# Presentation: 236091

## Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC2006

**Division of Tuberculosis Elimination**

**Still need some other photos****for this**

**Notes:**
ML - Would be nice to include endorsers: ACET, NCCHC and ACA

## Contents (1)

**Summary of Changes from 1996 Recommendations **
**Background**
**Screening**
**Case Reporting**
**Airborne Infection Isolation**
**Environmental Controls**
**Respiratory Protection**

## Contents (2)

**Diagnosis and Treatment of Latent Tuberculosis Infection and Tuberculosis Disease**
**Discharge Planning**
**Contact Investigation**
**Tuberculosis Training and Education of Correctional Workers and Inmates**
**Program Evaluation**
**Collaboration and Responsibilities**

## Summary of ChangesMade to the 1996 Recommendations

## Summary of Changes (1)

**Target audience has broadened to include persons working in jails and other detention facilities**
**Screening procedures for inmates and detainees should be based on assessment for risk of Tuberculosis (TB) **
**TB symptoms of all inmates and detainees should be reviewed at entry**

**Notes:**
EM - First Bullet – Target audience has broadened to include other persons working in jails, and includes all correctional and detention facilities.
Third bullet – TB symptoms should be reviewed at entry and at all medical encounters

## Summary of Changes (2)

**All inmates and detainees with suspected TB should be placed in airborne infection isolation (AII) immediately**
**Quantiferon has been added to testing recommendations **
**Recommendations for ventilation have been added**

**Notes:**
EM - No changes

## Summary of Changes (3)

**Recommendations for respiratory protection have been added**
**Treatment recommendations for TB and LTBI have been updated**
**Case management of inmates with TB disease and LTBI have been emphasized**
**Early discharge planning that is coordinated with local public health staff is emphasized**

**Notes:**
EM - No changes

## Summary of Changes (4)

**Recommendations for US Immigration and Customs Enforcement detainees have been included**
**Collaboration between the correctional facility and public health staff is emphasized**
**Comprehensive training programs to achieve and sustain TB control should be tailored by corrections and public health staff**

**Notes:**
EM - No changes

## Summary of Changes (5)

**Public health workers need to be educated about the correctional environment**
**Program evaluation is emphasized**

**Notes:**
EM - No changes

## Background

## Number of Incarcerated Personsin the United States, 1980 and 2003

**Notes:**
EM - No changes – but I have a different slide (from Mark Lobato) that demonstrates this a little bit differently.  I will send

ML - How was 1980, pre upsurge, chosen? Should update to 2006 

## Disproportionately High Percentage of TB Cases Occurring in Incarcerated Persons in the US, 2003

**0.7% of the total US population was confined in prisons and jails**
**3.2% of all TB cases nationwide occurred among residents of correctional facilities**

**Notes:**
EM - No changes

ML - Update to 2006

## TB Case Rates 

**United States, 1993 - 2006**
**<10 cases per 100,000 persons (general population)**
**New Jersey, 1994**
**91.2 cases per 100,000 inmates**
**11.0 cases per 100,000 persons among all New Jersey residents**
**California, 1991**
**184 cases per 100,000 inmates of a California prison (10 times greater than the statewide rate)**
**California, 1998**
**72.1 cases per 100,000 inmates in an urban jail in a high-prevalence area (10% of the county’s cases that year)**
**New York, 1993**
**139.3 cases per 100,000 inmates, an increased rate from 15.4 during 1976-78**

**Notes:**
EM - Great information

ML - Delete or add rates for prisons from Am J Public Health 2005 Oct;95(10):1800-5

## Factors Contributing to High Rate of TB in Correctional and Detention Facilities

**Disparate numbers of incarcerated persons are at high risk for TB**
**Physical structure of facilities (e.g. close living quarters, overcrowding, inadequate ventilation)**
**Movement of inmates into and out of overcrowded and inadequately ventilated facilities**

**Notes:**
EM - No changes

## Challenges with Detained Immigrants

**Most come from countries with high prevalence of TB (i.e., Mexico, the Philippines, and Vietnam)**
**Social and legal barriers often make testing and treatment interventions inadequate**
**Some are infected with *****M. tuberculosis***** resistant to first-line anti-TB drugs because of interrupted treatment received in their countries of origin**

**Notes:**
EM - First bullet – in the parentheses – (i.e., Mexico, the Philippines, Vietnam, etc.) – the way it is now appears to be inclusive, and I believe there are more countries than these three.  

ML - Include language as a barrier

## Rationale for Updating and Strengthening TB Control and Prevention Guidelines (1)

**Transmission of *****M. tuberculosis *****continues to be documented within correctional facilities**
**Inmates with undiagnosed TB disease place other inmates and correctional staff at risk for TB and when released they can infect members of the community**
**Immediate isolation of infectious patients can interrupt transmission of *****M. tuberculosis***

**Notes:**
EM - No changes

## Rationale for Updating and Strengthening TB Control and Prevention Guidelines (2)

**Prompt initiation of an adequate regimen of directly observed therapy (DOT) helps ensure adherence to treatment**
**Inmates have relatively high rates of HIV infection. Persons who are co****-****infected with HIV and *****M. tuberculosis***** are at high risk for progressing from LTBI to TB disease.**
**Treatment for LTBI can prevent the development of TB disease**

**Notes:**
EM - Fixed second bullet – second sentence – was coninfected – should be co-infected.
Third bullet should read – Completion of treatment for LTBI can prevent the development of TB disease.

## Rationale for Updating and Strengthening TB Control and Prevention Guidelines (3)

**Inmates who have TB disease or LTBI can be treated before they are released into the community**
**The correctional setting can be a primary source of health information, intervention, and maintenance**

**Notes:**
EM - No changes

## Screening

## Screening (1)

**Early identification and successful treatment of persons with TB disease is the most effective means of preventing disease transmission**
**Inmates who are likely to have infectious TB should be identified and begin treatment before they are integrated with other inmates**
**Newly arrived inmates should not be housed with other inmates until they have been screened for TB disease**

**Notes:**
EM - Third bullet – add “adequately” screened for TB disease.  Many facilities believe they have a good screening program in place, however, it is not always adequate. 

ML - Bullets 2 and 3 are same (converse)

## Screening (2)

**Screening programs can also detect persons with LTBI who are at high risk for progressing to TB disease **

**Notes:**
EM - If possible, may want to add a bullet here
Inmates may enter the facility free of symptoms of TB disease, but if infected, could progress to active disease at some point during this or subsequent incarcerations.  Important to screen at every medical encounter.

## Factors for Determining Screening Activities

**Type of facility**
**Prevalence of TB infection and disease in the facility**
**Prevalence of TB in the inmates’ communities**
**Prevalence of other risk factors for TB (e.g., HIV)**
**Average length of stay of inmates in the facility**

**Notes:**
EM - No changes

## Determining the Types of Screening

**Determined by an assessment of the risk for TB transmission within the facility**
**Risk assessments should be **
**Performed at least annually**
**Done in collaboration with the local or state health department**
**Can include**
**Symptom review**
**Chest radiograph **
**Mantoux TST**
**QuantiFERON****®**** –TB Gold Test**

**Notes:**
EM - Second bullet – add risk assessments “for facilities” should be 
Third bullet – does not flow well – is the third bullet relating to the inmate/staff, or how many of these are done in the facility?  If possible, may want to place this elsewhere as Risk Assessment or screening for inmates.

