Controlling Tuberculosis in Community Corrections.

MENU TITLE: Controlling TB in Corrections
Series: NIJ Research in Action
Published: May 1995
22 pages
47,650 bytes

Controlling Tuberculosis in Community Corrections

by Karen Wilcock, Theodore M. Hammett, and Dale G.
Parent
NCJ 153211
------------------------------
Highlights

The increasing incidence of tuberculosis infection
and active disease in the United States raises
significant issues because much of the increase has
occurred in populations involved with the criminal
justice system. Persons with TB, moreover, are
often also infected with HIV. In addition, new
strains of drug-resistant TB have appeared in part
because of patients' failure to follow prescribed
courses of medication. Unless inmates with TB
infection and disease are identified and
appropriately treated while incarcerated, TB--
including drug-resistant TB--can later develop
among released inmates, who then may transmit the
infection to their families, community corrections
officials, and the general public.

Challenges and opportunities facing the criminal
justice community concern:

o Screening inmates, parolees, probationers, and
criminal justice staff for TB infection and active
disease.

o Controlling the spread of the disease through:

- Providing training and education to staff in
understanding how the infection is transmitted and
what can be done to contain its spread.

- Establishing protective procedures for staff.

- Ensuring prophylactic therapy for infected
inmates and an appropriate medical regimen for
those with active disease.

- Linking with public health agencies to ensure
followup with releasees.

An examination of six community corrections
jurisdictions indicated that the development and
implementation of effective policies and procedures
for TB control involve close cooperation with State
and local health departments. 

Challenges to establishing effective interagency
cooperation include differences in perceptions of
roles and responsibilities between justice and
public health agencies. However, where effective TB
control programs already exist in community
corrections agencies, health departments have been
key players; they have provided training and other
educational materials, screening and treatment
services, as well as coordination of treatment for
inmates released while receiving TB treatment or
preventive therapy.

------------------------------

The resurgence of tuberculosis (TB) in the United
States, the occurrence of several major outbreaks
of TB in prisons, and the concentration in prisons
and jails of persons at high risk for TB suggest
the need for treatment and control measures at all
phases of the system--from pretrial release to
incarceration to parole. The population that comes
under the supervision of the criminal justice
system is at relatively high risk for TB. This
population tends to be poor and includes
disproportionate numbers of racial and ethnic
minorities, recent immigrants from high-incidence
countries, injection drug users, and individuals
infected with HIV. In general, this population is
characterized by poor access to health care. 

Correctional facilities may be high-risk settings
for TB transmission because of overcrowding,
inadequate ventilation, and high concentrations of
TB infection and disease. Inmates released into the
community pose special problems. They may carry TB
infection or disease with them; and if they
interrupt their course of treatment, their disease
may become drug resistant and thus all the more
dangerous to them, their families, and to the
community at large. Parole and probation officers
may also be at risk of infection through contact
with their clients.

Many prison and jail systems have active screening
programs for identifying inmates with TB infection
and disease and for providing appropriate
treatment. What happens when individuals on TB
therapy return to the community? The probation and
parole agencies that supervise them could work with
public health departments to identify clients with
TB infection and disease and encourage compliance
with prophylactic and treatment regimens. Although
such opportunities for TB control may exist, there
are challenges to translating them into action.

This Research in Action presents an overview of
tuberculosis as a criminal justice and public
health issue and discusses the particular problem
of TB in community corrections. It reports on six
examples of TB control efforts in community
corrections and summarizes some of the problems and
benefits that can be expected. Special attention is
given to inmates released on parole, but the
policies and strategies discussed can be tailored
to other community corrections settings.

Detection and transmission

The resurgence of TB as a public health problem is
the result of the association of TB with the HIV
epidemic, immigration from countries where TB is
common, transmission of TB in congregative settings
(e.g., correctional facilities), and the
de-emphasis and dismantling of a national detection
and control infrastructure. Moreover, the increased
risk of exposure resulting from rising rates of TB
infection and disease is exacerbated by the
presence of HIV infection in the same populations. 

