Tuberculosis Control in

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

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

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

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

Why Care about TB?

Oregon Administrative Rules (OARS)

333-019-0041
Each Facility specified below shall formally assess the
risk of tuberculosis transmission among staf
(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

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.

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

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)

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

What to do?
Prevention and Control of Tuberculosis in
Correctional and Detention Facilities:
Recommendations from CDC
July 7, 2006 / 55(RR09);1-44

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

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

Categories of Risk
1-Minimal risk facility
(not much TB or risk of, many in Oregon)

2-Nonminimal TB Prison
3-Nonminimal TB Jail

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

Risk Factors
and
Substantial Numbers?

Substantial=significant amount
>70% 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

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 < 7days dont need testing!

Non-Minimal Risk

Cases of infectious TB occurred in the

facility in the past year
Facility houses substantial numbers
(>70%) of inmates with risk factors for TB
Facility houses substantial numbers
(>70%) of new immigrants

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 < 7days dont need testing!

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

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.

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?
>10 for most, > 5 if HIV+, recent contact, etc.

Measuring TST

Record induration (bump) only

Measure transverse (across arm)
Record: Date given, date read, mm, + or

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

Containment

Signs and Symptoms of TB

Cough for more than three weeks

Coughing up blood
Unexplained weight loss
Night sweats
Fever
Feeling tired

NoteveryonewithTBlooksreallysick

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?

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

Collaboration

Corrections

Local Health Department

State TB Control

Building relationships before theres a

problem is a good idea

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

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

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
> 7days

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

Resources
Oregon TB Control
heidi.behm@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/correctionssum.pdf

CDC Guidelines
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm