The recent increase in tuberculosis in the U.S. has been attributed to: the HIV epidemic, immigration of persons from countries where TB is endemic, facilitation of spread in congregate settings such as correctional facilities, and a deteriorating public health infrastructure. Most TB control programs focus on active disease; prevention of activation of latent TB infection is equally critical in high risk populations for control of the TB epidemic. The purpose of this RCT is to investigate strategies for TB control among jailed persons with latent TB infection who are released from jail before completing preventive therapy. This application proposes a randomized clinical trial (RCT) to study the effects of three educational interventions on two outcomes: the first post-jail visit to the county TB Clinic; and the completion of subsequent follow-up visits to complete a full course of TB preventive therapy. Screening in jail identifies persons who are infected with TB, and many are begun on isoniazid (INH) preventive therapy while in jail. Most, however, are released from jail prior to INH completion. Inmates are released without medication, and must go to the TB clinic to continue preventive therapy. Pilot work has shown that less than 4% of released inmates who need further INH actually report to the county TB clinic for follow-up. Data demonstrate the need to test intervention strategies to increase the percent of released inmates who go to the TB Clinic to continue and complete preventive therapy for TB. This RCT proposes to randomize TB-infected inmates on INH in the jail into one of three intervention groups: usual care (standard education and counseling, provided once at the time of INH prescription); usual care plus reinforced education at two-weekly intervals and at release; and usual care plus incentive valued at $25 (hotel vouchers, bus tokens, or food coupons) given if the first TB Clinic visit is within two weeks of release.
Three specific aims are to measure: 1) the effects of the three educational interventions on the percent who make a first visit to the TB Clinic within two weeks of release; 2) the effects of the interventions on the percent who complete enough visits to finish INH preventive therapy; and 3) the reasons why persons do or do not complete a first TB Clinic visit. The significance of this project is: 1) as nursing strengthens its focus on patient-centered care, persons in jail are increasingly recognized as a vulnerable group at high risk for TB; 2) the jail is a venue of care for those who may not have other sources of care; 3) education and financial incentives have not been studied as predictors of adherence to preventive TB therapy in this population; and 4) this project strengthens the link between the jail's health services and the Public Health Department TB control services, and may serve as a model for other jail systems and public health systems in the U.S.
