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Changes in characteristics of inmates with latent tuberculosis infection
p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 7 5 2 e7 5 9
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Public Health journal homepage: www.elsevier.com/puhe
Original Research
Changes in characteristics of inmates with latent tuberculosis infection M.C. White a,*, R.W. Nelson a,d, L.M. Kawamura b, J. Grinsdale b, J. Goldenson c a
Community Health Systems, University of California, San Francisco School of Nursing, 2 Koret Way, N511R, Box 0608, San Francisco, CA 94143, USA b Tuberculosis Control Section, City and County of San Francisco Department of Public Health, San Francisco, CA, USA c Jail Health Services, City and County of San Francisco Department of Public Health, San Francisco, CA, USA d Tulane University School of Medicine (first year medical student), Kawamura: Qiagen, Valencia, CA, USA
article info
summary
Article history:
Objectives: Health and social characteristics place prisoners at high risk for progression
Received 24 November 2010
from latent tuberculosis infection (LTBI) to tuberculosis (TB), but completion of LTBI
Received in revised form
therapy is low with many patients lost to follow-up after release. Despite decreases in
2 November 2011
active TB, demographic characteristics of active cases have remained relatively
Accepted 19 April 2012
unchanged. This study investigated whether characteristics have changed in inmates
Available online 25 July 2012
diagnosed with LTBI in San Francisco, CA, USA. Study design: Cross-sectional.
Keywords:
Methods: Data from baseline interviews of randomized trials conducted in 1998e1999 and
Latent tuberculosis infection
2004e2007 were compared.
TB screening
Results: In both time periods, most subjects with LTBI (>60%) were Latinos, while the
Jail
proportion in both the jail and San Francisco remained at 15e20%. Overall, the prisoners
Medication beliefs and attitudes
interviewed in 2004e2007 were less likely to have been on medication for LTBI previously, and expressed more likelihood of finishing their medication compared with those interviewed in 1998e1999. In 2004e2007, the foreign-born subjects were more likely to prefer English to Spanish, to have been in stable housing and to have been employed before jail compared with 1998e1999, while no such changes were seen between the two time periods for US-born subjects. Conclusions: The pool of TB-infected individuals coming from a jail is not static, and understanding the changes over time is of importance for targeted programmes. Given the high infection rate and the predominance of foreign-born individuals who may have received bacillus Calmette-Gue´rin vaccination, screening with interferon-gamma release assay may be beneficial to identify those with true infection. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 415 476 5213; fax: þ1 415 476 6042. E-mail address: [email protected] (M.C. White). 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2012.04.009
p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 7 5 2 e7 5 9
Introduction Rates of both active tuberculosis (TB) and latent tuberculosis infection (LTBI) have been declining in the USA over the past several years.1,2 However, identification and treatment of individuals with LTBI who are at high risk for progression to active TB remain important public health goals.3 Prisoners are a high-risk group as they frequently have health and social characteristics including substance abuse, human immunodeficiency virus (HIV), homelessness and congregate housing, coming from minority or foreign-born populations, and poor access to care.4e12 Completion of therapy for LTBI in this group has been poor,13 partly due to loss to follow-up after release from facilities before completion of the recommended 9month isoniazid (INH) regimen.14e17 It is often difficult to locate individuals after release for continuity of care, as prerelease information on housing, support and employment often does not reflect post-release status.17 Jails in particular are congregate settings where screening to find active TB is critical to prevent unrecognized transmission of Mycobacterium tuberculosis, and also where the diagnosis of LTBI can be made and treatment initiated. However, practices in jails are often not consistent with recommendations from the Centers for Disease Control and Prevention in terms of screening, treatment, or record-keeping that are based on the facility’s risk profile.18e20 In a few jails, healthcare providers who initiate treatment for LTBI attempt to make links with the local county TB clinic where inmates will be released, and gather information that will help outreach workers to locate them to ensure that treatment continues.21 Inmates with LTBI at the highest risk of loss to follow-up are those with unstable housing, substance abuse, mental health problems or poor access to care before jail,13,15,17,19 and these have been the focus of targeted efforts to minimize loss. As the overall prevalence of active TB in San Francisco has declined over the past decade, the demographic and social characteristics of these cases have remained relatively unchanged. This study investigated whether the characteristics of those identified with LTBI in a jail setting had also remained stable. Characteristics of inmates with LTBI were compared between two time periods using baseline data from two randomized trials designed to improve completion of therapy. The research questions were: (1) Have the characteristics of inmates diagnosed with LTBI and eligible for therapy changed from 1998 to 1999 to 2004e2007? (2) Are there differences in self-reported health status and medical experience? (3) Are there differences in attitudes towards, or experience with, TB medication?
Methods Design, setting and sample This cross-sectional study used baseline interview data from inmates from two different time periods. The sample cohorts
753
for this analysis were from two randomized trials with human subjects approval conducted in the San Francisco City and County Jail. In each, potential subjects were identified as having LTBI and being eligible for treatment. The first study consented and enrolled subjects for a trial of three interventions: multiple educational sessions on the importance of going to the TB clinic after release and finishing LTBI therapy; a single monetary incentive for completing a visit to the TB clinic after release; or a single educational session.13 For the remainder of this paper, the subjects will be referred to as the ‘first cohort’. The second trial compared two approved regimens for LTBI, rifampin vs INH, on completion of therapy, toxicity and cost.22 Subjects in this trial represent the second cohort. For both trials, inmates who did not speak Spanish or English, who were determined by Sheriff’s personnel to be violent, or who were determined by Jail Health Services mental health staff to have serious psychiatric illness were excluded. In addition, known HIV-positive inmates under the care of the Forensic AIDS Project were excluded, as they receive different treatment for LTBI in jail and intensive follow-up in the community after release, including additional incentives to continue care. No inmates participated in both studies.
Measures Data for this analysis came from interviews conducted immediately after consent and enrolment. In both studies, male and female interviewers were trained and provided repeat training with investigators to minimize bias. The first cohort interviews took place between 2/27/1998 and 5/27/1999, and the second cohort interviews took place between 11/30/ 2004 and 9/24/2007. The structured interview asked for selfreport on general sociodemographic data, such as age, gender, marital status, country of birth, housing, employment before jail, previous incarceration, health status, insurance, perception of a problem with drugs or alcohol, and access to and experience with health care. General attitudes towards medications were assessed using a Likert scale with four options ranging from agreement to disagreement. They included: it is hard to keep track of when to take medicines; taking medicine makes me feel like I am not a healthy person; I dislike taking pills; if a doctor prescribes medicine, I usually try to take it; I believe that taking medicine usually improves my health; I believe in taking medicine; and I continue a medicine even if it makes me feel sick. Questions specific to LTBI medication included: how worried are you about TB? (Likert scale with five options ranging from not at all to a great deal); if you are released from jail, how likely are you to go to the TB clinic?; how likely are you to complete the medicine?; and if you did not take medicine for LTBI, how likely is it that you would get TB? (Likert scale with five options ranging from definitely will to definitely won’t). Subjects were also asked: is there support from a spouse or partner, other family member, friend, or other person to encourage and remind you to take your medicine for LTBI? The questions were separated into 4 questions with yes/no responses: support from spouse or partner; support from other family member, and so on. Then any “yes” answer was used in a single variable (yes/no) indicating that they had support.
