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Correctional Medicine: A Public Health Approach

Janet Mohle-Boetani , Deputy Medical Executive, Public Health ,CCHCS. Correctional Medicine: A Public Health Approach. Public Health in Corrections. Public Health/Medicine comparison Why public health in corrections? Public Health Framework Exercises on public health interventions

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Correctional Medicine: A Public Health Approach

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  1. Janet Mohle-Boetani, Deputy Medical Executive, Public Health ,CCHCS Correctional Medicine: A Public Health Approach

  2. Public Health in Corrections • Public Health/Medicine comparison • Why public health in corrections? • Public Health Framework • Exercises on public health interventions • Public Health in Corrections: challenges • Public Health in CCHCS • Exercises on public health and primary care • Summary

  3. Medicine:Public Health Crosswalk

  4. Medicine: Public Health Crosswalk

  5. Public Health In Corrections: the 7 Cs • Risk for CDs– 3 Cs • Correctional staff, Concentrated Communicable Diseases, Crowded Environment • Why- 4 Cs • Constitutional right, Control CDs, Continuity of Care, Community public health impact

  6. Risks for CDs in corrections- 3 Cs • Correctional Staff • Introduce influenza, pertussis, tuberculosis • May work while symptomatic • No occupational health program • Concentrated communicable disease (high prevalence) • TB (25%), Hepatitis (40%), STIs • Crowded Environment- 175% capacity • High incidence of chicken pox (transmission from shingles) • TB transmission

  7. Public Health in Corrections: Why? The 4 Cs • Constitutional care/civil right to no deliberate indifference • Control communicable diseases in prison • Prevent exposure (Env. Mitigation/hand hygeine/ condoms?) • Prevent infection (vaccinations [disease with higher rate than gen pop vs other diseases) • Detect disease/infection (screening/surveillance: TB/varicella) • Isolation (ill)and quarantine (exposed during incubation period): influenza, norovirus • Offer intervention to those exposed to communicable diseases (contact investigation) • Continuity of care with community for communicable diseases- e.g., tuberculosis treatment on admit and after parole

  8. Public health in Corrections- Why? (the 4th C): Community Pub Health Impact Opportunity to impact an underserved population

  9. Community: Incarcerated Treatment inside: Impact outside

  10. Public Health Framework • Ongoing Prevention Programs • Primary (infection) • Vaccinations • Secondary (disease among infected) • LTBI Rx • Tertiary (disease complications) • TB case management

  11. PH Diseases/Pathogens: CCHCS • S • N • I • T • C • H

  12. PH Disease/Pathogens: CCHCS • Shingles/Skin Diseases (MRSA)/STDs/Scabies • Norovirus infections • Influenza • Tuberculosis • Chickenpox/Coccidioidomycosis • HIV/Hepatitis

  13. Outbreak Control, CCHCS 2011

  14. Outbreak Component/Intervention 1 Introduce Agent Intervention • Employees • Jail/Community • Reactivation (TB) • Environment (cocci) • Visitors • Occ Health Program • RC screening • LTBI treatment • Env. Mitigation • Notices/screening

  15. Outbreak Control, CCHCS 2011

  16. Outbreak Components/Intervention 2 Step/Component Intervention • Susceptible Population • Unvaccinated • Immunocompromised (susceptible to severe cocci) • Vaccinations • Exclude from Cocci endemic area

  17. Outbreak Control, CCHCS 2011

  18. Outbreak Component Intervention 3 Component Contact between infectious and susceptible population Intervention Isolation (separate diseased) Quarantine (separate exposed) Handwashing Respiratory Hygiene Condoms Decrease overcrowding Realignment (AB109)

  19. Outbreak Control, CCHCS 2011

  20. Challenges of Public Health in Corrections • Isolation from mainstream public health • Inmate vs occupational health issues : role of healthcare in public health contact investigations • Personal medical care/public health overlap • Disease management (HIV, TB, STDs, viral hepatitis): chronic care vs public health clinics • Prevention: public health campaigns vs public health clinics vs incorporate into primary care • Transfer of medical information: jail/prison, prison/community • Quality management: standard measures?

