RIF/PZA goes to jail, but not for long enough
Delays, early releases hinder completion
One thing researchers in Atlanta knew about the city’s TB community was that many patients had no regular health care provider. At best, many of them resorted to the emergency room of the public hospital when they got sick.
Researchers also found that 60% of the city’s TB patients had spent some time in jail. Putting two and two together, Naomi Bock, MD, MS, a Georgia Department of Health medical epidemiologist, concluded that jail might be a good place to find people latently infected with TB, and provide them with preventive therapy.
Bock already knew from work she’d done at the city jail that numbers wouldn’t be a problem; during an average month, the jail held about 100 inmates with positive skin tests who were candidates for preventive therapy. But since inmates in that system only stay an average of 100 days, there was a problem with time.
A trial of six months of isoniazid ended on a discouraging note, when only two of 100 released inmates showed up to continue their INH — despite generous incentives including hot breakfasts and $20 payments. But once the CDC approved the new two-month short-course regimen for HIV-negative patients, Bock decided to give the new treatment a try.
"Basically, all the [eligible] inmates were very interested," says Bock. "No one refused, which surprised me." By last September, Bock had recruited 131 eligible inmates whose records promised they’d be staying put for at least 100 days. In 56 instances, the records turned out to be wrong; plus, another 24 of the 131 had a history of previous INH treatment. That left Bock with 41 eligible inmates.
The first 10 who started treatment all suffered stomachaches, Bock says, but none wanted to quit; so she adjusted their PZA dosage downward, and the stomachaches resolved. Successive pools of subjects had their PZA adjusted downward, too.
Four subjects experienced itching, leading Bock to take them off the meds. ("If they’d been my patients in the real world, I’d probably have treated them through it; but in jail, I didn’t want to take any chances," she notes.)
Then, to her frustration, another 17 inmates were released ahead of schedule. Of those, Bock was gratified when two actually showed up at the county health department to get more pills. Other challenges along the way have included delays in getting test results and X-rays back. What Bock terms "friendly persistence" has gone a long way to resolving most of these snags.
So far, eight of 41 inmates who started RIF/PZA have finished; the rest are in the midst of treatment, and Bock plans to keep enrolling inmates until she’s reached at least 100. "So we’ve lost close to a third," she adds. "But when they’re there, they’re happy to do it."
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