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Statistical analysis
Results
The three research questions focused on differences in sample characteristics by cohort, and the cross-sectional design allowed the examination of correlations with cohort as the dependent variable. The cohorts were described on the basis of the sociodemographic and pre-jail characteristics, and included variables significant at alpha ¼ 0.10 from bivariate ttests or Chi-squared analyses in a logistic regression. This analysis allowed the authors to control for confounding variables and to present those characteristics that were independently associated with the second cohort compared with the first cohort using odds ratios (OR) and 95% confidence intervals (CI). For the second and third questions, differences in selfreported health status and medical experiences, attitudes towards general and LTBI medications, and attitudes towards jail medical care were examined. These descriptive summaries compared the two cohorts using t-tests and Chi-squared tests. For this analysis and for the logistic regression, alpha was set at 0.05 to determine final statistical significance.
Sociodemographic data are presented in Table 1. Ethnicity differed between the two time periods, with a decrease in African Americans and an increase in Asians in the second cohort, but the majority of subjects in both cohorts were Latino (60.4% in the second cohort vs 61.8% in the first cohort, P ¼ 0.688). The majority of subjects were born outside the USA, mainly in Mexico and Central America (61.3% and 57.6% in the second and first cohorts, respectively). Among those born outside the USA, the average time since immigration was longer for the subjects in the second cohort (9.1 years, median 7) compared with those in the first cohort (7.8 years, median 6) (P ¼ 0.058). Preferred language and Latino ethnicity were highly correlated (Pearson correlation 0.787, P < 0.005). Compared with the subjects in the first cohort, those in the second cohort were less likely to have been in jail previously (OR 0.64, 95% CI 0.48e0.87, P ¼ 0.004), but the total incarceration time did not differ significantly between the groups (343
Table 1 e Characteristics of inmates in the San Francisco City and County Jail with latent tuberculosis infection, first cohort (1998e1999, n [ 557) and second cohort (2004e2007, n [ 364). Characteristic Gender Male Female Age in years, mean (SD) Ethnicity Latino Black White Asian Other, mixed heritage Preferred language Spanish English Birthplace Outside USA USA Education in years, mean (SD) Median Marital/partnered status Not partnered Partnered Living status before jailb Stable housing Unstable housing Employed before jail Yes No Imprisoned previously Yes No
First cohort n (%)a
Second cohort n (%)
Total n (%)
P- value 0.298
508 (91.2) 49 (8.8) 30.5 (8.5)
338 (93.1) 25 (6.9) 30.9 (9.6)
846 (92) 74 (8) 30.6 (9.0)
344 (61.8) 100 (18.0) 30 (5.4) 26 (4.7) 57 (10.2)
220 (60.4) 50 (13.7) 30 (8.2) 32 (8.8) 32 (8.8)
564 (61.2) 150 (16.3) 60 (6.5) 58 (6.3) 89 (9.7)
343 (61.6) 241 (38.4)
194 (53.3) 170 (46.7)
537 (58.3) 384 (41.7)
395 (70.9) 162 (29.1) 9.1 (4.0)
276 (76.2) 86 (23.8) 8.8 (4.1)
671 (73.0) 248 (27.0) 9.0 (4.0)
10
9
9
355 (63.7) 202 (36.3)
216 (59.8) 145 (40.2)
571 (62.2) 347 (37.8)
373 (67.0) 184 (33.0)
282 (77.5) 82 (22.5)
655 (71.1) 266 (28.9)
316 (56.8) 240 (43.2)
244 (67.2) 119 (32.8)
560 (60.9) 359 (39.1)
435 (78.1) 122 (21.9)
252 (69.6) 110 (30.4)
687 (74.8) 232 (25.2)
0.463 0.020
0.013
0.075
0.288
0.234
0.001
0.002
0.004
SD, standard deviation. a Number and percent of each group unless otherwise specified; numbers do not add up to total sample size if questions were not answered, and percentages may not equal 100 because of rounding. b Stable housing included own apartment or home, living with friends or relatives, or living at a board and care facility or alcohol/drug treatment programme; unstable housing included living in a homeless shelter or hotel, or living in a car, a park or on the street.
755
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days average for second cohort, 407 days for first cohort, P ¼ 0.306). The authors examined whether the differences seen were similar in foreign-born and US-born groups (Table 2), and found that the changes in demographic characteristics only occurred among the foreign-born subjects. Among the foreign-born subjects, those in the second cohort were more likely to prefer English to Spanish, and to have been employed and in stable housing before incarceration. Health-related and medical characteristics (Table 3) demonstrated small differences in self-rated health status. While subjects in the second cohort were less likely to have a regular place to go for medical care compared with those in the first cohort (OR 0.69, 95% CI 0.50e0.95, P ¼ 0.023), both groups reported the same number of visits to a healthcare provider in the past year (1.5 on average). Overall, 52.7% of subjects reported that they had a problem with drugs or alcohol, and this did not differ between the cohorts. Few subjects reported that they had seen a mental healthcare provider, but those in the second cohort were slightly more likely to have done so than those in the first cohort (11.3% vs 7.6%, respectively). Subjects in the second cohort were half as likely to report having previously been on medication for LTBI (OR 0.56, 95% CI 0.39e0.79, P ¼ 0.001), and half as likely to report having previously been on medication for LTBI in jail (OR 0.55, 95% CI 0.35e0.83, P ¼ 0.004) compared with those in the first cohort. Foreign or US birth did not affect the changes seen between the first and second cohorts for these variables.
General and LTBI medication attitudes are presented in Tables 4 and 5. When collapsed into ‘absolute and sometimes yes’ vs ‘sometimes and definitely no’, those in the second cohort were more likely to say that it was hard to remember to take their medication (OR 2.32, 95% CI 1.72e3.12, P ¼ 0.000), but also more likely to say that they would continue to take their medication even if it made them feel sick (OR 3.92, 95% CI 2.85e5.39, P ¼ 0.000) compared with those in the first cohort. When dichotomized, none of the other attitudes remained statistically different between the cohorts, and none were significantly different by birthplace. Specific to taking LTBI medication (Table 5), subjects in the second cohort were nearly twice as likely as those in the first cohort to say that they had some support from a partner, family member, friend or other for encouragement and reminders to take their medication (OR 1.88, 95% CI 1.34e2.62, P ¼ 0.000). Subjects in the second cohort were considerably more likely to say that they trusted the medical advice in the jail (OR 3.79, 95% CI 2.34e6.12, P ¼ 0.000) and that medical care in the jail was good (OR 3.08, 95% CI 2.02e4.72, P ¼ 0.000) compared with those in the first cohort. Both attitudes towards jail care were correlated with each other, and both were negatively correlated with having been in jail previously (P < 0.01, Spearman’s pairwise comparisons). Among these questions related to taking medication for LTBI, both the likelihood of going to a TB clinic and completing their medication differed by birthplace. Among the foreign-born subjects, a smaller proportion
Table 2 e Logistic regression results, stratified by foreign or US birthplace, comparing the second cohort (2004e2007, n [ 364) with the first cohort (1998e1999, n [ 557) in terms of sociodemographic characteristics among inmates in the San Francisco City and County Jail with latent tuberculosis infection. Characteristic of those in the second cohort compared with those in the first cohort Born outside USA (n ¼ 670a) Ethnicity White Black Asian Other, mixed heritage Latino Preferred English to Spanish Stable housingb before jail Employed before jail Not imprisoned previously Born in the USA (n ¼ 247a) Ethnicity White Black Asian Other, mixed heritage Latino Preferred English to Spanish Stable housingb before jail Employed before jail Not imprisoned previously
Adjusted odds ratio
95% confidence interval
P-value
2.870 2.844 0.574 0.441 Reference 3.792 1.626 1.553 1.361
1.037e7.944 0.523e15.456 0.262e1.259 0.212e0.918 e 2.130e6.752 1.107e2.388 1.091e2.211 0.962e1.925
0.042 0.226 0.166 0.029 e 0.000 0.013 0.015 0.082
0.600 0.402 3.968 0.398 Reference 2.456 1.398 1.331 1.432
0.178e2.022 0.139e1.165 0.334e47.128 0.114e1.391 e 0.534e11.282 0.765e2.555 0.765e2.315 0.529e3.877
0.410 0.093 0.275 0.149 e 0.248 0.276 0.312 0.479
a Data on one or more variables were missing for one participant in each group (foreign-born and US-born); data were missing on birthplace for two participants. b Stable housing included own apartment or home, living with friends or relatives, or living at a board and care facility or alcohol/drug treatment programme; unstable housing included living in a homeless shelter or hotel, or living in a car, a park or on the street.