## Definition of TB Risk Facilities

**Minimal TB Risk Facility**
**No cases of Infectious TB within the last year**
**Few inmates with risk factors for TB**
**Few new immigrants**
**Employees of the facility are not otherwise at risk of TB **

**Nonminimal TB Risk Facility**
**Any facility that does not meet the criteria for Minimal TB Risk should be categorized as a Nonminimal TB Risk Facility**

**Notes:**
EM - No changes

## Screening MethodsSymptom Screening (1)

**Initial screening should be performed by **
**Health-care professionals whenever possible**
**Or adequately trained correctional officers**
**Symptom screening alone is an unsatisfactory screening mechanism for TB except for Minimal Risk Facilities**

**Add photo of Symptom Screening**

**Notes:**
EM - No changes

## Screening MethodsSymptom Screening (2)

**All incoming inmates should be immediately screened for symptoms of pulmonary TB **
**During medical screening inmates should be asked -**
**Do they have a history of TB?**
**Have they ever been treated for LTBI or TB disease?**
**Do they have**
**A prolonged cough ****≥ ****3 weeks**
**Hemoptysis (bloody sputum)**
**Chest pain**

**Notes:**
EM - No changes

ML - Change “immediately” to “at intake”
      2nd bullet- 2nd and 3rd questions are the same

## Screening MethodsSymptom Screening (3)

**Systemic Symptoms of TB**
**Fever**
**Chills**
**Night sweats**
**Easy fatigability**
**Loss of appetite**
**Weight loss**

**Pulmonary Symptoms**
**Prolonged cough ****≥ ****3 weeks**
**Hemoptysis (bloody sputum)**
**Chest pain**

**Suspicion of TB is high when pulmonary symptoms****are accompanied by general systemic symptoms of TB**

**+**

**Notes:**
EM - Fourth bullet – under Systemic Symptoms of TB – If possible, could we change “Easy fatigability” to “Tires easily”?

ML - Could delete this slide and add system questions to slide 26 

## Screening MethodsSymptom Screening (4)

**   ****All inmates who have symptoms suggestive of TB disease should immediately receive a a thorough medical evaluation including**
**TST or QFT-G**
**Chest radiograph**
**Sputum examinations (if indicated) **

**Notes:**
EM - I would add – “All inmates who have symptoms suggestive of TB disease should immediately be masked and placed into an AII room and receive a thorough medical evaluation, including . . .

ML - Type 3rd line, a a
      If patient has symptoms, immediate place in AII, then evaluate including history, PE

## Screening MethodsSymptom Screening (5)

**Symptoms ****Suggestive of ****TB disease**

**History **
**Of inadequate treatment**
** ****for TB disease**

**Place immediately ****in an AII room until they have **
**undergone a thorough medical evaluation**

**Infectious**** ****Should remain in isolation****until treatment has ****rendered them****noninfectious**

**Noninfectious**** ****May be released from AII**
**If TB diagnosis excluded****OR**
**After patient is improving on ****multidrug anti-TB treatment if****suspicion for TB diagnosis remains**

**Notes:**
EM - I would add – “mask immediately and place in an AII” in the middle box.  No changes.

ML - 3 consecutive smears negative for AFB

## Screening MethodsChest Radiograph Screening (1)

**Can be an effective means****of detecting new cases of****unsuspected TB disease ****at intake to a correctional****facility**
**Requires fewer subsequent****visits than a TST**
**Will not identify inmates with LTBI**
**Might be appropriate for facilities that**
**House substantial numbers of inmates for short periods **
**Serve populations at high risk for TB**

**Notes:**
EM - Add to first bullet – I would add “unsuspected TB disease at intake or during incarceration . . .”
Many facilities use the chest x-ray if an inmate refuses a TST or as a form of screening after symptom screen has identified a suspect.  

## Screening MethodsChest Radiograph Screening (2)

**Factors that determine the extent to which chest radiographs are used for TB screening in a facility include**
**Local epidemiologic characteristics of TB disease**
**Inmate length of stay**
**Ability of staff to conduct careful histories, TST, QFTG testing, and cross-matches with state TB registries**
**Promptness of radiographic study and its reading **

**Notes:**
EM - No changes – looks great. 

## Facilities that Do Not Perform Routine Radiographs

**Chest radiograph should be part of initial screening for**** **
**All HIV-infected patients**
**Those at risk for HIV infection but whose status is unknown**

**Notes:**
EM - No changes

ML - 2nd bullet: at “high” risk?

## Facilities with On-site Radiographic Screening

**Chest radiograph should be performed****as part of intake screening**

**Should be read by a **
**physician within 24 hours**

**Persons Who have Radiographs **
**Suggestive of TB**** **
**   ****Should be isolated immediately and evaluated further**
**   ****Should receive a sputum smear and culture examination ****(might also be indicated for certain persons ****regardless of TST, QFT-G, or chest radiograph)**

**Notes:**
EM - Bottom box – First bullet – “Should be masked and isolated immediately . . .”

## Screening MethodsMantoux Tuberculin Skin Test (TST)

**Most common method of****testing for TB infection**
**Is not completely sensitive****for TB disease**
**TST with symptom screening is the most practical approach to screen for TB disease in many facilities**

**Notes:**
EM - No changes

## Persons Exempt from a TST

**Persons who have any of the following**
**Documented history of a positive TST result**
**Documented history of TB disease**
**Reported history of a sever****e**** necrotic reaction to tuberculin**

**Notes:**
EM - Third bullet – I added an “e” to sever

## Mantoux TST Screening

**Interdermal injection of 0.1 mL of 5 tuberculin units (TU) of purified protein derivative (PPD) is the most common method of testing**
**The multiple puncture tests (e.g., tine test) are not recommended**

**Notes:**
EM - First bullet – Should read “Intradermal” 
Second bullet – “The” is not needed – should read “Multiple puncture tests . . .”

ML - Delete

## Considered a Positive TST Result in Inmates and Correctional Facility Employees

| ≥ 10mm Induration | ≥ 5mm Induration |
| --- | --- |
| Majority of inmates and correctional facility employees  | Is HIV infected
Is a recent contact of patients with TB disease
Has fibrotic changes on chest radiograph consistent with previous TB disease
Is an organ transplant recipients or has other immunocompromising conditions
Is suspected of having TB disease |

**Notes:**
EM - First bullet – remove “Is”
Second bullet – remove “Is a”
Third bullet – remove “Has”
Fourth bullet – remove “Is an” organ transplant recipients or (and remove) “has” other . . .”
Fifth bullet – remove “Is”
Might make it a little shorter – not much.

## Persons with Positive TST Results

**Persons with a Positive TST**

**No Symptoms ****of TB Disease**
**Should have a **
**chest radiograph****within 72 hours**

**Symptoms of ****TB Disease**
**Should be**
**evaluated immediately and**
**placed in an AII room **
**until TB is ruled out**

**Notes:**
EM - Last box – add “Should be masked and evaluated immediately . . .”

## Two-Step Testing

**Can reduce the number of positive TSTs that would be misclassified as TST conversions due to booster effect**
**Should be considered for the baseline testing of persons who report no history of a recent TST and who will receive repeated TSTs as part of an institutional periodic skin-testing programs**
**Is often not practical in jails because of the short average length of stay of inmates**

**Notes:**
EM - No change

## Anergy Testing

**No longer recommended routinely for screening programs for *****M. tuberculosis***** infection in the U****.****S****.**
**Has not  been demonstrated to assist in diagnosing or excluding LTBI**

**Notes:**
EM - First bullet – added periods after initials U.S.

## BCG

**Used worldwide as a vaccine against TB**
**Cannot distinguish between TST reactions caused by BCG or natural mycobacterial infection, but ****≥ 20 mm induration is usually NOT caused by BCG**
**TST is not contraindicated for persons vaccinated with BCG and TST. Results are used to support or exclude the diagnosis of *****M. tuberculosis***** infection**
**The same criteria for interpretation of TST results are used for both BCG vaccinated and nonvaccinated persons **

**Notes:**
EM - No changes

## Screening MethodsQuantiFERON® – TB Gold Test

**Diagnostic tool for *****M. tuberculosis***** infection, including both TB disease and LTBI**
**Should be used with risk assessment, radiography, and other diagnostic evaluations**
**As with TST, cannot distinguish between LTBI and TB disease**
**Available data indicate that QFT-G is as sensitive as TST for detecting TB disease and more specific than TST for detecting LTBI **

**Add photo of QFT Screening**

**Notes:**
EM - No changes

ML - Is QFT-G “as sensitive” as TST?

