Date of Award

January 2014

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Frederick L. Altice MD

Subject Area(s)

Medicine, Epidemiology

Abstract

Background: Tuberculosis (TB) is a known public health threat to prison systems due to poor hygiene, crowded living conditions, poor health of inmates, and poor prison healthcare systems. The large population of HIV-infected people living in prisons is especially susceptible to increased TB transmission and higher mortality. In Northeastern Malaysia, there is no screening for active or latent TB infection (LTBI) in the prison system.

Aims and Hypothesis: This study serves to measure the prevalence and correlates of LTBI and active TB symptoms in HIV-infected and non-HIV-infected prisoners in Northeastern Malaysia. Given the host of factors that contribute to TB transmission and burden in prisons, it is expected that the burden of LTBI is high. In studying a population of HIV-infected inmates who are not receiving antiretroviral therapy, it is expected that a significant number of inmates will display active TB symptoms.

Methods: This is a cross sectional study design that uses Tuberculin Skin Testing (TST) to measure LTBI, and the World Health Organization (WHO) TB symptom survey to measure active TB symptom prevalence. A total of 266 prisoners in Penjara Pengkalan Chepa, Kelantan, Malaysia, were enlisted in the study. After consent, participants underwent two-step TST and were surveyed for active TB symptoms. Standardized cutoffs of ≥5mm and ≥10mm were used to define reactive TST among prisoners with and without HIV, respectively. Clinical and behavioral data were assessed with a questionnaire and HIV-infected prisoners were stratified by CD4 status.

Results: LTBI prevalence in Penjara Pengkalan Chepa in July-August 2011 was 87.6%, with significantly lower TST-reactivity among HIV-infected compared to non-HIV-infected prisoners (83.6% vs. 91.5%; p<0.05); however, TB symptoms were similar (16.9% vs. 10.1%; p=0.105). On multivariate analysis, previous incarceration (AOR=4.61: 95%CI=1.76-12.1) was the only significant correlate of LTBI. Increasing age (AOR=1.07: 95%CI=1.01-1.13), lower body mass index (AOR=0.82: 95%CI=0.70-0.96) and having a negative TST (AOR=3.46: 95%CI=1.20-9.97) were correlated with TB symptoms.

Conclusion: LTBI is highly prevalent, associated with previous incarceration, and suggests the need for routine TB screening at entry to Malaysian prisons as well as continued surveillance. The prevalence of LTBI symptoms among HIV-infected inmates is alarming and provides further justification for active screening measures. Treating LTBI in prisons is challenging, but new, shorter regimens hold promise for feasible treatment options in prisons.

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