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Table 3 e Self-reported health and medical characteristics of inmates in the San Francisco City and County Jail with latent tuberculosis infection (LTBI), first cohort (1998e1999, n [ 557) and second cohort (2004e2007, n [ 364).
Health insurance Yes No Regular place for health care Yes No Health status Poor Fair Good Very good Excellent Problem with drugs or alcohol Yes No Seen by mental health provider in past year Yes No Previous use of LTBI medication Yes No
First cohort n (%)a
Second cohort n (%)
Total n (%)
108 (19.4) 449 (80.6)
68 (18.7) 296 (81.3)
176 (19.1) 745 (80.9)
142 (25.5) 414 (74.5)
69 (19.1) 293 (80.9)
211 (23.0) 707 (77.0)
30 178 181 87 80
32 96 116 75 43
62 274 297 162 123
P-value 0.789
0.023
0.035 (5.4) (32.0) (32.6) (15.6) (14.4)
(8.8) (26.5) (32.0) (20.7) (11.9)
(6.8) (29.8) (32.4) (17.6) (13.4) 0.441
298 (53.7) 257 (46.3)
186 (51.1) 178 (48.9)
484 (52.7) 435 (47.3) 0.054
42 (7.6) 513 (92.4)
41 (11.3) 322 (88.7)
83 (9.0) 835 (91.0)
127 (22.8) 430 (77.2)
51 (14.1) 311 (85.9)
178 (19.4) 741 (80.6)
0.001
reported that they were definitely or probably likely to go to the TB clinic (P ¼ 0.000) or complete their medication (P ¼ 0.009) in the second cohort compared with the first cohort, while differences among US-born subjects were not statistically significant.
Discussion The aim of this study was to examine whether inmates diagnosed with LTBI and eligible for therapy in jail differed between two time periods that were 5 years apart. Differences in characteristics between the two time periods occurred primarily among the foreign-born subjects. In particular, those in the second cohort seemed to have come from more stable situations prior to incarceration. The longer time in the USA and the higher proportion of subjects preferring English over Spanish in the second cohort may indicate more acculturation among those born outside the USA. Language facility and use has been shown to be the most frequently used and most robust indicator for acculturation.23 Other differences unaffected by birthplace included health status and access to care. Although the subjects in the second cohort were less likely to receive medical care from a regular place, their average number of visits to a healthcare provider was the same as that for subjects in the first cohort. The subjects in the second cohort were less likely to have been on medication for LTBI in the past, and were more likely to report that they would continue taking their medication even if it made them feel sick compared with those in the first cohort. These characteristics, and the fact that they were less likely to have been in jail before and more likely to say that they trusted the medical care in jail, may indicate that the subjects in the second cohort were more amenable to seeking care/
treatment in jail and possibly more amenable to follow-up after release compared with those in the first cohort. In this study, the majority of inmates with LTBI were born outside the USA and were of Latino ethnicity. The proportion did not differ between the two cohorts. Latinos represent approximately 15e20% of the San Francisco population as well as those in the jail system, yet this group accounts for the majority of those with LTBI (>60%) in this study. In contrast, during the two time periods, only 15% of cases of active TB were diagnosed in Latinos and <2% were diagnosed while in jail. This suggests that while the rate of LTBI in the jail may be high, this may not translate to a higher incidence of active TB in San Francisco. The outcomes of this study highlight the need for better targeting of those with true infection as well as those at the highest risk of disease progression. The higher specificity of interferon-gamma release assay testing, such as QFT, offers hope in eliminating false-positive TST results caused by prior bacillus Calmette-Gue´rin vaccination or atypical mycobacterial infection. In addition, limiting treatment to those with overlapping medical co-morbidities may help to conserve resources for individuals who are most likely to progress to active TB. Performance indicators for 2015 from the US National Tuberculosis Indicators Project are set at 79% treatment completion for newly diagnosed LTBI patients who are contacts of active cases,24 but there are no comparable guidelines for individuals from high-risk settings such as jails, and completion rates have been considerably lower.13,15e18 Interventions in the community such as a nurse casemanaged intervention among homeless shelters and substance abuse recovery sites revealed poor completion rates,25 and failure to complete treatment among high-risk groups managed by county TB clinic providers was associated with a number of factors including not being insured and
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Table 4 e Medication attitudes of inmates in the San Francisco City and County Jail with latent tuberculosis infection, first cohort (1998e1999, n [ 557) and second cohort (2004e2007, n [ 364). Attitude towards medications It is hard to keep track of when to take medicines Absolutely yes Sometimes yes Sometimes no Definitely no Taking medicine makes me feel like I am not a healthy person Absolutely yes Sometimes yes Sometimes no Definitely no I dislike taking pills Absolutely yes Sometimes yes Sometimes no Definitely no If a doctor prescribes medicine, I usually try to take it Absolutely yes Sometimes yes Sometimes no Definitely no I believe that taking medicine usually improves my health Absolutely yes Sometimes yes Sometimes no Definitely no I believe in taking medicine Absolutely yes Sometimes yes Sometimes no Definitely no I continue a medicine even if it makes me feel sick Absolutely yes Sometimes yes Sometimes no Definitely no
First cohort n (%)a
Second cohort n (%)
Total n (%)
P-value 0.000
31 78 29 416
(5.6) (14.1) (5.2) (75.1)
37 94 27 204
(10.2) (26.0) (7.5) (56.4)
68 172 56 620
(7.4) (18.8) (6.1) (67.7) 0.018
81 103 20 352
(14.6) (18.5) (3.6) (63.3)
41 82 26 212
(11.4) (22.7) (7.2) (58.7)
122 185 46 564
(13.3) (20.2) (5.0) (61.5)
51 64 22 419
(9.2) (11.5) (4.0) (75.4)
30 37 33 262
(8.3) (10.2) (9.1) (72.4)
81 101 55 681
(8.8) (11.0) (6.0) (74.2)
0.015
0.016a 485 (87.2) 56 (10.1) 9 (1.6) 6 (1.1)
328 (90.9) 29 (8.1) 0 (0.0) 4 (1.1)
813 85 9 10
(88.7) (9.3) (1.0) (1.1) 0.015a
440 84 17 10
(79.7) (15.2) (3.1) (1.8)
317 36 7 2
(87.6) (9.9) (1.9) (0.6)
757 120 24 12
(82.9) (13.1) (2.6) (1.3)
463 52 13 27
(83.4) (9.4) (2.3) (4.9)
285 56 10 10
(78.9) (15.5) (2.8) (2.8)
748 108 23 37
(81.7) (11.8) (2.5) (4.0)
0.018
0.000 52 27 33 434
(9.5) (4.9) (6.0) (79.5)
81 63 44 173
(22.4) (17.5) (12.2) (47.9)
133 90 77 607
(14.7) (9.9) (8.5) (66.9)
a Likelihood ratio was calculated because Pearson Chi-squared assumptions were not met.
