Tuberculosis Control in Correctional Facilities

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Tuberculosis Control in Correctional Facilities

• Heidi Behm, RN, MPH
• Acting TB Controller
• Tuberculosis Control
• Oregon Department of Human Services

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A Small Disclaimer

• This presentation will NOT teach you everything
  there is to know about tuberculosis or even
  tuberculosis control in correctional facilities

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TB 101

• Caused by M. tuberculosis
• Tuberculosis is airborne, not on things.
• Latent TB infection is not contagious (no
  symptoms, TST, CXR normal)
• TB disease can occur in any body part
• Most cases of pulmonary TB disease are infectious
• Symptoms of pulmonary TB are cough, hemoptysis,
  fever, weight loss, night sweats

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Individuals at High Risk for TB

• HIV/AIDS
• Recent immigration (5 years)
• History of TB
• Recent close contact to person with TB disease
• Injection-drug use (IDU)
• Diabetes
• Immunosuppressive therapy (chronic steroid use,
  TNF alpha inhibitor)
• Hematologic malignancy or lymphoma
• Chronic renal failure
• Substantial weight loss or malnutrition
• History of gastrectomy or jejunoileal bypass

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Why Care about TB?

• Oregon Administrative Rules (OARS)333-019-0041
• Each Facility specified below shall formally
  assess the risk of tuberculosis transmission
  among staff (professional and volunteer),
  residents, inmates, and patients at least
  annually and shall follow appropriate
  tuberculosis screening recommendations as
  outlined in the relevant publication or as
  otherwise approved by DHS
• Correctional Facilities "Controlling TB in
  Correctional Facilities," published by the
  Centers for Disease Control and Prevention

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From the Headlines

• Ramsey County sued over handling of inmate with
  TB At least 80 former inmates and 30 county
  employees were later found to have the infection,
  according to the class-action lawsuit.
• County Jail Failing to Test Prisoners for
  Tuberculosis as Required by Department of Health
• A Denver parolee claims he got tuberculosis in
  the Arapahoe County Jail or the state prison in
  Canon City.

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TB in Corrections Affects the Community

• Corrections employees are exposed and infected.
  May develop active TB disease
• Employees live in the community, may infect
  family and friends
• Inmates may move frequently in and out of system

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Why is TB a Problem in Corrections?

• Inmates have histories that put them at greater
  risk for TB exposure (homelessness, IVDU)
• Inmates are frequently in poor health and get
  sick (and contagious) with TB disease much
  quicker (HIV, poorly nourished)

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Why is TB a Problem in Corrections (Continued)?

• Structure of facilities makes transmission likely
  (close living conditions, poor ventilation)
• Frequent movement of inmates makes TB control
  hard

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What to do?

• Prevention and Control of Tuberculosis in
  Correctional and Detention Facilities
  Recommendations from CDC
• July 7, 2006 / 55(RR09)1-44

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Whats in the Guidelines?

• Screening
• (trying to find people with latent TB
  infection and TB disease)
• Containment (making sure others dont get TB if
  someone is infectious)
• Collaboration

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Risk Assessment and Screening

• Risk Assessment determines how much screening
  should be done and environmental controls
• Performed annually
• Conducted in collaboration with Local and State
  Health Departments

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Categories of Risk

• 1-Minimal risk facility
• (not much TB or risk of, many in Oregon)
• 2-Nonminimal TB Prison
• 3-Nonminimal TB Jail

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Minimal Risk Facility

• No cases of infectious TB occurred within the
  facility during past year
• Facility does not house substantial numbers of
  inmates with risk factors for TB (HIV, homeless,
  IVDU)
• Facility does not house substantial numbers of
  new immigrants

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Risk Factors and Substantial Numbers?

• Substantialsignificant amount
• gt70 of the inmate population have risk factors
  and/or are new immigrants your facility is NOT
  minimal risk
• Risk factors include IVDU, HIV or other
  immunocompromised state, diabetes, recent
  exposure to TB, immigration to U.S. from high
  incidence area within past 5 years

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Screening if Minimal Risk

• Screen all inmates on intake for symptoms of TB
  (questionnaire and observation)
• Screen all inmates on intake for risk factors
  (questionnaire and observation)
• HIV, immunocompromised need a CXR on intake
• If TB risk factor present, need a TB skin test
  (TST), quantiferon (QFT) or CXR within 7 days of
  arrival.
• Those in the facility lt 7days dont need testing!