## Advantages of QuantiFERON® – TB Gold Test

**Results can be obtained after a single patient visit (possible cost-benefit)**
**Variability associated with skin-test reading can be reduced because “reading” is performed in a qualified lab**
**QFT-G test is not affected by previous BCG vaccination (eliminates unnecessary treatment for false-positives)**
**QFT-G does not affect the result of future QFT-G tests (no boosting occurs)**

**Notes:**
EM - No changes

ML - 2nd bullet – problems with lab variability and QA

## Limitations of QuantiFERON® – TB Gold Test

**Phlebotomy is needed **
**Blood specimens need to be processed within 12 hours of collection**
**Limited number of laboratories can process the test**
**Lack of clinical experience in interpreting test results**

**Notes:**
EM - No changes

## Use of Local Health DepartmentTB Registry

**Correctional facilities and local health departments should collaborate to ensure effective TB screening in the correctional setting**
**Inmates might provide inaccurate information due to forgetfulness, confusion or deliberate misrepresentation**
**Health departments should perform cross-mat****ch****es with the local TB registry and search for aliases, birth dates, maiden names and other personal information for TB suspects**
**Readily accessible records are useful when dealing with patients suspected of TB **

**Notes:**
EM - Third bullet – “ Health departments should perform cross-matches . . .” 
ML - 3rd bullet typo – mates

## Initial ScreeningInmates in Minimal TB Risk Facilities

**All inmates**** **
**Evaluate upon entry for symptoms of TB**

**TB symptoms**** **
**Evaluate immediately to ****rule out infectious TB disease and ****kept in an AII room until they are evaluated**
** ****(or transported to a facility that has an AII room)**

**Infectious**** ****Each person should remain in **
**isolation until treatment has **
**rendered them noninfectious**

**Noninfectious**** ****May be released from AII**
**If TB diagnosis excluded****OR**
**After patient is improving on ****multidrug anti-TB treatment if ****suspicion for TB diagnosis remains**

**No symptoms but ****risk factors**** **
**Provide additional****screening within 7 days**

**Notes:**
EM - Second box, second line – TB Symptoms – add “Mask and evaluate . . . and keep (was kept) in an AII room 

## Initial ScreeningInmates in Nonminimal TB Risk Prisons

**All Inmates ****Evaluate upon entry for symptoms of TB and for ****clinical conditions and risk factors for infection and disease**

**TB Symptoms**** **
**Evaluate immediately to rule out infectious TB disease****and keep in a AII room until they are evaluated****(or transported to a facility that has an AII room)**

**Infectious**** ****Each person should remain in **
**isolation until treatment has **
**rendered them noninfectious**

**No TB Symptoms**** **
**Require further ****screening within ****7 days of arrival**

**Noninfectious**** ****May be released from AII**
**If TB diagnosis excluded****OR**
**After patient is improving on ****multidrug anti-TB treatment if ****suspicion for TB diagnosis remains**

**Notes:**
EM - Second line, second box – TB Symptoms – “Mask and evaluate . . . And keep in an AII . . .
Do you want to recommend two-step testing here, as discussed in the guidelines for prisons?  

## Initial ScreeningInmates in Nonminimal TB Risk Jails and Other Short-Term Detention Facilities (1)

**All inmates ****Evaluate upon entry for symptoms of TB **

**Positive Results**** ****Each person should remain in **
**isolation until treatment has **
**rendered them noninfectious**

**No TB Symptoms**** **
**Require further ****screening within ****7 days of arrival**

**Noninfectious**** ****May be released from AII**
**If TB diagnosis excluded****OR**
**After patient is improving on ****multidrug anti-TB treatment if ****suspicion for TB diagnosis remains**

**TB Symptoms**** **
**Evaluate immediately to rule out infectious TB disease****and keep in a AII room until they are evaluated****(or transported to a facility that has an AII room)**

**Notes:**
EM - Second line, second box – TB Symptoms – “Mask and evaluate . . . And keep in an AII . . .

## Inmates in Nonminimal TB Risk Jails and Other Short-Term Detention Facilities (2)

**Primary purpose of screening in correctional settings is to detect TB disease**
**It is often not practical to initiate LTBI therapy because the high rate of turnover and short lengths of stay**
**Treating LTBI in the jail setting is most effective if resources dedicated to discharge planning and reliable access to community-based treatment are available**
**Some interventions (e.g., education and incentives) can lead to improvements in linking released detainees to post****-****release medical care and increase likelihood LTBI treatment will be completed**

**Notes:**
EM - First bullet – “Primary purpose of screening in (add) short term correctional . . .”
Fourth bullet – I hyphenated postrelease (now reads: post-release)

ML - Need to prioritize those at risk (HIV+, converters) AND start therapy
      Regimens: 9H. Acceptable to use 4R if incarceration <6 months

## Persons in Holding or Booking Facilities

**All Persons****Provide TB symptom screening ****at the time of entry**

**TB Symptoms**** **
**Immediately isolate**
**and transfer to a facility or hospital ****that has an AII room and **
**evaluate for TB disease**

**Notes:**
EM - Second box – TB Symptoms – add “Immediately mask and isolate . . .”

## Employees in All Correctional and Detention Facilities

**All New Employees ****Evaluate at time of hiring with medical history related to TB ****and a physical examination for TB disease**

**No Documented History of a Positive TST or QFT-G Result**
**Should receive a TST ****or**** QFT-G**
**(For those not tested during the preceding 12 months**
**they should receive two step TST or single step QFT-G)**

**Positive TST or QFT Results**** ****Should have a chest radiograph **
**and a medical evaluation**

**No TB Disease**** ****Consider for LTBI treatment**

**TB Disease**** ****Should NOT return to work ****until no longer infectious**

**Notes:**
EM - No changes

## Other Persons Who Might Need to be Screened

**People who are neither inmates nor employees but who visit high-risk facilities on a regular bases should b e considered for screening (e.g., food handlers, service workers, volunteers, and those providing religious ministries)**
**Screening should follow the same procedures as for employees**

**Notes:**
EM - First bullet – changed bases to basis and deleted the space in the word “be” – should read “People who are neither inmates nor employees but who visit high-risk facilities on a regular basis should be considered . . . “

ML - Visitors screened if they have contact with inmates

## Periodic Screening

**Long term inmates and all employees who have a negative baseline TST or QFT-G result should have follow-up testing at least annually**
**Persons who have a history of a positive test result should be screened for symptoms of TB disease**

**Notes:**
EM - Second bullet – might want to add “at least annually”

## HIV Counseling, Testing, and Referral

**Provide routine HIV counseling, testing, and referral to inmates and correctional facility staff with LTBI or TB disease if their HIV infection status is unknown at the time of their TB diagnosis**

**Notes:**
EM - No change

## Use of Data to Refine Policies and Procedures

**Collect and analyze data on the effectiveness of the facility screening policies and procedures**
**Refine policies and procedures based on the data**

**Notes:**
EM - No change

## Case Reporting

## Requirements for Case Reporting

**All states require reporting of suspected and confirmed cases of TB to their local or state health department**
**Correctional facility medical staff should report any suspected or confirmed TB cases among inmates or employees to the health agency designated by state and local laws and regulations **

**Notes:**
EM - No changes

## Reporting Drug-Susceptibility

**Report drug-susceptibility to**** **
**The state or local health department for use in monitoring rates of drug resistance**
**All health departments managing the infectious person’s contacts to assist with medication for LTBI treatment**

**Notes:**
EM - No changes

## Isolation in an Airborne Infection Isolation (AII) Room

## Initiation of TB Airborne Precautions

**Signs ****or ****symptoms of ****TB disease**

**Documented ****TB disease**_**and**_** ****has NOT completed treatment**_**or**_** ****has NOT been determined previously to be noninfectious**

**Or**

**Initiate for any patient with the following**

**Notes:**
EM - No changes

## Discontinuation of Airborne Precautions for Suspected TB

**Infectious TB is considered unlikely **
**AND**
**Another diagnosis is made that explains the clinical syndrome**

**The patient has 3 negative acid-fast bacilli (AFB) sputum-smear results**
**Should be collected 8 – 24 hours apart**
**At least one should be an early morning specimen**

**Or**

**Notes:**
EM - Second box – add “have received standard multidrug anti-TB treatment, and have demonstrated clinical improvement”
In the correctional setting, it is important to add all the criteria – as many may not read the guidelines in-depth and just go to the slides.  

ML - If sputum AFB negative and patient is not a low suspicion for TB, should be started 
      on 4 drugs before release from AIIR

## Remaining in an AII Room

**All patients with confirmed TB disease should remain in an AII room while incarcerated until they have had ALL of the following**
**Had 3 consecutive negative AFB sputum-smear results collected 8-24 hours apart with at least 1 being an early morning specimen**
**Received standard multidrug anti-TB treatment **
**Demonstrated clinical improvements**

**Notes:**
EM - Add the word “and”  to the first two bullets.  

## Environmental Controls

## Environmental Controls (1)

**Should be implemented when the risk for TB transmission persists despite efforts to screen and treat infected inmates**
**Used to remove or inactivate *****M. tuberculosis *****in areas in which the organism could be transmitted**

**Notes:**
EM - No changes

## Environmental Controls (2)

**Primary environmental controls**** - control the source of infection with local exhaust ventilation**
**Secondary environmental controls**** – control airflow to prevent contamination of air adjacent to the source or clean air using a HEPA filter or ultraviolet germicidal irradiation (UVGI)**

**Note add photos**

**Notes:**
EM - No changes

## Airborne Infection Isolation (AII) Rooms

**Inmates known or suspected of having TB disease should be placed in an AII room or AII cell**
**Inmates deemed infectious should remain in isolation until treatment or further evaluation has ensured they are noninfectious**
**Facilities without an on-site AII room should have a written plan for referring patients with suspected or confirmed TB to a facility that can isolate, evaluate, and treat TB patients**

**Notes:**
EM - Since the first two bullets have been covered previously, you could delete them.  However, the third bullet is important and should remain. 

## Environmental Control Maintenance

**To be most effective, environmental controls should be installed, operated, and maintained correctly**
**TB infection-control plans should include ongoing maintenance and identify **
**Responsibility and authority for maintenance**
**Staff training needs**
**Routine preventive maintenance should be scheduled and cover all components of the ventilation systems and air-cleaning devices**

**Notes:**
EM - No changes

## Respiratory Protection

## Considerations for Selection of Respirators

**Respiratory protection is used when administrative and environmental controls alone have not reduced the risk for infection with *****M. tuberculosis***** to an acceptable level**

**Notes:**
EM - Consider deletion of this slide if some need to be removed. Although this is important information (and if you can keep it – definitely), it may be misguided in facilities who do not routinely identify cases but whom cases are being released to the community undetected.  

## Respirators

**Respirators should be selected from ****those approved by ****CDC/National Institute for ****Occupational Safety and Health (NIOSH) **

**N-95 Respirator**

**Notes:**
EM - No changes

ML - Add N-95

## Implementing a Respiratory Protection Program

**All facilities should develop, implement, and maintain a respiratory-protection program for health-case workers or other staff who use respiratory protection**
**Respiratory protection programs are required for facilities covered by the US Occupational Safety and Health Administration (OSHA)**

**Notes:**
EM - First bullet – third line – “ . . . Protection program for health-care . . .”  Since most facilities are not governed by OSHA, it might be prudent to add to the second bullet “and are recommended for others not governed by OSHA”

## Key Elements of a Respiratory Protection Program

**Assignment of responsibility**
**Training**
**Fit testing**

**Notes:**
EM - No changes

## Precautions for Transporting Patients Between Correctional or Detention Facilities (1)

**Transporting in an ambulance**
**Transport patients with suspected or confirmed infectious TB disease in an ambulance whenever possible**
**Operate the ventilation system in the noncirculating mode with maximum amount of outdoor air provided**
**Use a rear exhaust fan if possible**
**Airflow should be from the cab, over the patient, and out the rear exhaust**

**Notes:**
EM - No changes

ML - Consider deleting

## Precautions for Transporting Patients Between Correctional or Detention Facilities (2)

**Transporting in a vehicle that is NOT an ambulance**
**Ventilation system should bring in as much outdoor air as possible**
**Set ventilation system to noncirculatiing**
**Isolate the cab from the rest of the vehicle if possible**
**Place patient in the rear seat**
**Drivers and other persons should wear at least an N95 disposable respirator**
**If the patient has signs or symptoms of infectious TB they should wear a surgical or procedure mask during transport, in waiting areas, or when others are present**

**Notes:**
EM - Last bullet – second line – “the patient should wear a surgical or procedure mask . . . “

## Diagnosis and Treatment of Latent Tuberculosis Infection and Tuberculosis Disease

## TB Disease Symptoms

**Persistent cough (****≥ 3 weeks)**
**Hemoprysis (coughing up blood) **
**Night sweats**
**Weight loss**
**Anorexia**
**Fever**

**Notes:**
EM - Second bullet – “Hemoptysis”

## Diagnostic Tests for TB Disease and LTBI

**TST**
**QFT-G**
**Chest radiograph**
**Laboratory examination of sputum samples or other body tissues and fluid**

**Notes:**
EM - No changes 

## Criteria for Evaluation of Correctional Facility Staff and Inmates with LTBI for TB Disease by Test Result (1)

| Purpose | TST Result | QFT-G Result |
| --- | --- | --- |
| Baseline | ≥ 10 mm * (either 1st or 2nd step) | Positive single-step test result |
| Serial testing (no known exposure) | Increase of ≥ 10 mm  | Change from negative to positive |
| Known exposure (close contact) | ≥ 5 mm in those with a baseline TST of 0mm
Increase of ≥ 10mm in those with baseline or previous follow-up screening TST result of < 10 mm | Change from negative to positive |

*** ****See footnote on next slide**

**Notes:**
EM - No changes

## *  Except for persons in whom 5 mm is considered positive: 
Persons infected with HIV
Persons who are recent contacts of   patients with TB disease
Persons with fibrotic changes on chest radiograph consistent with previous TB disease
Organ transplant receipients and patients with other immunocompromising conditions (e.g., persons receiving >15 mg/day of prednisone for 1 month)
Persons suspected of having TB disease

**Persons infected with HIV**
**Persons who are recent contacts of   patients with TB disease**
**Persons with fibrotic changes on chest radiograph consistent with previous TB disease**
**Organ transplant receipients and patients with other immunocompromising conditions (e.g., persons receiving >15 mg/day of prednisone for 1 month)**
**Persons suspected of having TB disease**

**Criteria for Evaluation of Correctional Facility Staff and Inmates with LTBI for TB Disease by Test Result (2)****(Footnote)**

**Notes:**
EM - #2 – delete the space after “contacts of”
#4 – Organ transplant “recipients” 

## Special Considerations in Interpreting the TST

**Interpretation might be complicated by **
**Vaccination with BCG**
**Anergy**
**Boosting effect**

**Notes:**
EM - Add another bullet – improper training/technique when administering or reading the TST

## Correctional Staff and Inmates who Refuse Testing forM. tuberculosis Infection

**Educate the person on the importance of routine screening of correctional facility staff and inmates**
**If the person continues to refuse a TST offer QFT-G test (and vice versa)**

**Notes:**
EM - Add another bullet – “Screen for symptoms of active TB disease”

## QuantiFERON®-TB Gold Test Results and Interpretation

| Laboratory Interpretation | Clinical Interpretation |
| --- | --- |
| Positive QFT-G test | Mycobacterium tuberculosis infection likely; medical evaluation indicated |
| Negative QFT-G test | M. Tuberculosis infection unlikely but cannot be excluded, especially when illness is consistent with TB disease and likelihood of progressions to TB disease is increased |
| Indeterminate QFT-G test | Not possible to determine likelihood of M. tuberculosis infection from blood sample supplied |

**Notes:**
EM - No changes

## Interpreting Chest RadiographsPersons with Suspected Pulmonary TB (1)

**Multiple types of abnormalities****strongly suggest pulmonary****TB disease**
**Upper-lobe infiltration**
**Cavitation**
**Pleural effusion**
**Infiltrates can be patchy or nodular and observed in the apical or subapical posterior upper lobes or superior segment of the lower lobes**

**Notes:**
EM - No changes

## Interpreting Chest RadiographsPersons with Suspected Pulmonary TB (2)

**Radiographic presentation of pulmonary TB in HIV infected persons might be atypical**
**Apical cavitary disease is less common than in HIV negative patients**
**More common findings include infiltrates in any lung zone, mediastinal or hilar adenopathy, or in rare cases, a normal chest radiograph**

**Notes:**
EM - No changes

## Interpreting Chest RadiographsPersons with LTBI

**Exclude pulmonary TB disease with a chest radiograph for all persons with LTBI**
**Persons with LTBI typically have normal chest radiographs **
**If chest radiographs do not indicate pulmonary TB and no symptoms consistent with TB disease are present, persons with positive tests for TB infection should be considered for treatment of LTBI**