younger age.26 Cultural case management, using bilingual and bicultural outreach workers who mediate between the healthcare system and foreign-born patients, and provide assistance to individuals beyond the goals of the diseasespecific clinic, has been proposed as a strategy to facilitate follow-up for those at high risk for loss to follow-up.27 This should be considered for management of those released from jail with LTBI needing follow-up to complete therapy. The primary limitation of this study is that the two randomized trials providing baseline data involved different interventions, and although the exclusion criteria were the same, the nature of the trials e the first involving a verbal and financial intervention (education/incentive) and the second involving a difference in medication (rifampin/INH) e may have resulted in differences in those consenting to participate. In the first trial, individuals were approached after they had agreed to take medication for LTBI, and 14% refused to
participate. In the second trial, individuals were approached for consent at the time of LTBI diagnosis; 24% refused to take any medication at all, and an additional 6% refused to participate in the study, resulting in a total 30% refusal rate. Differences in recruitment methods for the two studies make comparisons of refusals difficult, and the overall difference in refusal rates, and the possibility that the samples differed because of the interventions, should be taken into account in interpreting the findings of this study. Further limitations include potential bias based on the gender of the interviewers, as well as the selection bias inherent in two cross-sectional data sets that may not represent the jail population and the inability to determine causality from this study. This study demonstrates that the pool of TB-infected individuals coming from a jail system is not static, and that understanding the changes in that pool over time is of importance in the design of targeted programmes to ensure
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Table 5 e Attitudes towards latent tuberculosis infection (LTBI) treatment and jail medical care among inmates in the San Francisco City and County Jail with LTBI, first cohort (1998e1999, n [ 557) and second cohort (2004e2007, n [ 364). Attitude Worry about tuberculosis Not at all Only a little Some A fair amount A great deal Likely to go to the tuberculosis clinic after release Definitely will Probably will Maybe Probably won’t Definitely won’t Likely to complete LTBI medication Definitely will Probably will Maybe Probably won’t Definitely won’t If not on LTBI medication, how likely to get tuberculosis Definitely will Probably will Maybe Probably won’t Definitely won’t Any support for taking LTBI medication Yes No Trust medical advice in jail Yes No Think medical care in jail is good Yes No
First cohort n (%)a
Second cohort n (%)
Total n (%)
P-value 0.030
93 143 82 64 167
(16.9) (26.0) (14.9) (11.7) (30.4)
46 105 64 59 88
(12.7) (29.0) (17.7) (16.3) (24.3)
139 248 146 123 255
(15.3) (27.2) (16.0) (13.5) (28.0) 0.000a
472 (85.0) 69 (12.4) 12 (2.2) 2 (0.4) 0 (0.0)
263 69 22 5 3
(72.7) (19.1) (6.1) (1.4) (0.8)
735 (80.2) 138 (15.0) 34 (3.7) 7(0.8) 3 (0.3) 0.048a
441 (79.9) 93 (16.8) 16 (2.9) 2 (0.4) 0 (0.0)
271 66 23 3 1
(74.5) (18.1) (6.3) (0.8) (0.3)
712 159 39 5 1
(77.6) (17.3) (4.2) (0.5) (0.1) 0.002
179 (34.3) 162 (31.0) 123 (23.6) 33 (6.3) 25 (4.8)
87 (24.0) 134 (37.0) 107 (29.6) 26 (7.2) 8 (2.2)
266 (30.1) 296 (33.5) 230 (26.0) 59 (6.7) 33 (3.7) 0.000
406 (72.9) 151 (27.1)
303 (83.5) 60 (16.5)
709 (77.1) 211 (22.9)
429 (80.0) 107 (20.0)
334 (93.8) 22 (6.2)
763 (85.5) 129 (14.5)
414 (77.7) 119 (22.3)
322 (91.5) 30 (8.5)
736 (83.2) 149 (16.8)
0.000
0.000
a Likelihood ratio was calculated because Pearson Chi-squared assumptions were not met.
continuity of care in the community. While the same proportion of subjects in each cohort were foreign-born, data from San Francisco demonstrated differences in foreign-born individuals over time that are important for TB controllers both in the USA and worldwide. Understanding these differences, and making use of new methods such as interferongamma release assay to identify true at-risk populations, is critical to the control of this disease.
Institute of Nursing Research (Award No. R01NR04456). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Allergy and Infectious Diseases, and the National Institute of Nursing Research, or the National Institutes of Health.
Competing interests None declared.
Acknowledgments Ethical approval University of California, San Francisco Committee on Human Research.
Funding National Institutes of Health/National Institute of Allergy and Infectious Diseases (Award No. U01AI051315) and the National
references
1. Centers for Disease Control and Prevention. Trends in tuberculosis e United States, 2008. MMWR Morbid Mortal Wkly Rep 2009;58:249e53. 2. Khan K, Wang J, Hu W, Bierman A, Li Y, Gardam M. Tuberculosis infection in the United States: national trends over three decades. Am J Respir Crit Care Med 2008;177:455e60.
