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Dr. Laniado-Laborín is a pulmonologist at Hospital General de Tijuana.
Correspondence to: Rafael Laniado-Laborín, MD, MPH, PMB 953, 482 W San Ysidro Blvd, No. 2, San Ysidro, CA 92173; e-mail: laniado{at}net-pla.net
Recent tuberculosis (TB) outbreaks, and an increase in both case rates and drug resistance rates in the prison systems of many regions of the world, have created an urgent need for improvement in the TB control efforts of correctional facilities.
This situation is magnified in underdeveloped countries, where prison TB prevalence rates 5 to 10 times the national average are not uncommon and can be up to 50 times the reported national rate1 ; in some of those areas, > 50% of the inmates with TB have strains of Mycobacterium tuberculosis that are multidrug-resistant (MDR).2 Unfortunately, this is not a problem limited to some distant third-world country; outbreaks of MDR-TB already have been reported in correctional facilities in the United States.3
The population that comes under the supervision of the criminal system in the United States is at a relatively high risk for TB.4 The main reason for the high risk for M tuberculosis infection and active TB disease in prisons is the disproportionate number of inmates who have factors for exposure to the organism or, if infected, for development of active disease.5 These risk factors include prison overcrowding,6 inadequate ventilation, malnourishment, infection with HIV, infection with hepatitis B and C viruses, continued substance abuse,7 8 a high proportion of inmates from racial and ethnic minorities (frequently recent immigrants from high-incidence countries), and being a member of a lower socioeconomic population that has inadequate access to health care.5 Studies in TB transmission within a prison have shown a high degree of case clustering, with more than one quarter of the cases showing a unique fingerprint.9 Furthermore, correctional facility employees are also at risk due to occupational exposure to TB. Approximately one third of new TB infections among New York State prison employees are due to occupational exposure.10
Completion of anti-TB treatment is the maximum priority of TB control programs. Interrupted or incomplete treatment increases the risk of treatment failure, relapse of disease, and transmission of drug-resistant TB. Directly observed treatment and directly observed preventive therapy should be easier to implement in prison because of the greater control maintained over inmates than over citizens in the outside community: prisoners are literally a captive population. This should facilitate case finding, promote adherence to treatment, and allow accurate case recording and reporting. Nevertheless, in an inexcusable paradox, diagnosis of TB in a state prison is a strong predictor for defaulting from treatment.11
Correctional facilities also represent a magnificent opportunity as
screening and treatment sites for latent TB infection (LTBI), but,
regrettably, isoniazid prophylaxis is frequently not offered or, if
started in prison, is not continued after release. Among inmates
receiving preventive therapy while incarcerated, the majority will not
continue with prophylaxis after discharge,12
and
compliance within a month of discharge has been reported to be as low
as 3%.13
The solution to this lack of compliance with
prophylaxis of LTBI requires innovative approaches like the one
described by Bock et al in this issue of CHEST (see page
833); these authors tested a short-course treatment for LTBI with 2
months of rifampin and pyrazinamide (2RZ) in jail inmates for whom
completion of 
6 months of isoniazid therapy was difficult because
of the short duration of incarceration. 2RZ was found to be acceptable
and well-tolerated by inmates, and it led to a significant increase in
compliance and in the proportion of inmates completing treatment of
LTBI during incarceration.
The transmission of M tuberculosis in correctional facilities presents a health problem for both inmates and the communities into which they are released: inmates infected with M tuberculosis who develop TB disease after their release might infect other persons. Certainly, effective TB control in correctional facilities is necessary for the reduction of TB rates throughout society. The recognition of TB as a specific health problem in prisons, however, does not necessarily lead to action. Many prison systems have comprehensive written protocols for TB control, but the extent to which these protocols are being practiced is unknown. Essential control activities should include the screening of inmates and staff, the containment of the active cases to prevent transmission through isolation and treatment, and the use of preventive therapy when appropriate.5 We need international standards for the accreditation of health-care facilities in prisons, adequate funding to allow those standards to be met, and supervisory bodies (independent of prison authorities) to ensure compliance with the established protocols.14
Politicians, who can mandate necessary interventions and provide adequate funding for their implementation, also need to get involved in this effort. With prison health not being a priority, budget allocations are usually insufficient.1 Without political commitment, TB in correctional facilities will continue to be out of control. This effort also calls for strong support from international health organizations and from state and local health departments, which are ultimately responsible for TB control within their jurisdictions.
Most prisoners come from marginalized sectors of society. We have not only an opportunity but also a moral duty to address the health-care issues of a population that might otherwise not access the health-care system until their problems are well advanced. The principle that prisoners are entitled to the same level of health care as that provided to the general population is accepted in enlightened societies and within enlightened prison systems.14 Contracting TB in prison is most certainly not part of a prisoner’s sentence.15 Unquestionably, improved medical care for prisoners is not only a humane course of action, but also will serve the best interest of society as a whole. Failure to provide adequate screening and failure to provide timely treatment will increase the burden of ill health later on and, unquestionably, also will increase the costs to the health-care system. Transmissible diseases such as TB that spread in prisons and are left undetected and untreated ultimately will spread to the community. The opportunity for effective TB control in prisons is also an opportunity to contribute to effective TB control in the wider community.15
At present, there is clear evidence that we are failing in our responsibilities. This may be due to lack of funding, to lack of political will, or to public indifference but, most likely, it is a combination of all three of these factors.14 Lets not forget that TB in any segment of the population endangers every member of society. If TB is to be eradicated, special attention must be given to this segment of society in which both the prevalence and incidence of infection are still excessively high. For many countries, the alternative is bleak: a dreadful situation will become even worse.15
References
This article has been cited by other articles:
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  R. E. Chaisson, J. Armstrong, J. Stafford, J. Golub, and S. Bur Safety and Tolerability of Intermittent Rifampin/Pyrazinamide for the Treatment of Latent Tuberculosis Infection in Prisoners JAMA, July 10, 2002; 288(2): 165 - 166. [Full Text] [PDF]
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