TB Rates Higher in Prison Systems than General Population
A recent study analyzed data reported to the national tuberculosis (TB) surveillance system from 1993 through 2003 and sought to describe disparities and trends in TB risk factors and treatment outcomes between correctional inmate and non-inmate populations. Of the 210,978 total reported United States TB cases, 3.8% were from correctional systems. Federal and state prison case rates were 29.4 and 24.2 cases per 100,000 inmates, respectively, which was considerably higher than those in the non-inmate population (6.7 cases per 100,000 persons.) Inmates with TB were more likely to have at least one TB risk factor (excess alcohol use, injection drug use, non-injection drug use, homelessness and HIV) compared with non-inmates (60.1% vs. 42.0%) and to receive directly observed therapy (DOT) (65.0% vs. 41.0%). However, inmates were less likely to complete treatment within 12 months compared with non-inmates (76.8% vs. 89.4% in 2001). Rates of completion of therapy within 12 months were lower in persons with TB risk factors and lowest for those who had HIV infection at the time of TB diagnosis, in both inmates and non-inmates, but lower among inmates. The authors concluded that TB case rates in prison systems remain higher than in the general population and that inmates with TB are less likely than non-inmates to complete treatment.

MacNeil JR, Lobato MN, Moore M. An unanswered health disparity: tuberculosis among correctional inmates, 1993 through 2003. Am J Pub Health. 2005; 95(10):1800-5.

San Francisco Jail Inmates 59x More Likely to Develop Active TB
In a recent study, White, et al, measured rates of development of active TB and completion of TB therapy over five years in a cohort of inmates. The participants completed a randomized trial in 1998-1999 comparing education/incentive versus usual care to improve therapy completion after release from the San Francisco County Jail (SFCJ). Records from the SFCJ, the County TB Clinic and the California TB Registry were used to measure therapy completion and development of active TB. Of a total of 557 inmates, 31.6% completed therapy, of whom 59.7% did so in jail, during the term of the randomized trial or in subsequent incarcerations. Subjects who reported their country of birth as Mexico were least likely to finish therapy as compared to those from Central or South America, South-east Asia or the United States. Previous therapy for TB and greater education were both associated with TB therapy completion. Three subjects developed active TB during the five years of follow-up, resulting in an annual rate of 108 per 100,000 inmates. The standardized mortality ratio calculated against the California case rate for 2003 (9.1 per 100,000) indicates that this sample was 59 times as likely as those in the general California population to develop active TB. Study authors concluded that the high rate of TB seen in this jail cohort emphasizes the importance of screening for active TB, as well as improving efforts to ensure treatment completion.

White M, Tulsky J, Menendez E, et al. Incidence of TB in inmates with latent TB infection: 5-year follow-up. Am J Prev Med. 2005; 29(4):295-301.

Avoid Use of Rifampin with Atazanavir/Ritonavir
According to recent reports, the combination of Rifampin with Atazanavir (ATV) is no longer recommended. Atazanavir is metabolized largely via cytochrome P450 (CYP) 3A4 while Rifampin is known to be a strong inducer of CYP3A4. Therefore, unboosted ATV should not be prescribed with rifampin. Mallolas, et al hypothesizing that boosting ATV with low-dose ritonavir (a CYP3A4 inhibitor) would negate the effect of rifampin on ATV levels studied HIV-infected adults with a viral load <200 copies/mL while receiving a triple nucleoside regimen as well as 300 mg of rifampin daily as part of a TB regimen. ATV at a dose of (300 mg)/ritonavir (100 mg) per day was added and a complete pharmacokinetic study of ATV was performed three weeks later. In all of the first three of a total of eight planned patients who enrolled in the study, the plasma ATV Cmin, Cmax and AUC were undetectable. Study authors concluded that even in the presence of a low dose of ritonavir, there are clinically significant interactions between ATV and rifampin leading to a near absence of detectable ATV in the plasma. Rifampin should not be administered together with ATV even when the latter is ritonavir-boosted.

Mallolas J, Nomdedeu M, Soriano A, et al. Pharmacokinetic interaction between rifampin and the combination of atazanavir and low dose ritonavir in HIV-infected patients. Poster 123. 45th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC. December 17, 2005.

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