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3. American Thoracic Society. Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med 2000;161:S221e47. 4. Bennett DE, Courval JM, Onorato I, Agerton T, Gibson JD, Lambert L, et al. Prevalence of tuberculosis infection in the United States population: the national health and nutrition examination survey, 1999e2000. Am J Respir Crit Care Med 2008;177:348e55. 5. White MC, Tulsky JP, Menendez E, Goldenson J, Kawamura LM. Incidence of TB in inmates with latent TB infection: 5-year follow-up. Am J Prev Med 2005;29:295e301. 6. Minton TD, Sabol WJ. Jail inmates at midyear 2008 e statistical tables. Bur Just Stat Bull 2009:1e12. NCJ 225709. 7. Sabol WJ, Minton TD. Jail inmates at midyear 2007. Bur Just Stat Bull 2008:1e11. NCJ 221945. 8. Greenberg GA, Rosenheck RA. Jail incarceration, homelessness, and mental health: a national study. Psych Serv 2008;59:170e7. 9. Maruschak LM. HIV in prisons and jails, 2002. Bur Just Stat Bull 2004:1e11. NCJ 205333. 10. Wilper AP, Woolhandler S, Boyd JW, Lasser KE, McCormick D, Bor DH, et al. The health and health care of US prisoners: results of a nationwide survey. Am J Public Health 2009;99:666e72. 11. Oeltmann JE, Kammerer S, Pevzner ES, Moonan PK. Tuberculosis and substance abuse in the United States, 1997e2006. Arch Intern Med 2009;169:189e97. 12. Barnes PF, El-Hajj H, Preston-Martin S, Cave MD, Jones BE, Otaya M, et al. Transmission of tuberculosis among the urban homeless. JAMA 1996;275:305e7. 13. White MC, Tulsky JP, Goldenson J, Portillo CJ, Kawamura M, Menendez E. Randomized controlled trial of interventions to improve follow-up for latent tuberculosis infection after release from jail. Arch Intern Med 2002;162:1044e50. 14. Sterling TR. New approaches to the treatment of latent tuberculosis. Semin Respir Crit Care Med 2008;29:532e41. 15. Shieh FK, Snyder G, Horsburgh CR, Bernardo J, Murphy C, Saukkonen JJ. Predicting non-completion of treatment for latent tuberculous infection: a prospective survey. Am J Respir Crit Care Med 2006;174:717e21. 16. Horsburgh Jr CR, Goldberg S, Bethel J, Chen S, Colson PW, Hirsch-Moverman Y, et al. The Tuberculosis Epidemiologic
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Studies Consortium. Latent tuberculosis infection treatment acceptance and completion in the United States and Canada. Chest 2010;137:401e9. White MC, Cuttler S, Zhao X. Linking released inmates to TB clinic for treatment of latent tuberculosis infection (LTBI): why is it so difficult? J Correct Health Care 2007;13:206e15. Lobato MN, Leary LS, Simone PM. Treatment for latent TB in correctional facilities: a challenge for TB elimination. Am J Prev Med 2003;24:249e53. Roberts CA, Lobato MN, Bazerman LB, Kling R, Reichard A, Hammett TM. Tuberculosis prevention and control in large jails: a challenge to tuberculosis elimination. Am J Prev Med 2006;30:125e30. Rutz HJ, Bur S, Lobato MN, Baucom S, Bohle E, Baruch NG. Tuberculosis control in a large urban jail: discordance between policy and reality. J Public Health Manag Pract 2008;14:442e7. Menendez E, White MC, Tulsky JP. Locating study subjects: predictors and successful strategies in inmates released from a US county jail. Control Clin Trials 2001;22:238e47. White MC, Tulsky JP, Lee JR-J, Chen L, Goldenson J, Spetz J, et al. Isoniazid vs. Rifampin for latent tuberculosis infection in jail inmates: toxicity and adherence. J Correct Health Care, in press. Arcia E, Skinner M, Bailey D, Correa V. Models of acculturation and health behaviors among Latino immigrants to the US. Soc Sci Med 2001;53:41e53. Centers for Disease Control and Prevention. Monitoring tuberculosis programs e National tuberculosis indicator Project, United States, 2002e2008. MMWR Morbid Mortal Wkly Rep 2010;59:295e8. Nyamathi A, Nahid P, Berg J, Burrage J, Christiani A, Aqtash S, et al. Efficacy of nurse case-managed intervention for latent tuberculosis among homeless subsamples. Nurs Res 2008;57:33e9. Kwara A, Herold JS, Machan JT, Carter EJ. Factors associated with failure to complete isoniazid treatment for latent tuberculosis infection in Rhode Island. Chest 2008;133:862e8. Goldberg SV, Wallace J, Jackson JC, Chaulk CP, Nolan CM. Cultural case management of latent tuberculosis infection. Int J Tubercul Lung Dis 2004;8:76e82.
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Original Research
Changes in characteristics of inmates with latent tuberculosis infection M.C. White a,*, R.W. Nelson a,d, L.M. Kawamura b, J. Grinsdale b, J. Goldenson c a
Community Health Systems, University of California, San Francisco School of Nursing, 2 Koret Way, N511R, Box 0608, San Francisco, CA 94143, USA b Tuberculosis Control Section, City and County of San Francisco Department of Public Health, San Francisco, CA, USA c Jail Health Services, City and County of San Francisco Department of Public Health, San Francisco, CA, USA d Tulane University School of Medicine (first year medical student), Kawamura: Qiagen, Valencia, CA, USA
article info
summary
Article history:
Objectives: Health and social characteristics place prisoners at high risk for progression
Received 24 November 2010
from latent tuberculosis infection (LTBI) to tuberculosis (TB), but completion of LTBI
Received in revised form
therapy is low with many patients lost to follow-up after release. Despite decreases in
2 November 2011
active TB, demographic characteristics of active cases have remained relatively
Accepted 19 April 2012
unchanged. This study investigated whether characteristics have changed in inmates
Available online 25 July 2012
diagnosed with LTBI in San Francisco, CA, USA. Study design: Cross-sectional.
Keywords:
Methods: Data from baseline interviews of randomized trials conducted in 1998e1999 and
Latent tuberculosis infection
2004e2007 were compared.
TB screening
Results: In both time periods, most subjects with LTBI (>60%) were Latinos, while the
Jail
proportion in both the jail and San Francisco remained at 15e20%. Overall, the prisoners
Medication beliefs and attitudes
interviewed in 2004e2007 were less likely to have been on medication for LTBI previously, and expressed more likelihood of finishing their medication compared with those interviewed in 1998e1999. In 2004e2007, the foreign-born subjects were more likely to prefer English to Spanish, to have been in stable housing and to have been employed before jail compared with 1998e1999, while no such changes were seen between the two time periods for US-born subjects. Conclusions: The pool of TB-infected individuals coming from a jail is not static, and understanding the changes over time is of importance for targeted programmes. Given the high infection rate and the predominance of foreign-born individuals who may have received bacillus Calmette-Gue´rin vaccination, screening with interferon-gamma release assay may be beneficial to identify those with true infection. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 415 476 5213; fax: þ1 415 476 6042. E-mail address: [email protected] (M.C. White). 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2012.04.009
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Introduction Rates of both active tuberculosis (TB) and latent tuberculosis infection (LTBI) have been declining in the USA over the past several years.1,2 However, identification and treatment of individuals with LTBI who are at high risk for progression to active TB remain important public health goals.3 Prisoners are a high-risk group as they frequently have health and social characteristics including substance abuse, human immunodeficiency virus (HIV), homelessness and congregate housing, coming from minority or foreign-born populations, and poor access to care.4e12 Completion of therapy for LTBI in this group has been poor,13 partly due to loss to follow-up after release from facilities before completion of the recommended 9month isoniazid (INH) regimen.14e17 It is often difficult to locate individuals after release for continuity of care, as prerelease information on housing, support and employment often does not reflect post-release status.17 Jails in particular are congregate settings where screening to find active TB is critical to prevent unrecognized transmission of Mycobacterium tuberculosis, and also where the diagnosis of LTBI can be made and treatment initiated. However, practices in jails are often not consistent with recommendations from the Centers for Disease Control and Prevention in terms of screening, treatment, or record-keeping that are based on the facility’s risk profile.18e20 In a few jails, healthcare providers who initiate treatment for LTBI attempt to make links with the local county TB clinic where inmates will be released, and gather information that will help outreach workers to locate them to ensure that treatment continues.21 Inmates with LTBI at the highest risk of loss to follow-up are those with unstable housing, substance abuse, mental health problems or poor access to care before jail,13,15,17,19 and these have been the focus of targeted efforts to minimize loss. As the overall prevalence of active TB in San Francisco has declined over the past decade, the demographic and social characteristics of these cases have remained relatively unchanged. This study investigated whether the characteristics of those identified with LTBI in a jail setting had also remained stable. Characteristics of inmates with LTBI were compared between two time periods using baseline data from two randomized trials designed to improve completion of therapy. The research questions were: (1) Have the characteristics of inmates diagnosed with LTBI and eligible for therapy changed from 1998 to 1999 to 2004e2007? (2) Are there differences in self-reported health status and medical experience? (3) Are there differences in attitudes towards, or experience with, TB medication?