Tuberculous infection in persons with intact immune
systems does not typically progress to active
disease within the first year or two of infection
and may never do so. An initial infection typically
goes unnoticed. The infection generally enters a
latent phase after a few weeks, where it may remain
dormant or may become active at a later time (see
"Tuberculosis Glossary"). Early signs of active
disease include fever, chills, fatigue, weight
loss, and night sweats. 

Susceptibility to TB is thought to increase among
persons with damaged or suppressed immune systems.
It has been shown that where co-infection with HIV
exists, an individual is far more likely to develop
active and infectious TB disease. In a New York
State prison study, for example, HIV-infected
prisoners were not necessarily more likely to
become infected with TB, but they were far more
likely to develop active disease once infected than
were HIV-negative prisoners.1 

Detection. Infection with TB is generally detected
through the standard tuberculin skin test (also
known as a PPD or Mantoux test). In individuals
with compromised immune systems (caused by HIV
infection, another disease like leukemia, or a
history of chemotherapy or treatment with
steroids), a phenomenon called anergy often leads
to false negative skin test results. Anergy testing
can help to distinguish a true negative from a
false negative skin test result. However, the
Centers for Disease Control and Prevention (CDC)
recommend that "all HIV-infected persons--whether
anergic or not--should receive a chest radiograph
and further diagnostic evaluation if indicated."2

Transmission. TB is not usually a highly contagious
disease but, given the right conditions (such as
crowding, poor ventilation and increased close
contact with persons with active disease), the
probability of transmission increases
significantly. Persons with active pulmonary TB can
spread the disease through coughing, sneezing,
laughing, or other means that result in the
propulsion of airborne droplets carrying the
bacteria. Prolonged, close exposure is associated
with increased rates of transmission. It is
possible to contract TB from contaminated articles
or dust, but this is very rare. Persons with
extrapulmonary TB do not normally represent a
public health risk (see "Tuberculosis Glossary").

A constellation of factors often exists in prisons
and jails that makes the transmission of TB more
likely than in other settings. These factors
include crowding, old and inadequate ventilation
systems, and the concentration in close quarters of
people at elevated risk for TB due to substance
abuse and poor access to health care. Individuals
with HIV who become infected with TB are far more
likely to become infectious to others because of
the increased probability that their infection will
progress to active pulmonary disease. Correctional
populations and the communities from which inmates
generally come may also include greater numbers of
immigrants from countries with high rates of TB.

A serious outbreak of multidrug resistant TB
(MDR-TB) in New York State prisons in 1990-91,
which claimed the lives of 36 inmates and one
correctional officer, helped to focus national
attention on this problem. However, this outbreak
was not the first indication that a TB problem
existed in prison. A survey conducted by the
Centers for Disease Control and Prevention (CDC) in
1984-85 found that in the 29 States studied, the
incidence of TB disease among inmates was more than
three times the rate in the total population of
those same States. CDC also noted the occurrence of
at least 11 TB outbreaks in the prisons of 8 States
between 1985 and 1989. In fact, studies dating back
at least to 1950 have shown that the incidence of
TB is higher in prisons than in the total
population.3 

Prison inmates are often moved from facility to
facility. This mobility provides new opportunities
to spread infection. Almost all inmates return to
the communities from which they came and, if they
carry infection with them, they can add to
increasing rates of TB in these communities. 

-------------------------------
SIDEBAR 1

Tuberculosis Glossary 

Extrapulmonary TB: Active TB where the disease is
not localized in the lungs, but in other anatomical
sites such as the kidneys, spine, or intestines. It
is rarely infectious. Transmission is possible in
the rare cases of contact with a discharge (such as
from an open wound) that contains TB bacilli.

Mantoux (also known as the PPD) test: The preferred
skin test for detecting TB infection. A purified
protein derivative (ppd) of killed TB bacteria is
injected between the top layers of the skin.
Between 48 and 72 hours later, a health care worker
determines the presence or absence of TB infection
based on the diameter of the swelling at the
injection site.

Multi-drug Resistant TB (MDR-TB): Primary or
Reactivation TB that is resistant to at least two
TB medications, most commonly isoniazid and
rifampin. MDR-TB occurs primarily in individuals
with active disease who interrupted, inaccurately
followed, or failed to complete the initially
prescribed medical regimen. 

Mycobacterium bacilli: The Latin medical term for
the Tuberculosis bacteria.

