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Tuberculosis Control in Correctional Facilities

Tuberculosis Control in Correctional Facilities. Heidi Behm, RN, MPH Acting TB Controller Tuberculosis Control Oregon Department of Human Services. A Small Disclaimer….

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Tuberculosis Control in Correctional Facilities

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

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

  3. 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

  4. 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

  5. Why Care about TB? • Oregon Administrative Rules (OARS)333-019-0041 • Each Facility specified below shall formally assess the risk of tuberculosis transmissionamong staff (professional and volunteer), residents,inmates, and patients at least annually and shallfollow 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

  6. From the Headlines… • Ramsey County sued over handling of inmate with TBAt 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.

  7. 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

  8. 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)

  9. 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

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

  11. What’s in the Guidelines? • Screening (trying to find people with latent TB infection and TB disease) • Containment (making sure others don’t get TB if someone is infectious) • Collaboration

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

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

  14. 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

  15. 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

  16. 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 don’t need testing!

  17. 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

  18. Screen all inmates on intake for symptoms of TB (questionnaire and observation) Screenall 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 don’t need testing! Screening Non-Minimal

  19. Employee Screening • Applies to all facilities • All employeesmust be screened on hire for symptoms of TB • All employees who don’t have a previous positive need a two step TB test OR single QFT

  20. 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. Don’t repeat the CXR • Minimal risk may not need annual screening. Consult.

  21. FAQ on Screening • What if an inmate or employee says they’re positive, but there’s 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 • What’s considered a positive TST? >10 for most, > 5 if HIV+, recent contact, etc.

  22. Measuring TST • Record induration (bump) only • Measure transverse (across arm) • Record: Date given, date read, mm, + or –

  23. 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

  24. Containment

  25. 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…

  26. 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?

  27. 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

  28. Collaboration • Corrections • Local Health Department • State TB Control Building relationships before there’s a problem is a good idea…

  29. 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

  30. 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

  31. 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 QFTs…amount 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

  32. 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 doesn’t 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

  33. 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

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