Methods Design, setting and sample This cross-sectional study used baseline interview data from inmates from two different time periods. The sample cohorts
753
for this analysis were from two randomized trials with human subjects approval conducted in the San Francisco City and County Jail. In each, potential subjects were identified as having LTBI and being eligible for treatment. The first study consented and enrolled subjects for a trial of three interventions: multiple educational sessions on the importance of going to the TB clinic after release and finishing LTBI therapy; a single monetary incentive for completing a visit to the TB clinic after release; or a single educational session.13 For the remainder of this paper, the subjects will be referred to as the ‘first cohort’. The second trial compared two approved regimens for LTBI, rifampin vs INH, on completion of therapy, toxicity and cost.22 Subjects in this trial represent the second cohort. For both trials, inmates who did not speak Spanish or English, who were determined by Sheriff’s personnel to be violent, or who were determined by Jail Health Services mental health staff to have serious psychiatric illness were excluded. In addition, known HIV-positive inmates under the care of the Forensic AIDS Project were excluded, as they receive different treatment for LTBI in jail and intensive follow-up in the community after release, including additional incentives to continue care. No inmates participated in both studies.
Measures Data for this analysis came from interviews conducted immediately after consent and enrolment. In both studies, male and female interviewers were trained and provided repeat training with investigators to minimize bias. The first cohort interviews took place between 2/27/1998 and 5/27/1999, and the second cohort interviews took place between 11/30/ 2004 and 9/24/2007. The structured interview asked for selfreport on general sociodemographic data, such as age, gender, marital status, country of birth, housing, employment before jail, previous incarceration, health status, insurance, perception of a problem with drugs or alcohol, and access to and experience with health care. General attitudes towards medications were assessed using a Likert scale with four options ranging from agreement to disagreement. They included: it is hard to keep track of when to take medicines; taking medicine makes me feel like I am not a healthy person; I dislike taking pills; if a doctor prescribes medicine, I usually try to take it; I believe that taking medicine usually improves my health; I believe in taking medicine; and I continue a medicine even if it makes me feel sick. Questions specific to LTBI medication included: how worried are you about TB? (Likert scale with five options ranging from not at all to a great deal); if you are released from jail, how likely are you to go to the TB clinic?; how likely are you to complete the medicine?; and if you did not take medicine for LTBI, how likely is it that you would get TB? (Likert scale with five options ranging from definitely will to definitely won’t). Subjects were also asked: is there support from a spouse or partner, other family member, friend, or other person to encourage and remind you to take your medicine for LTBI? The questions were separated into 4 questions with yes/no responses: support from spouse or partner; support from other family member, and so on. Then any “yes” answer was used in a single variable (yes/no) indicating that they had support.
754
p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 7 5 2 e7 5 9
Statistical analysis
Results
The three research questions focused on differences in sample characteristics by cohort, and the cross-sectional design allowed the examination of correlations with cohort as the dependent variable. The cohorts were described on the basis of the sociodemographic and pre-jail characteristics, and included variables significant at alpha ¼ 0.10 from bivariate ttests or Chi-squared analyses in a logistic regression. This analysis allowed the authors to control for confounding variables and to present those characteristics that were independently associated with the second cohort compared with the first cohort using odds ratios (OR) and 95% confidence intervals (CI). For the second and third questions, differences in selfreported health status and medical experiences, attitudes towards general and LTBI medications, and attitudes towards jail medical care were examined. These descriptive summaries compared the two cohorts using t-tests and Chi-squared tests. For this analysis and for the logistic regression, alpha was set at 0.05 to determine final statistical significance.
Sociodemographic data are presented in Table 1. Ethnicity differed between the two time periods, with a decrease in African Americans and an increase in Asians in the second cohort, but the majority of subjects in both cohorts were Latino (60.4% in the second cohort vs 61.8% in the first cohort, P ¼ 0.688). The majority of subjects were born outside the USA, mainly in Mexico and Central America (61.3% and 57.6% in the second and first cohorts, respectively). Among those born outside the USA, the average time since immigration was longer for the subjects in the second cohort (9.1 years, median 7) compared with those in the first cohort (7.8 years, median 6) (P ¼ 0.058). Preferred language and Latino ethnicity were highly correlated (Pearson correlation 0.787, P < 0.005). Compared with the subjects in the first cohort, those in the second cohort were less likely to have been in jail previously (OR 0.64, 95% CI 0.48e0.87, P ¼ 0.004), but the total incarceration time did not differ significantly between the groups (343
Table 1 e Characteristics of inmates in the San Francisco City and County Jail with latent tuberculosis infection, first cohort (1998e1999, n [ 557) and second cohort (2004e2007, n [ 364). Characteristic Gender Male Female Age in years, mean (SD) Ethnicity Latino Black White Asian Other, mixed heritage Preferred language Spanish English Birthplace Outside USA USA Education in years, mean (SD) Median Marital/partnered status Not partnered Partnered Living status before jailb Stable housing Unstable housing Employed before jail Yes No Imprisoned previously Yes No
First cohort n (%)a
Second cohort n (%)
Total n (%)
P- value 0.298
508 (91.2) 49 (8.8) 30.5 (8.5)
338 (93.1) 25 (6.9) 30.9 (9.6)
846 (92) 74 (8) 30.6 (9.0)
344 (61.8) 100 (18.0) 30 (5.4) 26 (4.7) 57 (10.2)
220 (60.4) 50 (13.7) 30 (8.2) 32 (8.8) 32 (8.8)
564 (61.2) 150 (16.3) 60 (6.5) 58 (6.3) 89 (9.7)
343 (61.6) 241 (38.4)
194 (53.3) 170 (46.7)
537 (58.3) 384 (41.7)
395 (70.9) 162 (29.1) 9.1 (4.0)
276 (76.2) 86 (23.8) 8.8 (4.1)
671 (73.0) 248 (27.0) 9.0 (4.0)
10
9
9
355 (63.7) 202 (36.3)
216 (59.8) 145 (40.2)
571 (62.2) 347 (37.8)
373 (67.0) 184 (33.0)
282 (77.5) 82 (22.5)
655 (71.1) 266 (28.9)
316 (56.8) 240 (43.2)
244 (67.2) 119 (32.8)
560 (60.9) 359 (39.1)
435 (78.1) 122 (21.9)
252 (69.6) 110 (30.4)
687 (74.8) 232 (25.2)
0.463 0.020
0.013
0.075
0.288
0.234
0.001
0.002
0.004
SD, standard deviation. a Number and percent of each group unless otherwise specified; numbers do not add up to total sample size if questions were not answered, and percentages may not equal 100 because of rounding. b Stable housing included own apartment or home, living with friends or relatives, or living at a board and care facility or alcohol/drug treatment programme; unstable housing included living in a homeless shelter or hotel, or living in a car, a park or on the street.
755
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days average for second cohort, 407 days for first cohort, P ¼ 0.306). The authors examined whether the differences seen were similar in foreign-born and US-born groups (Table 2), and found that the changes in demographic characteristics only occurred among the foreign-born subjects. Among the foreign-born subjects, those in the second cohort were more likely to prefer English to Spanish, and to have been employed and in stable housing before incarceration. Health-related and medical characteristics (Table 3) demonstrated small differences in self-rated health status. While subjects in the second cohort were less likely to have a regular place to go for medical care compared with those in the first cohort (OR 0.69, 95% CI 0.50e0.95, P ¼ 0.023), both groups reported the same number of visits to a healthcare provider in the past year (1.5 on average). Overall, 52.7% of subjects reported that they had a problem with drugs or alcohol, and this did not differ between the cohorts. Few subjects reported that they had seen a mental healthcare provider, but those in the second cohort were slightly more likely to have done so than those in the first cohort (11.3% vs 7.6%, respectively). Subjects in the second cohort were half as likely to report having previously been on medication for LTBI (OR 0.56, 95% CI 0.39e0.79, P ¼ 0.001), and half as likely to report having previously been on medication for LTBI in jail (OR 0.55, 95% CI 0.35e0.83, P ¼ 0.004) compared with those in the first cohort. Foreign or US birth did not affect the changes seen between the first and second cohorts for these variables.