**Notes:**
EM - No changes

## Evaluation of Sputum Samples

**Sputum examination is a ****key diagnostic procedure ****for pulmonary disease and ****is indicated for the following ****inmates and correctional ****facility staff **
**Persons suspected of having pulmonary TB disease based on chest radiograph or symptoms**
**HIV infected persons with any pulmonary TB symptoms regardless of chest radiograph findings**
**Persons suspected of having pulmonary TB for which bronchoscopy is planned**

**Notes:**
EM – No changes

## Specimen Collection

**Collect at least 3 sputum specimens **
**8 – 24 hours apart**
**At least 1 specimen in the early morning**
**Preferably in a sputum induction booth or an AII room**
**Outdoors in resource limited settings**
**While observed by a health-care professional if possible**
**Instruct patients how to produce an adequate sputum specimen**
**For patients who are unable to produce an adequate sputum specimen induce by inhalation of an aerosol of warm hypertonic saline**

**Notes:**
EM - Sub-bullet #5 – delete “while”

## Laboratory Examination

**Detection of AFB in stained smears can provide the first mycobacteriologic indication of TB disease**
**Definitive identification of *****M. tuberculosis***** can only be made with a culture or nucleic acid amplification (NAA)**

**Notes:**
No changes

## Laboratory Examination

| Feature | Sputum Smear | Culture |
| --- | --- | --- |
| Time  | Usually within 1 day | Usually within 28 days |
| Basis of procedure | Look for AFB on slide under microscope | Growth of tubercle bacilli or other mycobacteria on culture media in incubator |
| Significance of test | Detect mycobacteria | Definitive identification of specific mycobacteria species necessary for drug susceptibility |
| Significance of a negative report | Patient is less likely to be infectious Does NOT exclude TB disease | No live tubercle bacilli found in the specimenDoes not rule out TB disease (live tubercle bacilli maybe be in other specimens and/or In the patient)  |
| Significance of a positive report | Patient is more likely to be infectious (if AFB are tubercule bacilli)AFB could be nontuberculous mycobacteria | Confirms diagnosis of TB disease |
| Report positive results | Within 24 hours of collection | Within 24 hours of notation of a positive culture |

**Notes:**
Under “Culture”, 4th box down – “No live tubercle bacilli found in the specimen.  Does not rule out TB disease (live tubercle bacilli may be (delete second be) in other specimens and/or in the patient)
Do you want to say something about Nucleic Acid Amplification here?  Also, I would add to this – must be an adequate specimen.  

## Drug-susceptibility Tests

**Perform on initial isolates****from all patients**
**Repeat if**
**Sputum specimens continue to be culture-positive 3 months after initiation of treatment**
**Persons whose cultures had converted to negative subsequently revert to positive **

**Notes:**
No changes

## Treatment for LTBI

**Reduces the risk that ****TB infection will progress ****to TB disease**
**Before treatment is started,****rule out TB disease by**
**History**
**Medical examination**
**Chest radiograph**
**Mycobacteriologic studies (when needed)**

**Notes:**
No changes

## Candidates for Treatment of LTBI (Correctional Facility Staff and Inmates) 

**High risk groups with a ****≥ 5 mm TST result, regardless of age:**
**HIV-infected persons**
**Recent contacts of a TB patient**
**Persons with fibrotic changes on chest radiograph consistent with previous TB disease**
**Patients with organ transplants and other immuno-compromising conditions who receive the equivalent of ≥ 15 mg/day of prednisone for ≥ 1 month **
**All others with a ≥ 10 mm TST result**
**Positive QFT-G result**

## Common Drug Regimens for Treatment of LTBI (administered by DOT) (1)

| Drugs | Duration (mos) | Interval | No. of doses | Rating (evidence) † |  |
| --- | --- | --- | --- | --- | --- |
|  |  |  |  | HIV - | HIV + |
| Isoniazid | 9 | Daily | 270 | A (II) | A (II) |
|  |  | Twice wkly | 78 | B (II) | B (II) |
| Isoniazid
 | 6 | Daily | 180 | B (I) | C (I) |
|  |  | Twice wkly | 52 | B (II) | C (I) |
| Rifampin * | 4 | Daily | 120 | B (II) | B (III) |

*** ****See footnotes on next slide**

**Notes:**
ML - Remove ratings from table. Add twice weekly should be by DOT.

## Common Drug Regimens for Treatment of LTBI (administered by DOT) (2)(Footnotes)

******* **** Substitution of rifabutin for rifampin might be indicated in HIV-infected patients taking certain antiretroviral medications because drug-drug interaction might be less frequent when rifabutin is used**
**†****	****Ratings are based on modification of the U.S. Public Health Service rating system (American Thoracic Society, CDC, Targeted tuberculin testing and treatment of latent tuberculosis infection. **

**A = Preferred**
**B = Acceptable alternative**
**C = Offer when A and B ****  cannot be given**

**I =   Randomized clinical data**
**II =  Data from clinical trials that****  are not randomized or were ****  conducted in other populations**
**III = Expert opinion**

**Notes:**
EM - On second bullet – close parentheses at the end of the sentence. 

ML - Delete. Place rifabutin footnote on slide 93 

## Contacts of Patients withDrug-Susceptible TB Disease (1)

**Contacts of patients with drug-susceptible TB disease who once tested negative but subsequently have a positive TST result (i.e., ****≥ 5 mm) should be evaluated for treatment of LTBI**
**Majority of persons who are infected will have a positive TST within 6 weeks of exposure**
**Retest those who have negative TST 8-10 weeks after exposure**

**Notes:**
EM - No changes

## Contacts of Patients withDrug-Susceptible TB Disease (2)

**Consider the following high risk groups for LTBI if they have not been treated previously ****HIV-infected persons (regardless of TST result or previous LTBI treatment history)**
**Persons receiving immunosuppressive therapy (regardless of TST result or previous LTBI treatment history)**
**Persons with a known previous (to current exposure) positive TST **

**Notes:**
EM - Second sub-bullet – “Persons with a known (add) documented previous . . . “

## Contacts of Patients with Drug-Resistant TB Disease

**Treatment for LTBI caused by drug-resistant M. tuberculosis orgnisms is complex and should be conducted in consultation with the local health department TB control program and persons with expertise in the medical management of drug-resistant TB**
**Will require waiting for drug-susceptibility testing results**

**Notes:**
EM - First bullet – second line – “resistant M. tuberculosis “organisms” 

## Treatment for TB Disease

**A decision to initiate ****treatment should be ****made based on **
**Epidemiologic information **
**Clinical, pathological and radiographic findings**
**Results of microscopic examination of AFB-stained sputum smears**
**Results of cultures for mycobacteria**

**Notes:**
EM - No changes

## Initial Drug Regimens for Culture-positive Pulmonary Tuberculosis Caused by Drug-Susceptible Organisms (1)

| Regimen | Drug | Interval | Dose | Minimum Duration |
| --- | --- | --- | --- | --- |
| 1 | IsoniazidRifampin *PyrazinamideEthambutol † | Daily | 56 | 8 weeks |
| 2 | IsoniazidRifampin * PyrazinamideEthambutol † | Daily, then twice weekly § | 14 daily, then 12 twice weekly | 2 weeks daily, then 6 weeks twice weekly |
| Other | See sources sited on the next slide for less commonly used regimens |  |  |  |

*** ****See footnotes on next slide**

**Notes:**
EM - No changes

## Initial Drug Regimens for Culture-positive Pulmonary Tuberculosis Caused by Drug-Susceptible Organisms (2)(Footnotes)

**Source:**** Modified from American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR 2003; 52(No. RR-11):1-80**
*******  Substitution of rifabutin for rifampin might be indicated in HIV-infected patients taking certain antiretroviral medications because drug-drug interaction might be less frequent when rifabutin is used**
**† **** ****May be discontinued if the infecting organism is confirmed to be susceptible to isoniazid and rifampin**
**§****	****Not recommended for HIV-infected patients with CD4+ T-lymphcyte cell counts of <100 cells/mm****3****. Additional information is available at http://www.cdc.gov/nchstp/tb/tb_hiv_drugs/toc.htm**

