Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCof 232 new cases per 100,000 prisoners (range: 0-17,808). Highest rates were observed in countries of theformer Soviet Union, and have been attributed to overcrowding, poor hygiene and ventilation. 308Outbreaks of TB have been reported in prisons in the US and UK. 15;309 Although TB in prisons was notthought to be a problem in England and Wales in the 1980s, 310 routine surveillance has recently shown anincrease in cases in this setting. Prisons in London have been associated with a large outbreak of isoniazidresistantTB since 2001. 311 In the US, outbreaks have involved MDR-TB in HIV-infected individuals. 309Maintaining control of TB in prisons is challenging because of difficulties with practicalities such as promptdiagnosis of cases, identification of contacts, screening and compliance with prophylaxis and treatment.Contact tracing is typically complex in prison settings due to short stays and mobility of inmates. Amultidisciplinary team, led by the local public health department (who will undertake the contact tracing),should be convened to manage the intervention. 26;312 In addition to key prison staff and prison medicalservices, the team may include other staff who have regular contact with prisoners such as social worker/education worker/probation officer representatives. CDC guidelines highlight the important role ofcorrectional information systems (e.g. an inmate medical record system and inmate tracking system) inefficient contact tracing. 312 Any contacts who are HIV positive or immunosuppressed should be amongthose receiving the highest priority evaluation for infection. 312If a suspect infectious TB case is encountered on contact tracing there should be prompt transfer out ofthe facility for diagnostic evaluation if airborne infection-isolation rooms are not available. If the processis delayed, a substantial number of persons might be exposed as a result of the congregate livingarrangements that characterise correctional facilities.Continuity of care following transfer between prisons and release into the community is seen as a majorbarrier to treatment completion. For this reason, DOT is recommended for all prisoners receiving treatmentfor LTBI and active disease. Prison medical services in liaison with local public health departments areencouraged to make arrangements to facilitate treatment completion. 26Recommendation:A multidisciplinary team approach to effectively manage TB contact tracing in prisons isrequired. This team should be led by the local public health department who will undertakecontact tracing.DOT is recommended for all prisoners receiving treatment for active disease and should beconsidered for those receiving treatment for LTBI.8.14 Other High Risk SettingsHomeless shelters are important sites for transmission of M. tuberculosis and an important cause of thecontinuing high incidence of TB among the homeless population. 313 Contact investigations may be wideranging.Genotyping may help with the rapid identification of clustered cases and sites of transmission.In addition, epidemiological investigations prompted by an increase in the incidence of TB in a communityor by the identification of clusters of cases with identical M. tuberculosis genotype patterns have detectedtransmission in such venues as bars. 314 Transmission has been identified with social activities includingamong persons who drink together in multiple drinking establishments. 3158.15 Incorporating New Approaches to Contact TracingDNA fingerprinting can be used to confirm or disprove suspected linkages between cases. Genotyping alsohelps to identify case clusters that would otherwise not be recognised. 111 The Massachusetts Departmentof Public Health evaluated the impact of DNA fingerprinting on their practice and reported that-111-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCgenotyping identified enough unexpected links and sites not considered by the concentric circle method tojustify consideration of more casual contacts. 316 Genotyping allows earlier recognition of clusters for timelyinvestigation and institution of control measures. All culture positive isolates are eligible for genotyping atthe Irish Mycobacterial Reference Laboratory.8.16 Evaluation of Contact TracingThe evaluation of outcomes from contact tracing is important for evaluating the TB control programme,determining the appropriateness of decisions made regarding the contact investigation and futureplanning. The results of the investigation of each circle of contacts should be evaluated to determine therisk of transmission, attack rates, etc. The following information should be collected: 317• The number of contacts identified (particularly close contacts)• The number of contacts who underwent a full evaluation• The number of contacts diagnosed with active disease• The number eligible for preventive therapy and• The number who accepted and completed preventive therapy.Recommendation:Evaluation of all contact tracing activities is recommended. The following information shouldbe collected: (a) number of contacts identified, (b) number of cases of active disease and LTBIand (c) the number of persons who accepted and completed preventive therapy.8.17 Mycobacterium bovisM. bovis is not frequently isolated from clinical specimens provided by suspected TB patients. Due to milkpasteurisation, the risk of disease from M. bovis infection is negligible. Four to five cases of M. bovis arereported to the National TB Surveillance System (NTBSS) annually (2002-2006). The mean age of cases overthis time period was 62.3 years (range 32 – 86 years).There is little evidence of cattle-to-human or human-to-human transmission of M. bovis in the UK andIreland. The NICE guidelines have advised using diagnostic tests for LTBI in previously unvaccinatedindividuals under 16 years of age who have regularly drunk unpasteurised milk from animals with TB udderlesions. Treatment of LTBI should be offered to those with positive results. All individuals in contact withTB-diseased animals should be informed and advised of the signs and symptoms of TB disease.-112-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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