Primary TB: The infection progresses directly to
active disease within a few months to a year or 2
after initial infection. This occurs in about 5
percent of newly infected persons, but may be more
common in individuals with HIV infection or other
immunosuppressive conditions.

Pulmonary TB: Active TB where the disease is
localized in the lungs. This form of the disease is
usually infectious since the bacilli move easily
into the air through tiny droplets exhaled when
individuals with pulmonary TB cough or sneeze.

Pulmonary TB should be suspected among offenders
with heavy coughing, chest pain, hoarseness, and
spitting blood, which are indicative of advanced
stages of the disease. Offenders with these
symptoms should receive a chest radiograph and
bacteriologic examination of sputum in order to
confirm the diagnosis of TB regardless of the skin
test result. 

Reactivation TB: TB infection is latent for 1 or 2
years, sometimes longer, but then progresses to
active disease. Overall, infected persons have an
estimated 5 to 10 percent risk of developing active
disease during their lifetime. For persons
co-infected with TB and HIV, the risk increases
dramatically to 10 percent each year.

------------------------------

Treatment

Periods of incarceration afford opportunities to
implement preventive therapy and treatment that can
help inmates with TB and protect people in present
and future close contact with them.

The probability that an infection will progress to
active disease is considerably reduced with
preventive therapy. Individuals who are infected
with TB are often prescribed a course of preventive
therapy, which involves taking an anti-tuberculosis
medication for 6 to 12 months, depending on HIV
status. The drug most frequently used for
preventive therapy is isoniazid, which can be given
daily or twice weekly. CDC recommends that a
medical worker (or a specially trained corrections
officer) should watch the inmate swallow each dose
of medication and should monitor the patient for
adverse reactions; this process constitutes
directly observed preventive therapy.4

Treatment for TB disease may involve a battery of
drugs. The actions of the three major anti-TB drugs
are different, but each acts in combination with
the body's defenses to effect healing. Treatment
regimens are relatively long. 

Individuals with active disease must be isolated
until they are no longer infectious and must
generally take two or more anti-tuberculosis
medications for 6 to 12 months, again depending on
HIV status and drug susceptibility test results.
Again, CDC recommends directly observed therapy in
treatment of active disease.5

By completing the prescribed course of treatment,
persons with active infectious disease can achieve
a noninfectious state where the progress of the
disease is arrested. Incomplete or inconsistent
treatment can result in the development of drug
resistance. This drug-resistant TB (MDR-TB) can
then spread to other noninfected individuals. The
emergence of drug resistance has posed serious
problems for TB control. In some cases of 
MDR-TB, effective drug regimens have not been
identified.

-------------------------------
SIDEBAR 2

Tuberculosis in the United States

Tuberculosis is a mycobacterial disease with a
worldwide distribution. In the United States prior
to 1985, the incidence of TB had been declining
steadily for several decades, with an average
annual decline of about 5.8 percent. Between 1985
and 1992, however, the number of TB cases increased
by 20 percent. 

Who contracted TB in the United States during this
period of resurgence? Research has shown that:

o Two-thirds of the "excess" cases--that is, the
cases in excess of the numbers that would have been
expected had the pre-1985 downward trend continued-
-were among males, and 90 percent of these cases
were among individuals 25 to 44 years of age.7 

o Increases in TB were also found to be heavily
concentrated among racial and ethnic minorities,
with case rates per 100,000 ranging from 4.0 per
100,000 in non-Hispanic whites to 46.6 in Asians
and Pacific Islanders. 

o Immigrants accounted for 60 percent of the total
increase in the number of TB cases in the United
States.

o Five States accounted for 92 percent of the total
U.S. increase: California, Florida, New Jersey, New
York, and Texas. The number of TB cases grew
fastest in States with high cumulative rates of
HIV/AIDS, which is not surprising given the
established relationship between HIV and TB.8 

o There was also a definite trend in the average
annual incidence of TB according to socioeconomic
status. Estimates ranged from 4.2 per 100,000 in
the group with the highest median household income,
to 33 per 100,000 in the group with the lowest.9

------------------------------

Control

Public health measures can help to interrupt the
cycle of disease transmission and safeguard those
who work and live with inmates or former inmates. 