General and LTBI medication attitudes are presented in Tables 4 and 5. When collapsed into ‘absolute and sometimes yes’ vs ‘sometimes and definitely no’, those in the second cohort were more likely to say that it was hard to remember to take their medication (OR 2.32, 95% CI 1.72e3.12, P ¼ 0.000), but also more likely to say that they would continue to take their medication even if it made them feel sick (OR 3.92, 95% CI 2.85e5.39, P ¼ 0.000) compared with those in the first cohort. When dichotomized, none of the other attitudes remained statistically different between the cohorts, and none were significantly different by birthplace. Specific to taking LTBI medication (Table 5), subjects in the second cohort were nearly twice as likely as those in the first cohort to say that they had some support from a partner, family member, friend or other for encouragement and reminders to take their medication (OR 1.88, 95% CI 1.34e2.62, P ¼ 0.000). Subjects in the second cohort were considerably more likely to say that they trusted the medical advice in the jail (OR 3.79, 95% CI 2.34e6.12, P ¼ 0.000) and that medical care in the jail was good (OR 3.08, 95% CI 2.02e4.72, P ¼ 0.000) compared with those in the first cohort. Both attitudes towards jail care were correlated with each other, and both were negatively correlated with having been in jail previously (P < 0.01, Spearman’s pairwise comparisons). Among these questions related to taking medication for LTBI, both the likelihood of going to a TB clinic and completing their medication differed by birthplace. Among the foreign-born subjects, a smaller proportion
Table 2 e Logistic regression results, stratified by foreign or US birthplace, comparing the second cohort (2004e2007, n [ 364) with the first cohort (1998e1999, n [ 557) in terms of sociodemographic characteristics among inmates in the San Francisco City and County Jail with latent tuberculosis infection. Characteristic of those in the second cohort compared with those in the first cohort Born outside USA (n ¼ 670a) Ethnicity White Black Asian Other, mixed heritage Latino Preferred English to Spanish Stable housingb before jail Employed before jail Not imprisoned previously Born in the USA (n ¼ 247a) Ethnicity White Black Asian Other, mixed heritage Latino Preferred English to Spanish Stable housingb before jail Employed before jail Not imprisoned previously
Adjusted odds ratio
95% confidence interval
P-value
2.870 2.844 0.574 0.441 Reference 3.792 1.626 1.553 1.361
1.037e7.944 0.523e15.456 0.262e1.259 0.212e0.918 e 2.130e6.752 1.107e2.388 1.091e2.211 0.962e1.925
0.042 0.226 0.166 0.029 e 0.000 0.013 0.015 0.082
0.600 0.402 3.968 0.398 Reference 2.456 1.398 1.331 1.432
0.178e2.022 0.139e1.165 0.334e47.128 0.114e1.391 e 0.534e11.282 0.765e2.555 0.765e2.315 0.529e3.877
0.410 0.093 0.275 0.149 e 0.248 0.276 0.312 0.479
a Data on one or more variables were missing for one participant in each group (foreign-born and US-born); data were missing on birthplace for two participants. b Stable housing included own apartment or home, living with friends or relatives, or living at a board and care facility or alcohol/drug treatment programme; unstable housing included living in a homeless shelter or hotel, or living in a car, a park or on the street.
756
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Table 3 e Self-reported health and medical characteristics of inmates in the San Francisco City and County Jail with latent tuberculosis infection (LTBI), first cohort (1998e1999, n [ 557) and second cohort (2004e2007, n [ 364).
Health insurance Yes No Regular place for health care Yes No Health status Poor Fair Good Very good Excellent Problem with drugs or alcohol Yes No Seen by mental health provider in past year Yes No Previous use of LTBI medication Yes No
First cohort n (%)a
Second cohort n (%)
Total n (%)
108 (19.4) 449 (80.6)
68 (18.7) 296 (81.3)
176 (19.1) 745 (80.9)
142 (25.5) 414 (74.5)
69 (19.1) 293 (80.9)
211 (23.0) 707 (77.0)
30 178 181 87 80
32 96 116 75 43
62 274 297 162 123
P-value 0.789
0.023
0.035 (5.4) (32.0) (32.6) (15.6) (14.4)
(8.8) (26.5) (32.0) (20.7) (11.9)
(6.8) (29.8) (32.4) (17.6) (13.4) 0.441
298 (53.7) 257 (46.3)
186 (51.1) 178 (48.9)
484 (52.7) 435 (47.3) 0.054
42 (7.6) 513 (92.4)
41 (11.3) 322 (88.7)
83 (9.0) 835 (91.0)
127 (22.8) 430 (77.2)
51 (14.1) 311 (85.9)
178 (19.4) 741 (80.6)
0.001
reported that they were definitely or probably likely to go to the TB clinic (P ¼ 0.000) or complete their medication (P ¼ 0.009) in the second cohort compared with the first cohort, while differences among US-born subjects were not statistically significant.
Discussion The aim of this study was to examine whether inmates diagnosed with LTBI and eligible for therapy in jail differed between two time periods that were 5 years apart. Differences in characteristics between the two time periods occurred primarily among the foreign-born subjects. In particular, those in the second cohort seemed to have come from more stable situations prior to incarceration. The longer time in the USA and the higher proportion of subjects preferring English over Spanish in the second cohort may indicate more acculturation among those born outside the USA. Language facility and use has been shown to be the most frequently used and most robust indicator for acculturation.23 Other differences unaffected by birthplace included health status and access to care. Although the subjects in the second cohort were less likely to receive medical care from a regular place, their average number of visits to a healthcare provider was the same as that for subjects in the first cohort. The subjects in the second cohort were less likely to have been on medication for LTBI in the past, and were more likely to report that they would continue taking their medication even if it made them feel sick compared with those in the first cohort. These characteristics, and the fact that they were less likely to have been in jail before and more likely to say that they trusted the medical care in jail, may indicate that the subjects in the second cohort were more amenable to seeking care/
treatment in jail and possibly more amenable to follow-up after release compared with those in the first cohort. In this study, the majority of inmates with LTBI were born outside the USA and were of Latino ethnicity. The proportion did not differ between the two cohorts. Latinos represent approximately 15e20% of the San Francisco population as well as those in the jail system, yet this group accounts for the majority of those with LTBI (>60%) in this study. In contrast, during the two time periods, only 15% of cases of active TB were diagnosed in Latinos and <2% were diagnosed while in jail. This suggests that while the rate of LTBI in the jail may be high, this may not translate to a higher incidence of active TB in San Francisco. The outcomes of this study highlight the need for better targeting of those with true infection as well as those at the highest risk of disease progression. The higher specificity of interferon-gamma release assay testing, such as QFT, offers hope in eliminating false-positive TST results caused by prior bacillus Calmette-Gue´rin vaccination or atypical mycobacterial infection. In addition, limiting treatment to those with overlapping medical co-morbidities may help to conserve resources for individuals who are most likely to progress to active TB. Performance indicators for 2015 from the US National Tuberculosis Indicators Project are set at 79% treatment completion for newly diagnosed LTBI patients who are contacts of active cases,24 but there are no comparable guidelines for individuals from high-risk settings such as jails, and completion rates have been considerably lower.13,15e18 Interventions in the community such as a nurse casemanaged intervention among homeless shelters and substance abuse recovery sites revealed poor completion rates,25 and failure to complete treatment among high-risk groups managed by county TB clinic providers was associated with a number of factors including not being insured and
