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/HPSCScreening in prisonsTB screening in prisoners should be provided as part of a routine health professional-led health screeningexercise on entry to prison. The 1996 TB guidelines recommended routine use of a simple questionnaireon entry to prison, followed by chest X-ray to investigate only those with signs and symptoms. 113 Ideally,inmate screening should be undertaken at the beginning of every prison sentence in order to identifyactive cases of disease and latent infection and to initiate treatment before individuals join the main prisonpopulation. 312At a minimum, all prisoners should be screened for symptoms using a health questionnaire at entry.Symptomatic inmates should have a chest X-ray, three sputum samples (at least one of which is a morningsample), and should be isolated from the main prison population until microscopy results can verify theindividual’s sputum smear status. 26 Symptom screening alone is unsatisfactory in facilities where TB hasbeen detected and where factors for increased risk of TB exist (e.g. prisoners with a condition/factorthat increases the risk of TB, environmental factors). 312 Ideally, HIV testing should be offered as part ofroutine health screening for prisoners starting every prison sentence (assists interpretation of TST, also HIVinfection is a contraindication for BCG vaccination). 312A risk assessment should be undertaken to establish an increased risk for TB transmission. Facilities atincreased risk of transmission include the following:• Documented cases of infectious TB have occurred in the facility in the last year• The facility houses substantial numbers of inmates with risk factors for TB (e.g. HIV infection andinjection-drug use) and• The facility houses substantial numbers of new immigrants (i.e. persons arriving in Ireland within theprevious 5 years from countries where the annual TB notification rate is ≥ 40 cases per 100,000). 312If the facility is deemed high risk, then individuals should be screened with a TST (2TU Mantoux test) and ifthis is positive, a chest X-ray will be required. 312Prisoners with a positive TST result or abnormal chest X-ray should be referred to a TB clinic. In congregatesettings, a TST induration of 10mm 312 or greater is considered a positive result (for both prisoners andprison workers) (see table 2.1). An induration of greater than 5mm is positive in:• Persons who are recent contacts of patients with TB disease• Persons with fibrotic changes on their chest radiograph consistent with previous disease• Organ transplant recipients• Immunocompromised individuals (including persons with HIV) and• Persons suspected of having TB disease.Prisoners with a TST result of ≥ 10mm and normal chest X-ray findings should be considered for LTBItreatment. Treatment of LTBI should be administered under medical supervision designated by the prisonservice. If prisoners decline LTBI treatment, a questionnaire screening for symptoms of TB should becompleted annually. Chest X-ray follow-up at three and 12 months is also recommended.HIV-infected or other immunosuppressed inmates (or those with other clinical conditions that renderindividuals at greater risk of latent infection) should have a TST and an IGRA test (which may be consideredin light of false-negative TST results in immunocompromised individuals) to detect LTBI in addition to achest X-ray to rule out active TB disease. 312A multidisciplinary approach to treating a case of active TB disease or LTBI is advised. The decision torefer an infectious case to a tertiary facility should be considered by the treating physician, consultantmicrobiologist, public health and the prison services. Individuals admitted for inpatient care in tertiarymedical facilities should only be discharged back to the prison facility when the patient is deemed noninfectious(as defined in chapter 6).Prison medical services should have liaison and handover arrangements to ensure continuity of care beforeany prisoner on TB treatment is transferred between prisons. 26-121-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCRecommendation:A programme of screening for TB in prisoners should be provided.Prisoners should receive chemotherapeutic treatment for active disease or LTBI by DOT, ashigh rates of treatment failure have been observed in this population. 337 Patients undergoingany form of TB treatment should be assigned a key worker (a health professional) to promotecompliance, monitor treatment effectiveness and the occurrence of adverse events. 26Prison medical services should liaise with community TB services to ensure the continuation ofDOT after release from prison.Prison staffNew staff should receive pre-placement screening which is equivalent to screening undertaken for newHCWs. 26 BCG should be offered to prison workers aged 35 years and under 26;255;257 if they are previouslyunvaccinated and tuberculin negative (≤ 5mm) (chapter 7).A high index of suspicion for TB should be maintained in all prisons and prison HCWs should raiseawareness of TB symptoms among prisoners and staff. It is important that prison officers are educatedto recognise the signs and symptoms of TB, the need to seek an early diagnosis by referral, methodsof diagnosis and the effectiveness of treatment, the importance of compliance with TB treatment andmonitoring for adverse events.9.4 Homeless IndividualsElevated rates of TB have been found in homeless individuals in low incidence countries. 338, 339 Many haveconcomitant risk factors for TB such as substance misuse, immunosuppression and malnutrition. High levelsof infectious and drug resistant TB have been observed and poor adherence to treatment regimens andloss to follow up care in this population pose a challenge to TB control. 340 Providing health services to thishigh risk group is problematic, as they are often mobile and hard-to-reach through conventional channels.Therefore, screening in this population should focus on the detection of active disease.Recommendation:An opportunistic active case finding strategy is advised among homeless individuals. Screeningby chest X-ray is recommended. TST and IGRA are believed to be less useful, as people maymove before test reading/results are available. 26Screening on an opportunistic basis and/or symptomatic basis is advised, as is the use of incentives (hotdrinks/snacks). 26 A recommendation on the frequency of screening was not made by the NICE guidelinedevelopment committee due to an absence of evidence, whilst in other European countries, e.g. theNetherlands, illicit drug users and homeless individuals are screened twice per year by digital chestX-ray for two years (this is already used for screening prisoners and asylum seekers). 341 Although routinescreening of homeless individuals is a preferred strategy for detecting disease in this high risk population,it is recognised that this is not always possible. Therefore, screening of homeless individuals in accordancewith UK guidance is recommended. 26 As homeless individuals are at risk of failing to complete treatment,appropriate steps should be taken to encourage compliance.-122-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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