Screening for latent tuberculosis infection (LTBI) in a local ...

Screening for latent tuberculosis infection (LTBI) in a local remand prison: findings and lessons learnt Dr Stephanie E Perrett Lead Nurse for Health & Justice 1st February 2019 RCGP Health and Justice Summit, Liverpool Introduction TB in Wales NICE guidance on TB in prisons Pilot objectives Overview of the pilot Results o Prevalence and risk o Acceptability of IGRA (for men in prison and prison health services) o Treatment outcomes (preliminary)

Lessons learnt Rate of TB per 100,000 population in the UK, 2017* *Tuberculosis in Wales Annual Report 2018: Data to the end of 2017 TB in Welsh prisons 1-2 cases each year Often late presenting, more likely to be Complex social factors making treatment of prison challenging Can result in lengthy, complex contact tracing Anxiety amongst prison staff infectious outside NICE Guidance on TB (2016) In high incidence areas (and at prisons that receive from high incidence areas), prison health services should offer an

interferon-gamma release assay (IGRA) for TB to inmates younger than 65 years who are in regular contact with substance misuse services or other support services. This is provided arrangements have been made for this support to continue after release prison health services should incorporate IGRA testing with screening for hepatitis B, hepatitis C and HIV If the IGRA is positiveoffer treatment for latent TB infection Why latent TB? Latent infection may develop into active disease o Risk of reactivation is not linear, most infections occur within 2 years of acquisition Identification and treatment of LTBI has the potential to protect the health of the individual Identification and treatment of LTBI has the potential to protect the health of the public BMJ 2018; 362: k2738 doi: 10.1136/bmj.k2738 (Published 23 August 2018)

Pilot objectives What is the prevalence of LTBI in a prison population in Wales? o Do we have enough infection to justify universal screening? What treatment outcomes can we achieve? o How robust are our treatment pathways? Project plan for an LTBI prison pilot Funding from Welsh Government (30k) 584 men tested alongside BBV screen o T-spot blood test (OxfordImmunotech) CXR on all LTBI positives o Using London based Find and Treat mobile service Referral into specialist TB services for all LTBI positive HMP Cardiff

Local category B remand prison Operational capacity of 830 men High turnover Healthcare team of GPs, 20 nurses, 6 HCAs Screening 30% of admissions for BBVs Good relationship with local TB specialist team Resources required to implement LTBI screening Allocated 2 nurses and 3 HCAs Men screened the morning after admission to prison Participation voluntary Initial target of 12 samples per day, changed to 20 samples per day Resource intensive clinical and administration time Medical hold until X-ray Support from prison to facilitate Find and Treat bus X-ray screening Study Population In the period (1 February 28 March 2018), there were 699 new admissions to HMP Cardiff

584 males were screened within 48 hours (83.5% sample rate) o Risk assessment/questionnaire o Blood Sample 17 records could not be verified This analysis focusses on the sample of 567 men Demographics Median age 31 years [18-69 years] Majority of men identified themselves as White ethnicity (82.7%) Deprivation o Majority provided a postcode in either Quintile 1 or 2 (most deprived; n=316) o A number of men (n=79) stated that they currently had no fixed abode o Those who identify with no fixed abode do not necessarily identify themselves as homeless, and vice versa Overview of IGRA and BBV prevalence IGRA positive (n=567)

40 (7.1%) Hep B positive (n=478)* <5 Hep C positive (n=478)* 39 (8.2%) HIV positive (n=475)* <5 *5 men declined the BBV screening, 4 samples were invalid, 80 results were not reported (83 HIV) One case of active respiratory TB infection identified via CXR Risk Factors (all men) Risk Factor Number of Men (%)

Previous Prison Stay 445 (78.5) No Previous BCG Vaccination 340 (60.0) History of Substance Misuse 324 (57.1) Homeless in the past 5 years 156 (27.5) History of Alcohol Abuse 147 (25.9)

Currently Homeless 130 (22.9) Non-White Ethnicity/Country of Birth (High Risk Region) 45 (7.9) Positive BBV Result 41 (7.2) Travelled outside Western Europe, North America or Australasia 37 (6.5) Close contact with TB 23 (4.1) Previous TB illness

4 (0.7) Risk Factors (IGRA Positive vs. Non Positive) Risk Factor IGRA Positive Non-Positive Odds Ratio [95% CI] 10/38 (26.3%) 35/477 (7.3%) 4.5 [2.0-10.0] Close contact with TB 4/40 (10.0%)

19/527 (3.6%) 3.0 [1.0-9.2] Positive BBV Result 5/40 (12.5%) 36/527 (6.8%) 1.9 [0.7-5.3] 4/40 (10.0%) 33/527 (6.3%) 1.7 [0.6-5.0] History of Substance Misuse

26/40 (65.0%) 298/527 (56.5%) 1.4 [0.7-2.8] Previous Prison Stay 33/40 (82.5%) 412/527 (78.2) 1.3 [0.6-3.1] 24/40 (60.0%) 316/527 (60.0%) 1.0 [0.5-1.9] 6/40 (15.0%)