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Non-Minimal Risk

• Cases of infectious TB occurred in the facility
  in the past year
• Facility houses substantial numbers (gt70) of
  inmates with risk factors for TB
• Facility houses substantial numbers (gt70) of new
  immigrants

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Screening Non-Minimal

• Screen all inmates on intake for symptoms of TB
• (questionnaire and observation)
• Screen all inmates on intake for risk factors of
  TB
• (questionnaire and observation)
• All inmates need a TB skin test (TST),
  quantiferon (QFT) or CXR within 7 days of arrival
• HIV/AIDS, immunocompromised need a CXR on intake
• Those in the facility lt 7days dont need testing!

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Employee Screening

• Applies to all facilities
• All employees must be screened on hire for
  symptoms of TB
• All employees who dont have a previous positive
  need a two step TB test OR single QFT

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Annual Screening

• Previously negative employees should be tested
  annually
• Previously negative long-term inmates should be
  tested annually
• If previously positive, a symptom check only.
  Dont repeat the CXR
• Minimal risk may not need annual screening.
  Consult.

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FAQ on Screening

• What if an inmate or employee says theyre
  positive, but theres no documents? Give them a
  TST or QFT. Document it well! If they are
  positive, a CXR is needed.
• What is Quantiferon (QFT)?
• A blood test for latent TB infection
• Whats considered a positive TST?
• gt10 for most, gt 5 if HIV, recent contact, etc.

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Measuring TST

• Record induration (bump) only
• Measure transverse (across arm)
• Record Date given, date read, mm, or

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Treating LTBI

• Ideally, all inmates who have LTBI should be
  offered treatment.
• In jails this might not be possible
• May prioritize treatment for high risk groups
  (HIV)
• Work with local health department to ensure
  completion of treatment after release

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Containment
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Signs and Symptoms of TB

• Cough for more than three weeks
• Coughing up blood
• Unexplained weight loss
• Night sweats
• Fever
• Feeling tired

• Not everyone with TB looks really sick

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Sounds easy, right?

• In a large correctional facility, an inmate went
  to medical
• reporting a cough and fatigue. It was flu
  season- everyone had a cough! Came back 2 weeks
  later, still coughing with slight fever. Given
  ABX. Came back 1 week later. Same complaint.
  Given ABX and a TB test. TB test was negative.
  Continued to cough 6 weeks later was transferred
  to another facility and diagnosed with TB
  disease.
• Over 400 contacts were identified. Many were
  not located.
• Could this happen in your facility?
• How do you catch chronic coughers?

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What to do if you suspect TB

• Call State TB program or local health department
  for help!
• Better to be safe than sorry
• If you have negative pressure, use it.
• If no negative pressure, put patient in mask
  (surgical) and remove from others. Staff should
  wear N95. PREPARE TO TRANSFER PATIENT OUT.
• All this should be in your infection control plan

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Collaboration

• Corrections
• Local Health Department
• State TB Control
• Building relationships before theres a
• problem is a good idea

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If you suspect TB

• If either an inmate or employee is suspected or
  confirmed to have active TB disease you must
  report this to the local health department

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Why report?

• The State and local health department will help
  you
• -coordinate care upon discharge
• -assist you in the facility contact
  investigation
• -assist you in organizing and analyzing
  contact
• data
• -ensure contacts who have been released or are
  no longer employed are screened

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Summary Points

• Each facility must determine if minimal or
  nonminimal risk
• All facilities need to assess every inmate for
  risk factors and TB symptoms on arrival
• All facilities will screen some inmate with TSTs
  or QFTsamount of screening depends on risk level
• All facilities should provide CXRs to inmates who
  are severely immunocompromised
• Focus testing efforts on inmates in facility
• gt 7days

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Summary Points Continued

• All facilities should screen for risk factors,
  signs symptoms and test new employees on hire
• Annual screening of employees and long term
  inmates is advised
• Knowing the signs/symptoms of TB and acting
  promptly is critical
• If your facility doesnt have negative pressure,
  you need a back up plan. This should be outlined
  in your facilities infection control plan
• The State TB program and your local health
  department are here to help

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Resources

• Oregon TB Control
• heidi.behm_at_state.or.us
• 971-673-0169
• Local Health Department Directory
• http//www.oregon.gov/DHS/ph/lhd/lhd.shtml
• Summary of Guidelines
• http//www.oregon.gov/DHS/ph/tb/docs/correctionssu
  m.pdf
• CDC Guidelines
• http//www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.
  htm