While in prison, inmates may be encouraged to be
more compliant with treatment regimens. Monitoring
mechanisms, such as directly observed therapy and
directly observed preventative therapy, are easier
to implement because of the greater control
maintained over inmates than over citizens in the
outside community. Indeed, CDC found that nearly 30
percent more correctional inmates than drug
treatment clients completed their TB therapy.6 

Infection control measures should be introduced
whenever there is a risk of disease transmission.
Facility infection control measures include the
improvement of ventilation and the use of air
filters and ultra-violet light. Individual control
measures include: 

o Isolating persons with known or suspected active
TB.

o Monitoring TB infection status through the
tuberculosis skin test to permit action to be taken
where there is evidence of new infection. 

o Ensuring that those who are infected or have TB
comply with treatment regimens.

o Limiting close contacts with persons who have
active TB. 

o Asking all people to cover their mouths when
coughing and dispose of soiled tissues in a careful
manner.

These activities can continue into the community
corrections system once the prisoner is released.
Even though the offender is no longer incarcerated,
he or she is still under the jurisdiction of the
criminal justice system, is reporting regularly to
a parole officer, and may be living in housing
arranged by this system.

The correctional system's contacts with community
corrections organizations can be used either to
establish or encourage the releasee's continued
involvement with a public-health-based TB program.
Integrating an awareness of the releasee's TB
status into the community corrections process can
also help staff protect themselves from TB
infection and disease. Universal precautions
represent the best approach to infection control.
Even when TB is not thought to be present, clients
and staff should be discouraged from coughing or
sneezing without covering their mouths. However,
staff should also be notified when releasees they
are working closely with have active TB, so they
can take additional precautions such as undergoing
more frequent TB skin tests. Moreover, efforts to
ensure that releasees have access to treatment and
are compliant with medication regimens will be
beneficial both for them and the community.

Current practices in six jurisdictions

Several jurisdictions have implemented procedures
designed to introduce collaboration between public
health and community corrections agencies, in an
effort to help control the spread of TB. Their
experiences are discussed below.

New York State

The incidence of TB disease is much higher in New
York (and in the other heavily urban States of the
Northeast and Middle Atlantic regions) than in
other parts of the country. Control measures
appropriate and necessary in New York may not be as
necessary outside large urban areas. 

The New York State Division of Parole has developed
a series of TB policies. Approximately 180 persons
with active (and potentially infectious) TB are
released from State correctional facilities into
the New York City community each year.10

TB screening policies. New York has separate
guidelines for inmates who are infected with TB,
those who have active disease but are not
infectious, and those who have active disease and
are infectious. TB screening is required for both
parolees and staff. TB status is determined on
admission to a program (including drug and alcohol
treatment programs), and followup testing is
conducted for clients who have had negative tests.
All staff receive preemployment screening for TB,
but those at the highest risk of exposure are
tested every 6 months. Testing is performed by the
Employee Health Service at the worksite and by
local health care organizations. These policies are
intended to protect the health and welfare of both
staff and parolees.

Because of this staff safety emphasis, the Division
of Parole has considered it natural and necessary
to involve the officers' union in the development
of TB policy and training. A TB training curriculum
was designed by a joint task force of labor and
management. The Division of Parole has also brought
in a regular medical consultant for the first time.
All of these initiatives have resulted in good
cooperative working relations between management
and labor on TB issues. Despite relatively high
annual rates of skin test conversions among parole
staff (5.6 percent per year statewide, but as high
as 23 percent per year in some New York City
sites), staff alarm regarding TB has been
effectively defused.

Discharge planning policies and procedures.
Discharge planning for inmates with TB is a
critical starting point for an effective community
corrections TB policy. Through a collaborative
effort between leaders and line staff of the New
York State Department of Correctional Services
(DOCS), the State Division of Parole, and the
Health Department, some effective discharge
planning and followup procedures for inmates with
infectious TB have been developed. Unfortunately,
because of resource limitations, the same level of
service is not given to persons on TB preventive
therapy. 