**Notes:**
EM - Last bullet – second line – “lymphocyte” cell counts of . . . “

ML - Delete and move HIV footnote to slide 93

## Continuation Phase Options for Initial Drug Regimens 1 and 2 (1)

| Regimen | Option | Drugs | Interval | Doses | Minimum Duration * | Rating (evidence) † |  |
| --- | --- | --- | --- | --- | --- | --- | --- |
|  |  |  |  |  |  | HIV -§ | HIV +¶ |
| 1 | a | IsoniazidRifampin ** | Daily | 126 | 18 weeks | A (I) | A (II) |
| 1 | b | IsoniazidRifampin ** | Twice weekly † † | 36 | 18 weeks | A (I) | A (II) |
| 2 | a | IsoniazidRifampin ** | Twice weekly † † | 36 | 18 weeks | A (II) | B (I) |
| Other | Refer to American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR 2003;52 (No. RR-11):1-80 for less commonly used options |  |  |  |  |  |  |

*** ****See footnotes on next 2 slides**

**Notes:**
EM - No changes

ML - remove ratings

## Continuation Phase Options for Initial Drug Regimens 1 and 2 (2)(Footnotes)

*******	****Patients with cavitation on initial chest radiograph and positive cultures at completion of 2 months of therapy should receive a 70month (31 wks; either 217 doses (daily) or 62 doses (twice wkly) continuation phase**
**†****	****Ratings are based on modification of the U.S. Public Health Service rating system (American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR 2003:52 (No. RR-1):1-80).  **

**A = Preferred**
**B = Acceptable alternative**
**C = Offer when A and B ****  cannot be given**

**I =   Randomized clinical data**
**II =  Data from clinical trials that are ****  not randomized or were  ****  conducted in other populations**
**III = Expert opinion**

**Notes:**
EM - First bullet – 3rd line - Add a space between 70 month . . .. 

## Continuation Phase Options for Initial Drug Regimens 1 and 2 (2)(Footnotes cont.)

**§****	**** Human immunodeficiency virus (HIV)-negative**
**¶****	**** HIV-infected**
**** **** Substitution of rifabutin for rifampin might be indicated   **** in HIV-infected patients taking certain antiretroviral **** medications because drug-drug interaction might be **** less frequent when rifabutin is used**
**††****	**** ****Not recommended for HIV-infected patients with CD4+   **** T-lymphocyte cell counts <100 cells/mm****3****. Additional **** information is available at **** www.cdc.gov/nchstp/tb/tb_hiv_drugs/toc.htm.**

**Notes:**
EM - No changes

ML - delete

## Drug-susceptibility Testing

**Should be performed on all initial isolates from patients with TB disease**
**When results are available adjust the treatment regimen accordingly**
**Medical providers treating patients with drug resistant TB disease should seek expert consultation and collaborate with the local health department for treatment decisions**

**Notes:**
EM - No changes

## Adherence to Treatment

**The primary determinant of treatment outcome is patient adherence to the drug regimen.**
**Measures should be designed to enable and foster adherence**
**DOT should be used throughout the entire course of therapy whenever feasible**
**DOT should be coordinated with the local health department on an inmate’s release**
**Local health department also may be involved in monitoring therapy for correctional facility staff**

**Notes:**
EM - No changes

ML - simplify

## Discharge Planning

## Discharge Planning

**Correctional facilities discharge planning process should include**
**Collaborating with public health and other community health care professionals**
**Ensuring continuity of case-management**
**Evaluating discharge-planning procedures and modifying procedures as needed to improve outcomes**

**Notes:**
EM - No changes

ML - State that “All TB patients require d/c planning that involves...”

## Collaboration Between Correction Facilities and Public Health Officials (1)

**Collaboration should address the following**
**Short length of stay in a facility**
**Unscheduled release or transfer**
**Poorly defined or implemented channels of communication between correctional and public health authorities**
**Limited resources (i.e., staff, equipment, and medications) available to provide recommended TB prevention, screening, treatment and discharge planning services**

**Notes:**
EM - No changes

## Collaboration Between Correction Facilities and Public Health Officials (2)

**Collaboration should address the following**
**Limited resources of the patient to make or keep appointments**
**High prevalence of mental illness and substance abuse among correctional patients**
**Mistrust among inmates, which might result in the provision of aliases or incorrect contact or locating information**
**Reincarceration with disruption in treatment or termination of public benefits**

**Notes:**
EM - No changes

## Comprehensive Discharge Planning

**Implement for inmates with confirmed TB disease, suspected TB disease and LTBI who are at high risk for TB disease**
**All inmates who have begun therapy for LTBI in a correctional facility should be given community contact information for follow-up and continuity of care**
**Discharge-planning should begin in the detention phase and continue in the post-detention phase to ensure continuity of care**

**Notes:**
EM - First bullet – add “Progression to” TB disease

## Components of Discharge Planning

**Initiate discharge planning early**
**Provide case management**
**Obtain detailed contact information **
**Assess and plan for substance abuse and mental health treatment and other social services**
**Make arrangements for postrelease follow-up**
**Make provisions for unplanned release and unplanned transfers**
**Provide education and counselin**

**Notes:**
EM - Last bullet – add “g” to counseling

ML - typo, counseling

## DOT for TB Disease or LTBI in the Correctional Setting

**Provides an opportunity for educating and counseling inmates**
**Establishes a routine of medication administration (this might enhance adherence after postrelease)**

**Notes:**
EM - No changes

## Community-Based Case Management after Release (1)

**Case-management strategies begun in the correctional facility should be continued after release for former inmates with**
**Confirmed or suspected TB disease**
**LTBI who are at high risk for progression **

**Notes:**
EM - No changes

## Community-Based Case Management after Release (2)

**Incentives combined with education and counseling optimize both short-and long-term adherence**
**Case management that takes into account cultural differences and addresses not only TB-control matters but patient-defined needs results in improved completion rates for LTBI**

**Notes:**
EM - No changes

ML - Delete if a single slide set is maintained

## Discharge Planning for Immigration and Customs Enforcement Detainees

**Persons with TB disease detained by Immigration and Customs Enforcement (ICE) officers are a potential public health threat because they**
**Typically are highly mobile**
**Likely to leave and reenter the United States before completion of TB therapy**
**Are at high risk for interrupting treatment**
**Ensuring treatment of such detainees is important to the national strategy to eliminate TB in the United States**

**Notes:**
EM - No changes

## Measurements Used to Evaluate Discharge Planning

**Adherence to therapy**
**Cost savings ****(from unduplicated testing for persons with LTBI and completion of care without re-starts and extensions)**
**Recidivism**
**The effectiveness of the collaboration between medical and corrections staff (both within and among facilities) and between correctional facilities and the public health department and other community agencies**

**Notes:**
EM - I would add another couple of bullets – 
Interviews by public health personnel while inmates are still incarcerated
Notification of pending release from the correctional facility to the public health department
Follow-through/completion of medications initiated in the correctional facility

ML - Delete

## Contact Investigation

**Notes:**

ML - The contact investigation section is word intense... 

## Overview of TB Contact Investigation (1)

**Overall goal is to interrupt transmission of *****M. tuberculosis***
**Ongoing transmission is prevented by**
**Identifying, isolating, and treating persons with TB disease**
**Identifying infected contacts of the source patient and secondary patients and providing them with a complete course of treatment for LTBI**

**Notes:**
EM - No changes

ML - 118 – 121: Consolidate to 3 slides

## Overview of TB Contact Investigation (2)

**The contact investigation can serve to **
**Educate corrections staff and inmates about the risk, treatment, and prevention of TB in correctional facilities**
**Inform staff and inmates regarding the importance of engaging in recommended TB-control practices and procedures within the correctional system**
**Emphasize the importance of completion of therapy for persons with TB disease and LTBI**

**Notes:**
EM - No changes

ML - 118 – 121: Consolidate to 3 slides

## Overview of TB Contact Investigation (3)

**Requires a multidisciplinary team**
**Health departments can help in planning implementing and evaluating a TB contact investigation**
**Data collection and management is an essential component and requires a systematic approach to collecting, organizing, and analyzing TB associated data**

**Notes:**
EM - Second bullet – add a comma “,” after planning.  Would read “Health departments can help in planning, implementing and evaluating a TB contact investigation

ML - 118 – 121: Consolidate to 3 slides

## Overview of TB Contact Investigation (4)

**Two correctional information systems are critical to the efficient conduct of a contact investigation**
**An inmate medical record system containing TST results and other relevant information**
**An inmate tracking system**

**Notes:**
EM - I would add a third – 3. An employee TST database

ML - 118 – 121: Consolidate to 3 slides

## TB Transmission Factors

**Characteristics of the source patient**
**Characteristics of persons who have been identified as contacts**
**Immunosuppression**
**Age**
**Exposure Characteristics**
**Air volume**
**Ventilation**
**Duration of exposure**

**Notes:**
EM - No changes

ML - Delete?