  21. Public Health in CCHCS by Functional Unit

  22. Goal: Change in Public Health Practice in CCHCS From To • Disjointed/Fragmented • Reactive • Isolated • Fear-based • Thriftless/High Cost • Systematic • Proactive • Integrated • Evidence-based • Saving resources

  23. Disjointed to Systematic • Outbreak Reporting – Email notes • No surveillance, dependent on state statistics for # of cases of TB • Written guidance for TB control • Use of state form, electronic • Systematic surveillance- outbreaks, TB disease, cocci, influenza (during H1N1) • Targeted eval of TB cases >6mos in CDCR (missed ops for prevention) • Guidance/Trainings for MRSA, norovirus, influenza, TB, chickenpox/cocci, HIV screening

  24. Reactive to Proactive • Norovirus: 200-500 cases and institutions shut down for weeks • Massive TB contact investigations- institution shut down for weeks, yards on med holds for months, incomplete investigations • Influenza Outbreaks- massive 200-500 cases, mass vaccinations after the outbreak was detected • Clusters of 10-20 cases, no shut downs • Targeted and complete investigations- usually 20 inmates/employees per CI • Most outbreaks are fewer than 10 cases, effective isolation/quarantine, vaccination in the fall

  25. Isolated to Integrated • No statewide PH committee participation • Minimal regional PH committee participation • Isolated within CCHCS • Active participation in • CCLHO-CD, CTCA, CocciWG • Formal structured meetings by regional PHNs with hospitals and local health departments • Participation in HQ committees (eg, RC), collaborate with nursing, QM, IT, and UM

  26. Fear-Based to Evidence-Based • Laborious HIV counseling for screening- backlogs • Massive TB contact investigations (e.g., all ees at an institution) • Emphasis on testing • Respiratory isolation and massive contact investigations for shingles • No condoms: fear of use as contraband • HIV opt out screening- quality measure 85% screened at RCs • Targeted TB contact investigations (usually 20 inmates and 10 staff) • Emphasis on LTBI Rx for infected • Respiso for chickenpox not localized shingles • Limited CIs for shingles • Condom distribution feasibility study- no evidence of abuse

  27. Thriftless/High Cost to Saving • Tuberculin Testing on Transfer between institutions • Reactive to chickenpox- screening and vaccination AFTER exposure • Coccidioidomycosis- Ongoing morbidity and high costs • Screen for TB disease not infection on transfer- • Saves $2 million each year • Varicella prevention- targeted screening and vaccination BEFORE exposure • Saves $1.3 million/5 years • Environmental Mitigation • ($200K) + evaluation

  28. Exercise: Public Health and Primary Care • What options are there for increasing access to public health clinical services in corrections? • Should public health be integrated into primary care? Pros and cons of integration • How could public health be integrated into primary care?

  29. Public Health and Primary Care – Level 1 (individual) • Free access to care for respiratory symptoms and rashes • Problem list: TB disease, recent TB infection, LTBI treatment • PH clinical services in primary care (combine appts) • Immunizations (prim and tertiary prevention) • LTBI treatment (sec prevention) • STD treatment (prim, sec, tertiary prev) • TB case management (tertiary prev) primary care team • Hospital discharge planning for suspect/confirmed TB patients (team plans for DC when pt admitted) • Continuity of medications when discharged from hospital • Appropriate discharges to the general population • Community standard vs discharge into high risk population

  30. Public Health Clinical Services- Options

  31. PH and Primary Care- Level II (registry based) • Registry of recent TB infections (within 2 years) • Registry of patients on LTBI treatment • Registry of patients with Hepatitis C

  32. Exercise: Quality Measures • What are some key public health quality measures?

  33. PH and Primary Care- Level III(pop based assessment) • Vaccination coverage by population • Recent infections- monitoring for 2 years by population • LTBI treatment- completion of 9 mos in 1 year by population • TB treatment-completion in 1 year by population

  34. Public Health In Corrections Summary: the 7 Cs • Risk for CDs– 3 Cs • Correctional staff, Concentrated CDs, Crowded Environment • Why- 4 Cs • Constitutional right, Control CDs, Continuity of Care, Community public health impact

  35. Public Health in Corrections: Summary Prevention Programs Standard Practice Primary Care • Primary (infection) • Vaccinations • Secondary (disease among infected) • LTBI Rx • Tertiary (disease complications) • TB case management

  36. Public Health in Corrections in a nutshell • Control • Communicable Diseases • Concentrated in the incarcerated population • Crowded environment • Prevention programs • Primary care setting • Population-based assessments

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