757
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Table 4 e Medication attitudes of inmates in the San Francisco City and County Jail with latent tuberculosis infection, first cohort (1998e1999, n [ 557) and second cohort (2004e2007, n [ 364). Attitude towards medications It is hard to keep track of when to take medicines Absolutely yes Sometimes yes Sometimes no Definitely no Taking medicine makes me feel like I am not a healthy person Absolutely yes Sometimes yes Sometimes no Definitely no I dislike taking pills Absolutely yes Sometimes yes Sometimes no Definitely no If a doctor prescribes medicine, I usually try to take it Absolutely yes Sometimes yes Sometimes no Definitely no I believe that taking medicine usually improves my health Absolutely yes Sometimes yes Sometimes no Definitely no I believe in taking medicine Absolutely yes Sometimes yes Sometimes no Definitely no I continue a medicine even if it makes me feel sick Absolutely yes Sometimes yes Sometimes no Definitely no
First cohort n (%)a
Second cohort n (%)
Total n (%)
P-value 0.000
31 78 29 416
(5.6) (14.1) (5.2) (75.1)
37 94 27 204
(10.2) (26.0) (7.5) (56.4)
68 172 56 620
(7.4) (18.8) (6.1) (67.7) 0.018
81 103 20 352
(14.6) (18.5) (3.6) (63.3)
41 82 26 212
(11.4) (22.7) (7.2) (58.7)
122 185 46 564
(13.3) (20.2) (5.0) (61.5)
51 64 22 419
(9.2) (11.5) (4.0) (75.4)
30 37 33 262
(8.3) (10.2) (9.1) (72.4)
81 101 55 681
(8.8) (11.0) (6.0) (74.2)
0.015
0.016a 485 (87.2) 56 (10.1) 9 (1.6) 6 (1.1)
328 (90.9) 29 (8.1) 0 (0.0) 4 (1.1)
813 85 9 10
(88.7) (9.3) (1.0) (1.1) 0.015a
440 84 17 10
(79.7) (15.2) (3.1) (1.8)
317 36 7 2
(87.6) (9.9) (1.9) (0.6)
757 120 24 12
(82.9) (13.1) (2.6) (1.3)
463 52 13 27
(83.4) (9.4) (2.3) (4.9)
285 56 10 10
(78.9) (15.5) (2.8) (2.8)
748 108 23 37
(81.7) (11.8) (2.5) (4.0)
0.018
0.000 52 27 33 434
(9.5) (4.9) (6.0) (79.5)
81 63 44 173
(22.4) (17.5) (12.2) (47.9)
133 90 77 607
(14.7) (9.9) (8.5) (66.9)
a Likelihood ratio was calculated because Pearson Chi-squared assumptions were not met.
younger age.26 Cultural case management, using bilingual and bicultural outreach workers who mediate between the healthcare system and foreign-born patients, and provide assistance to individuals beyond the goals of the diseasespecific clinic, has been proposed as a strategy to facilitate follow-up for those at high risk for loss to follow-up.27 This should be considered for management of those released from jail with LTBI needing follow-up to complete therapy. The primary limitation of this study is that the two randomized trials providing baseline data involved different interventions, and although the exclusion criteria were the same, the nature of the trials e the first involving a verbal and financial intervention (education/incentive) and the second involving a difference in medication (rifampin/INH) e may have resulted in differences in those consenting to participate. In the first trial, individuals were approached after they had agreed to take medication for LTBI, and 14% refused to
participate. In the second trial, individuals were approached for consent at the time of LTBI diagnosis; 24% refused to take any medication at all, and an additional 6% refused to participate in the study, resulting in a total 30% refusal rate. Differences in recruitment methods for the two studies make comparisons of refusals difficult, and the overall difference in refusal rates, and the possibility that the samples differed because of the interventions, should be taken into account in interpreting the findings of this study. Further limitations include potential bias based on the gender of the interviewers, as well as the selection bias inherent in two cross-sectional data sets that may not represent the jail population and the inability to determine causality from this study. This study demonstrates that the pool of TB-infected individuals coming from a jail system is not static, and that understanding the changes in that pool over time is of importance in the design of targeted programmes to ensure
758
p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 7 5 2 e7 5 9
Table 5 e Attitudes towards latent tuberculosis infection (LTBI) treatment and jail medical care among inmates in the San Francisco City and County Jail with LTBI, first cohort (1998e1999, n [ 557) and second cohort (2004e2007, n [ 364). Attitude Worry about tuberculosis Not at all Only a little Some A fair amount A great deal Likely to go to the tuberculosis clinic after release Definitely will Probably will Maybe Probably won’t Definitely won’t Likely to complete LTBI medication Definitely will Probably will Maybe Probably won’t Definitely won’t If not on LTBI medication, how likely to get tuberculosis Definitely will Probably will Maybe Probably won’t Definitely won’t Any support for taking LTBI medication Yes No Trust medical advice in jail Yes No Think medical care in jail is good Yes No
First cohort n (%)a
Second cohort n (%)
Total n (%)
P-value 0.030
93 143 82 64 167
(16.9) (26.0) (14.9) (11.7) (30.4)
46 105 64 59 88
(12.7) (29.0) (17.7) (16.3) (24.3)
139 248 146 123 255
(15.3) (27.2) (16.0) (13.5) (28.0) 0.000a
472 (85.0) 69 (12.4) 12 (2.2) 2 (0.4) 0 (0.0)
263 69 22 5 3
(72.7) (19.1) (6.1) (1.4) (0.8)
735 (80.2) 138 (15.0) 34 (3.7) 7(0.8) 3 (0.3) 0.048a
441 (79.9) 93 (16.8) 16 (2.9) 2 (0.4) 0 (0.0)
271 66 23 3 1
(74.5) (18.1) (6.3) (0.8) (0.3)
712 159 39 5 1
(77.6) (17.3) (4.2) (0.5) (0.1) 0.002
179 (34.3) 162 (31.0) 123 (23.6) 33 (6.3) 25 (4.8)
87 (24.0) 134 (37.0) 107 (29.6) 26 (7.2) 8 (2.2)
266 (30.1) 296 (33.5) 230 (26.0) 59 (6.7) 33 (3.7) 0.000
406 (72.9) 151 (27.1)
303 (83.5) 60 (16.5)
709 (77.1) 211 (22.9)
429 (80.0) 107 (20.0)
334 (93.8) 22 (6.2)
763 (85.5) 129 (14.5)
414 (77.7) 119 (22.3)
322 (91.5) 30 (8.5)
736 (83.2) 149 (16.8)
0.000
0.000
a Likelihood ratio was calculated because Pearson Chi-squared assumptions were not met.
continuity of care in the community. While the same proportion of subjects in each cohort were foreign-born, data from San Francisco demonstrated differences in foreign-born individuals over time that are important for TB controllers both in the USA and worldwide. Understanding these differences, and making use of new methods such as interferongamma release assay to identify true at-risk populations, is critical to the control of this disease.
Institute of Nursing Research (Award No. R01NR04456). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Allergy and Infectious Diseases, and the National Institute of Nursing Research, or the National Institutes of Health.
Competing interests None declared.
Acknowledgments Ethical approval University of California, San Francisco Committee on Human Research.
Funding National Institutes of Health/National Institute of Allergy and Infectious Diseases (Award No. U01AI051315) and the National
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