## Decision to Initiate a Contact Investigation

**Contact investigations are made on a case-by-case basis**
**Conduct contact investigations in the following circumstances**
**Suspected or confirmed pulmonary, laryngeal, or pleural TB with cavitary disease on chest radiograph or positive AFB smears (sputum or other respiratory specimens)**
**Suspected or confirmed pulmonary (noncavitary) or pleural TB with negative AFB smears (sputum or other respiratory specimens) and a decision has been made to initiate TB treatment**
**Contact investigations are NOT indicated for extrapulmonary TB cases (except for laryngeal and pleural TB) **

**Notes:**
EM - Add to first bullet – “Contact investigations are made on a case-by-case basis and in conjunction with the public health department”

ML - 1st bullet – delete
        2nd bullet, 1st subheading – delete “with cavitary disease”
        2nd bullet, 2nd subheading – In congregate setting, CIs ARE done for AFB negative

## Principles for Conducting the Contact Investigation (1)

**Stratify identified contacts by their duration and intensity of exposure to the source patient**
**Classify HIV-infected contacts as the highest priority group for screening and initiation of LTBI therapy regardless of duration and intensity of exposure**
**Screen immediately identified groups of contacts with the greatest degree of exposure, follow with repeat testing at 8 – 10 weeks if the initial TST or QFT-G is negative**

**Notes:**
EM - In corrections, there are greater numbers of “other” immune-compromised individuals, including chemotherapy patients, etc.  I would include in the second bullet – “Classify HIV-infected and other immune-suppressed contacts . . . “

## Principles for Conducting the Contact Investigation (2)

**Calculate the infection rate to assess the level of TB transmission**
**Make decisions to expand the contact investigation to groups with less exposure on the basis of the calculated infection rate **
**If NO evidence of transmission is observed, do NOT expand the investigation**
**If transmission is occurring, expand the investigation incrementally to groups with less exposure. Do NOT expand further when the group screened shows minimal or no evidence of transmission**
**Include corrections and medical staff in the contact investigation depending on their exposure risks**

**Notes:**
EM - No changes

## Medical Evaluation of Contacts

**Appropriate medical evaluation depends on both the immunologic status of the contact and previous TST or QFT-G results**
**Adequate knowledge of these data is possible only through use of a medical record system that is complete, up-to-date, and reliable with regard to TST or QFT-G status, testing date, and documentation of the reading in millimeters (for TST)**
**Without an adequate medical record system, the true infection and transmission rates cannot be determined**

**Notes:**
EM - No changes

ML - Can be a single bullet on another slide

## All contacts should be interviewed for symptoms of TB disease using a standard symptom questionnaire
Symptomatic contacts should
Receive a chest radiograph and a complete medical evaluation by a physician, regardless of TST or QFT-G status
Be isolated appropriately (i.e., placed in an AII room if infectious TB is suspected by chest radiograph or clinical findings; staff should not be permitted to work
HIV testing should be considered for all contacts whose HIV status is unknow

**Symptomatic contacts should**
**Receive a chest radiograph and a complete medical evaluation by a physician, regardless of TST or QFT-G status**
**Be isolated appropriately (i.e., placed in an AII room if infectious TB is suspected by chest radiograph or clinical findings; staff should not be permitted to work**
**HIV testing should be considered for all contacts whose HIV status is unknow**

**Medical Evaluation of All Contacts**

**Notes:**
EM - Second sub-bullet needs a closed parentheses at the end.  Should re “ . . . Staff should not be permitted to work)”
Third bullet – needs a “n” at the end of the word unknown

ML - Last bullet – change “considered’ to “offered” 

## Inmates who are asymptomatic, HIV-negative, and have previous positive TST or QFT-G results need no further follow-up, other than consideration for “routing” treatment of LTBI, if not completed in the past
Inmates who have signs or symptoms suggestive of TB should receive further evaluation (e.g., a chest radiograph for persons with respiratory symptoms)

**Inmates who have signs or symptoms suggestive of TB should receive further evaluation (e.g., a chest radiograph for persons with respiratory symptoms)**

**Medical Evaluation of Inmates with Documented Previous Positive ****TST or QFT-G Results**

**Notes:**
EM - No changes

ML - 1st bullet – Need CXR

## HIV-infected contacts should
Be interviewed for symptoms
Have a TST or QFT-G and chest radiograph performed
Initiate a complete course of treatment for LTBI (once TB disease has been ruled out) regardless of the TST or QFT-G result
Treatment should be initiated even for persons with a history of previous treatment of LTBI or TB disease because of the possibility of re-infection
Those with a history of a negative TST or QFT-G should have a TST or QFT-G placed at baseline again in 8 – 10 weeks

**Be interviewed for symptoms**
**Have a TST or QFT-G and chest radiograph performed**
**Initiate a complete course of treatment for LTBI (once TB disease has been ruled out) regardless of the TST or QFT-G result**
**Treatment should be initiated even for persons with a history of previous treatment of LTBI or TB disease because of the possibility of re-infection**
**Those with a history of a negative TST or QFT-G should have a TST or QFT-G placed at baseline again in 8 – 10 weeks**

**Medical Evaluation of HIV-Infected****Inmates Who Are Contacts**

**Notes:**
EM - Second sub-bullet – I would bold the “and” 
Third bullet – include “and” again in 8-10 weeks

## Mandatory tuberculin skin or QFT-G testing of all previously TST- or QFT-G negative inmate contacts should be conducted at baseline (unless previously tested within 1 – 3 months of exposure)
Repeat testing 8 – 10 weeks from the most recent contact with the source patient 

**Repeat testing 8 – 10 weeks from the most recent contact with the source patient **

**Medical Evaluation of HIV-Negative Inmates Who Are Contacts and Have Previous TST-Negative or QFT-G-Negative Test Results**

**Notes:**
EM - No change

## Persons whose TSTs or QFT-Gs convert or those with newly documented, positive TST or QFT-G results should be offered treatment for LTBI unless medically contraindicated
If inmate contacts refuse medically indicated treatment for LTBI, they should be monitored regularly for symptoms

**If inmate contacts refuse medically indicated treatment for LTBI, they should be monitored regularly for symptoms**

**Medical Evaluation of Contacts Who Are TST and QFT-G Converters**

**Notes:**
EM - No changes

ML - define “regularly”

## Contact Investigation Stepwise Procedures (1)

**Notify correctional management officials**
**Conduct a source patient chart review**
**Interview the source patient**
**Define the infectious period**
**Convene the contact investigation team**
**Update correctional management official**
**Obtain source case inmate traffic history**
**Tour exposure sites**

**Notes:**
EM - No changes

ML - Implication is the HD performs the CI. In many (most?) situations, the facility does.
        HD can help with identifying high-risk contacts, expansion, prioritize, LTBI therapy

## Contact Investigation Stepwise Procedures (2)

**Prioritize contacts**
**Develop contact lists**
**Conduct a medical record review on each high-priority contact**
**Evaluate HIV-infected contacts for TB disease and LTBI promptly**
**Place and read initial TSTs or perform QFT-Gs on eligible contacts**
**Make referrals for contact evaluation**

**Notes:**
EM - No changes

## Contact Investigation Stepwise Procedures (3)

**Calculate the infection rate and determine the need to expand the investigation**
**Place and read follow-up TSTs or perform follow-up QFT-Gs**
**Determine the infection/transmission rate**
**Write a summary report**

**Notes:**
EM - No changes

## Tuberculosis Training and Education of Correctional Workers and Inmates

## TB Training and Education of Correctional Workers and Inmates

**Correctional facilities and local or state health departments should collaborate when providing TB training and education **
**Routine TB education should be provided for all persons who spend significant time in the facility and additional training should be given to any employee who will interact with persons at risk for TB**
**TB training and education efforts and other TB-related events should be documented to ensure that these programs can be evaluated and updated**

**Notes:**
EM - No changes

## Training and Education in Correctional Facilities

**In-facility, preservice training or orientation should include training and education on *****M. tuberculosis***** to**
**Correctional workers**
**Volunteers**
**Inmates**
**Other persons spending significant time in correctional facilities**
**TB training should be provided at least annually thereafter**

