vol. 179, No. 2.

9 World Health Organization 2008 Tuberculosis Facts. Published April 2008. Available at http://www.who.int/tb/publications/2008/factsheet_april08.pdf. Accessed on August 27, 2015.

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