The facility parole officer includes information on
TB status and the treatment regimen on the medical
summary for each releasee with TB infection or
active disease. Compliance history and plans for
medical followup are checked. Consent forms for
releasing medical information are obtained from the
inmates. If consent is given, the discharge summary
is sent to the Health Department in the county to
which the individual is being released. However,
even if consent is refused, State law requires
notification of the Health Department of all cases
of active TB. The medical summary is sent to the
field parole officer. Before the prisoner is
released, he or she is given instruction on the
importance of complying with TB treatment or
prophylaxis as well as a referral to a
public-health-based TB program. Releasees also
receive a supply of their medications.

All persons with active TB who are about to be
released are given an appointment with the Health
Department or a private care provider in the
community in which they will live. The referral and
appointment sheet includes the names and telephone
numbers of three individuals (who actually have
knowledge of the case): a DOCS health services
staff member, a Division of Parole staff member,
and a Health Department staff member or private
health care provider.

Each New York City releasee with active TB also
receives an incentive to follow through on
treatment--a $25 voucher good for transit tokens or
food coupons. One-half of the value is redeemable
upon keeping the first treatment appointment and
the other half on completion of 1 week's directly
observed therapy. Outreach workers employed by the
New York City Department of Health assist in
locating patients and inducing them to remain on
their medication. 

Compliance in the community. As a result of these
and other strategies, overall compliance with
medication regimens among persons with active TB
released from New York City correction facilities
has increased from about 10 percent to about 70
percent in a single year.

Inmates determined to be infectious are released to
health care facilities for isolation and treatment
until they are no longer infectious. Such parolees
are permitted to make arrival reports to their
parole officers by telephone rather than in person.
The parole officer then contacts the health care
facility to arrange to be informed when the parolee
is no longer infectious.

Once the individual is released to the community,
his or her field parole officer reviews the medical
summary and discusses treatment status with the
parolee. The officer also provides additional
referrals as needed and ensures that the file
contains a consent to release medical information.
Even where no consent is obtained, the field parole
officer is expected to contact the county or city
health department to provide information that can
facilitate followup with the releasee.

If a parolee is discovered after release to be
infectious or to have been infectious while
incarcerated, the parole division is responsible
for identifying and advising staff who may have had
significant contact with the individual. Specific
recommendations are made for different situations.

The Releasee Assistance Program (RAP) is a
specialized program of the New York Division of
Parole for clients with HIV disease and TB. RAP
serves only New York City, where most of these
patients live, and provides intensive case
management, crisis intervention, medical advocacy,
and other supportive services. RAP parole officers,
who have much smaller than normal caseloads, have
provided critical assistance to many parolees in
the areas of medical care, housing, entitlements,
substance abuse treatment, and reestablishment of
relations with their families. RAP parole officers
do not provide directly observed therapy for
parolees on TB medications. However, the program
works with parolees to adhere to their regimens and
offers incentives for adherence, such as vouchers
for subway tokens and food coupons.

TB education programs. Education about TB is
available for parolees in New York State, as well
as for families of parolees and for parole staff.
The division issues an information kit called "A
Healthy New Start" to all persons being released on
parole. The kit is also sent to the head of the
household to whom the inmate will be released. The
Division of Parole also has a tuberculosis training
program for staff, including information on
symptoms, infection control measures, treatment,
the connection between HIV and TB, the problem of
MDR-TB, contact investigation, case reporting, and
Division of Parole procedures for contact between
staff and releasees.

Cooperation with health department. There has been
active cooperation and information sharing on TB
cases between the State Department of Health and
the Division of Parole. The New York State
Department of Health assisted the Division of
Parole with information and advice on development
of policies, guidelines, and education programs and
materials. 

In the spring of 1994, the Bureau of Tuberculosis
Control of the New York City Department of Health
and the State Division of Parole agreed to conduct
a pilot data matching program, in which the
Division of Parole assisted in the location and
return to treatment of parolees with TB who were
non-compliant with medication regimens. This was
done by matching the list of "unable to locate"
cases provided by the Health Department with the
data base of parolees maintained by the Division of
Parole. Health Department personnel, in turn,
informed the appropriate parole officer of control
measures or precautions that should be used in
further contacts with the parolee. This pilot
program identified only 6 complete matches out of
100 names; 1 of these individuals was subsequently
located. The number of matches achieved in this
pilot test was lower than expected.