**Notes:**
EM - First bullet – not really certain what “preservice” training is.  In corrections, generally called “in-service” training.  Add a sub-bullet – medical personnel

## Initial Training and Education for All Correctional Workers (1)

**Include the following components for all correctional workers ****(level and detail will vary according to job responsibilities)**
**Basic *****M. tuberculosis***** concepts transmission, signs, symptoms, diagnosis (include the difference between LTBI and TB disease), and prevention**
**Importance of following up on inmates or correctional workers demonstrating signs or symptoms of TB disease**
**Need for initiation of airborne precautions of inmates with suspected or confirmed TB disease**

**Notes:**
EM - No changes

## Initial Training and Education for All Correctional Workers (2)

**Include the following components for all correctional workers ****(level and detail will vary according to job responsibilities)**
**Policies and indications for discontinuing AII precautions**
**Basic principles of treatment for TB disease and LTBI**
**TB disease in immunocompromised persons**

**Notes:**
EM - No changes

ML - 1st bullet – ALL correctional workers do not need education on AII

## Required Training for Correctional Workers in Facilities with AII Rooms

**Include the following components for all correctional workers in facilities equipped with AII rooms**
**Use of administrative and engineering controls and personal protective equipment**
**Respiratory protection program**

**Notes:**
EM - No changes

## Enhanced Training and Education for Correctional Workers in High-Risk Facilities

**The signs and symptoms of TB disease**
**Transmission of TB disease**
**TB infection-control policies (including instruction on and location of the facility’s written infection-control policies and procedures, exposure control plan, and respiratory protection plan)**

**Notes:**
EM - No changes

ML - 1st & 2nd bullets – Not sure how this is “enhanced”? Previous slide said it was for all.

## Enhanced Training and Education for Correctional Workers in High-Risk Facilities

**Include the following components for correctional workers in high risk facilities if a contact investigation is because of suspected or confirmed infectious TB**
**Contact investigation guidelines**
**TB transmission**
**Method used to determine a contact’s risk for infection and prioritization for evaluation and treatment**
**Noninfectiousness of persons with TB disease who have responded to therapy and have submitted 3 AFB negative-sputum-smear results**
**Patient confidentiality issues**

**Notes:**
EM - No changes

142: 2nd bullet – OK in this slide, but redundant with previous slide

## Training and Education of Public Health Department Staff (1)

**Include the following (but not limited to) topics**
**TB related roles of correctional facility and health department staff**
**Methods of effectively collaborating with correctional facilities**
**Differences between and among jails, prisons, and other forms of detention facilities**

**Notes:**
EM - No changes

## Training and Education of Public Health Department Staff (2)

**Include the following (but not limited to) topics**
**Correctional culture and the importance of respecting the mission and purpose (i.e., custody) of correctional facilities and correctional workers**
**The health department’s role in the discharge of inmates**
**The effect of the custody and movement of foreign detainees on local facilities**

**Notes:**
EM - Second bullet – I would add The health department’s role in “case management, contact investigation and” the discharge of inmates

## Training and Education of Inmates

**Include the following components in the appropriate terms of education level and language**
**General TB information (provided at the time of admission or when being screened for TB)**
**The meaning of a positive TST or “QFT-G result and treatment options for LTBI**
**Comprehensive TB education including the infectiousness of and treatment for inmates being confined with suspected or confirmed TB disease**
**The importance of completing treatment for inmates with LTBI or TB disease**

**Notes:**
EM - Second bullet – I would remove the “ before QFT-G

## Program Evaluation

## Six steps for Monitoring and Evaluation of a TB Prevention and Control Program

**Identifying collaborators**
**Describing the TB-control program**
**Focusing the evaluation to assess TB risk and performance**
**Collecting and organizing data**
**Analyzing data and forming conclusions**
**Using the information to improve the TB program**

**Notes:**
EM - No changes

## Identifying Collaborators

**TB control requires collaboration**
**Correctional system**
**Health departments**
**Other community agencies**
**Teamwork**
**Early engagement of collaborators**
**Helps ensure that the evaluation will yield the most useful information to stakeholders**
**Promotes mutual cooperation for constructive change**
**Each program should have a single designated person responsible for data quality and program evaluation **

**Notes:**
EM - No changes

ML - 1st bullet – List possible collaborators and delete “teamwork”

## Describing the Program

**Evaluators should be knowledgeable about**
**Program goals and objectives**
**Strategies**
**Expected program-associated results**
**How the program fits into the larger organization and community**
**All stakeholders should agree on program goals before the evaluation is undertaken**

**Notes:**
EM - No changes

## Focusing the Evaluation to Assess Risk and PerformanceRisk Assessment

**Each facility should annually assess its level of TB risk and include the following indicators  **
**Burden of disease**
**Community rates of TB disease**
**The number of cases of TB disease in the facility during the preceding year**
**The number and percentage of inmates and staff with LTBI**** **
**Facility transmission**
**The number and percentage of staff and inmates whose tests for TB infection converted and the reasons for conversion**
**The number of TB exposure incidents (contact investigation)**
**Evidence of person-to- person transmission**

**Notes:**
EM - No changes

## Performance Measurement for Improving Quality Examples

**Timeliness of screening and isolation**
**Treatment**
**Continuity of care**

**Notes:**
EM - No changes

ML - Change “timeliness” to “timing”

## Assessment of Collaboration(conduct annually)

**Evaluate each program to determine its success in working with local and state public health departments in each area of TB control**** **
**Screening**
**Containment**
**Assessment**
**Correctional systems should meet with their respective public health departments to assess**** **
**Risk**
**Update TB policies and procedures **
**Assess compliance with environmental control and respiratory protection recommendations**** **

**Notes:**
EM - No changes

## Collecting and Organizing Data

**Data Sources**
**Review medical records **
**Annually - for facilities that house persons with confirmed or suspected TB disease (including low-risk facilities)**
**Quarterly – for facilities with numerous cases**** **
**Information Infrastructure**
**Health professionals responsible for TB control should have access to**
**Complete medical records**
**Database of essential TB-related activity and measurements**
**Retrievable aggregate record system is essential **
**For tracking all inmates**
**For assessing the status of persons who have TB disease and LTBI **
**Electronic medical databases can provide additional benefits**

**Notes:**
EM - No changes

## Analyzing Data and Drawing Conclusions

**In a multifacility correctional system, compile data for each facility separately and in aggregate**
**Analyze data against standards which can be defined externally or internally as established by the program collaborators**
**Draw conclusions from the data and recommendations for program improvement developed**
**Share evaluation and recommendations with program staff, administrators, and partners, including the local health departments**

**Notes:**
EM - No changes

## Using Information to Improve the TB Program

**Program staff should use data to identify and remove barriers to improving performance**
**Administrators should make necessary revisions to policies and procedures**
**Existing data can be used to clearly demonstrate the effects of implemented interventions**

**Notes:**
EM - No changes

## Collaboration and Responsibilities

## Liaisons for TB-associated Efforts

**Correctional facilities ****and health departments****should each designate**** liaisons**
**The duty of the correctional****facility liaison should be assigned to the ****person responsible for TB control or another staff member familiar with TB control**
**The liaisons should attend regular meetings between the correctional facilities and health departments**

**Notes:**
EM - No changes

## Roles and Responsibilities that Require Collaboration between Correctional Facilities and Health Departments (1)

**Screening and treatment of inmates for LTBI and TB disease**
**Reporting of TB disease**
**Follow-up of inmates with symptoms or abnormal chest radiographs**
**Medical consultation regarding persons with confirmed and suspected TB disease**

**Notes:**
EM - No changes

## Roles and Responsibilities that Require Collaboration between Correctional Facilities and Health Departments (2)

**Contact investigations for reported TB cases**
**Continuity of treatment and discharge planning for persons with TB disease and LTBI**
**Training and education of correctional facility staff**
**Evaluation of screening and case management**
**Facility risk assessment**

**Notes:**
EM - No changes

ML - 2nd bullet – best as last bullet on slide 158

## Additional Resources

**For additional information on TB, visit the CDC Division of Tuberculosis Elimination website at**
_**[http://www.cdc.gov/tb](http://www.cdc.gov/tb)**__** **_

**Notes:**
EM - No changes