141/527 (26.8%) 0.5 [0.2-1.2] Non-White Ethnicity/Country of Birth (High Risk Region) Travelled outside Western Europe, North America or Australasia No Previous BCG Vaccination History of Alcohol Abuse Risk Factors (Hep C Antibody Positive vs. NonPositive) Risk Factor Positive Non-Positive Odds Ratio 95% CI History of Substance Misuse

38/39 (97.4%) 233/439 (53.1%) 33.6 4.6-246.9 Previous Prison Stay 38/39 (97.4%) 342/439 (77.9%) 10.8 1.5-79.5 Homeless in the past 5 years

19/39 (48.7%) 121/439 (27.6%) 2.5 1.3-4.8 Currently Homeless 16/39 (41.0%) 100/439 (22.8%) 2.4 1.2-4.6 No Previous BCG Vaccination 22/39 (56.4%)

164/439 (37.4%) 2.2 1.1-4.2 History of Alcohol Abuse 16/39 (41.0%) 116/439 (26.4%) 1.9 1.0-3.8 Close contact with TB 2/39 (5.1%)

18/439 (4.1%) 1.3 0.3-5.7 Travelled outside Western Europe, North America or Australasia 2/39 (5.1%) 26/439 (5.9%) 0.9 0.2-3.8 Non-White Ethnicity/Country of Birth (High Risk Region) 0/37 (0.0%)

35/392 (8.9%) --- ------ Previous TB illness 0/39 (0.0%) 4/439 (0.9%) --- ------ Logistic Regression Model (IGRA Positive) Characteristic/Risk Factor AOR [95% CI]

P-value Non-White Ethnicity/Country of Birth (High Risk Region) 5.3 [2.3-12.3] <0.001 History of Substance Misuse 2.2 [1.0-4.7] 0.040 34 Years and Older (Median age IGRA Positive) 1.9 [1.0-3.7]

0.064 History of Alcohol Abuse 0.4 [0.2-1.1] 0.079 Logistic Regression Model (Hep C Antibody Positive) Characteristic/Risk Factor AOR [95% CI] P-value History of Substance Misuse 43.4 [5.1-368.5] 0.001

35-44 years 18.1 [2.3-142.0] 0.006 45 years and older 17.2 [1.9-152.4] 0.011 7.7 [0.0-60.2] 0.053 25-34 years Treatment outcomes (preliminary) Outcome unclear; 2

Completed; 10 Awaiting referral; 10 Discontinued treatment; 3 On treatment; 2 Refused/DNAd; 10 Treatment observations Of the 10 who completed treatment, 8 completed whilst in prison The two men still on treatment are within the community (including active case) All 10 awaiting referral were originally lost on release (lack of contact details). They have since been found (7 are in Wales and 3 in England) Patients have been followed up in Leicestershire, Leeds, Nottingham, Birmingham and Bristol

Lessons learnt We found more cases of LTBI than expected Those at risk of TB and HCV are two different groups sharing prison as a risk factor IGRA is acceptable to men in prison There are significant workload implications to consider The more mobile the patient the greater the challenge to complete treatment Focus future resources on active case finding? Discussion Does your service offer LTBI screening? What challenges do you face in delivering this service? Differences in remand and long stay facilities? How can we improve outcomes for those who move between prisons and between prison and community? Experience of active case finding? Thank you [email protected] Acknowledgements Cardiff and Vale University Health Board staff HMPPS UCL Find and Treat Service Public Health Wales Welsh Government Latent TB Pilot South Eastern Health and Social Care Trust NORTHERN IRELAND HMP Maghaberry Adult Males Sentenced & Remand High Security

Integrated & Separated conditions Population 818 (Dec 18) 356 remand/348 sentenced No. of Committals 256 (Dec 18) Pilot Cohort Sentenced Group Minimum 6 months remaining to serve Funding for 75 Igra tests PRISON SERVICE OUTCOME: WE ENJOY LONG, HEALTHY, ACTIVE LIVES Latent TB Screening Pilot: Maghaberry Prison A screening, testing and treatment service for Latent TB was established in June 2018 to detect Undiagnosed cases of Latent TB. How much did we do?

Reporting Period: August to November 2018 Outcome of Screening 29 75 104 clients were screened Number of IgRAs required Number of IgRAs not required How well did we do it? Reporting Period: August to November 2018 Of the 104 screened, 7 identified positive 7 3

72 6.75% Number of IgRAs declined Number of IgRAs carried out (of population screened) 97 Is Anyone Better Off? 100% of patients Requiring a chest x-ray accepted

Offered screening where given information and advice about Latent TB With a positive Latent TB diagnosis had an onward referral to a TB nurse specialist for treatment 6 people completed treatment and one in treatment All 7 positive patients offered a chest x-ray

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