Differences in EPAP and CPAP

The study design, however, does not support the conclusion of the authors that “there was no evidence of tuberculosis transmission within the institutions.” Their record review of 4,744 inmates showed that only 347(7.3 percent)had documented repeat skin tests during incarceration. The extent to which this small percentage of inmates, some ofwhom had been released from prison between skin tests, represents the entire inmate population is not known. Because ofthe absence ofdata on serial tuberculin testing on 92.7 percent of the prison population, the authors’ conclusion cannot be supported that inmates who stayed in the prison system did not experience skin test conversions. Of the 345 inmates with repeat skin tests, there were three identified converters, all ofwhom were identified after a break in incarceration and reimprisonment. Similarly, in the absence of serial testing of inmates it cannot be concluded, as the authors claim, that the readmitted inmates were infected while outside the prison. I applaud the efforts ofthe authors to measure the cost and some of the benefits derived from a large admission screening program. However, what is also needed from future evaluations is a measure of the extent to which screening and case-finding activities are protecting inmates from tuberculosis infection and disease. Results of retests on a representative sample of inmates for whom the number ofyears spent in prison is known would partially address this need. Incarceration can provide an ideal setting for transmission of tuberculosis, and the lack of reported cases in a prison system does not preclude the existence of unrecognized and unreported disas”2 Infected prison inmates may be at higher risk ofdisease than nonincarcerated individuals because reported TB risk factors such as Iv drug abuse, alcoholism, and HTLV-III/LAV infection have been shown in some studies to be disproportionately represented in prison populations. The prison population consists mainly of young adults, most of whom will return to the community. Inmates are a relatively accessible and potentially high-risk group. We need to assure that all feasible approaches are being taken to prevent this group from becoming (or perhaps continuing to be) a focus for unnecessary future tuberculosis morbidity and mortality. Thorough evaluation of existing programs will determine which approaches can most effectively achieve this purpose.