Another match of 100 names from the Health
Department's "unable to locate" list and the
parolee data base was attempted during 1994, and no
matches were found. Health Department staff suspect
that this result may have been an outcome of better
followup with State prison parolees so that they
rarely appeared on the "unable to locate" list. In
any case, another match attempt will probably be
made during 1995. 

Although the New York experience has not yielded
many matches, the approach remains a promising
strategy for jurisdictions seeking to improve TB
followup with parolees and others released from
correctional facilities.

This matching program illustrates important
differences in the perceived roles of agencies that
are attempting to forge cooperative relationships
to combat TB. Under the program, the Parole
Division helps locate parolees who are noncompliant
with TB treatment, but the Health Department does
not reciprocate by helping the Parole Division
locate persons who are violating their conditions
of parole. This is because the success of the
Health Department, as a health agency rather than a
justice system agency, depends on building trust
with clients; disclosing information to criminal
justice or immigration authorities would quickly
undermine this trust. 

The most recent example of interagency cooperation
with respect to TB in New York is in the
development of a community-placement pilot program
for housing individuals co-infected with HIV and
TB. The Department of Correctional Services, the
Division of Parole, and the AIDS Institute of the
Health Department are working together to identify
two or three sites for this purpose. The facilities
will be open to the community at large, and thus
other agencies could place patients there as well.
The Division of Parole will be able to place its
clients in these residential facilities but will
not be guaranteed a fixed number of beds in them.

Arkansas 

The TB control program in the Arkansas Department
of Corrections (ADC) is funded through a grant from
the Centers for Disease Control and Prevention. A
central TB Control Program Director oversees both
the Health Department and ADC, and an ADC employee
directs TB control activities for inmates and those
about to be released.

Prisoners being released who are receiving
medication for TB treatment or prophylaxis leave
the facility with a supply of medication, and a
notification letter is sent to the health
department in the county where they will live.
Medication and counseling are provided by the
county health departments free of charge to the
parolees. Parolees in Arkansas who are on TB
medication must, as a condition of their parole,
report to their county health department within 7
days of their release. If a releasee does not show
up for treatment, the health department notifies
the parole officer, as failure to seek treatment
constitutes a parole violation in Arkansas.

The county health departments supervise TB
treatment and medication compliance. Parole
officers become involved if parolees fail to show
up for treatment but are not otherwise charged with
responsibilities for testing, referral, and the
monitoring of compliance in Arkansas. The county
health departments monitor treatment compliance for
parolees more closely than for other patients, but
directly observed therapy is not the norm.

Arkansas community corrections staff are tested for
TB infection when they are hired. In late 1994,
State officials implemented a mandatory TB
screening program for corrections staff, paid for
by ADC and performed by the county health
departments.

Georgia 

An interagency task force involving representatives
from the State criminal justice system and the
State health department is drafting a policy for
infectious disease control in community corrections
that will cover HIV, TB, and Hepatitis B.
Agencywide staff testing for tuberculosis infection
was undertaken in the State's parole agency in
1992. This was intended to serve as a baseline.
Staff screening was carried out again in the fall
of 1994, and the agency is working toward a policy
of annual testing. Testing is done through the
correctional system's health services facilities,
except when a parole officer is too far from such a
facility. In these cases, testing is done at a
nearby county health department. As yet, however,
there is no screening of parolees in Georgia.

South Carolina 

The Department of Probation and Parole is not
routinely notified of the TB status of parolees.
Rather, the Department of Corrections notifies the
appropriate county health department when parolees
with TB are released to that jurisdiction.

Parolees in residential placements (for example,
restitution centers, half-way houses) receive
mandatory annual screening for TB infection.
Parolees living at home are not required to undergo
annual testing, however. Parole officers are
required to send parolees with suspected active TB
for followup. Failure to comply with treatment for
active TB may be a parole violation in South
Carolina if the offender has been notified of his
or her obligations in this regard. During the last
year there has been increased interagency
networking in South Carolina intended to enhance TB
control in community corrections. There have also
been increases in inservice staff training and
distribution of informational materials on TB to
community corrections staff.

Minnesota 

In Minnesota, a State statute provides for TB
screening of inmates and employees of facilities
operated, licensed, or inspected by the Department
of Corrections. However, it does not cover parole
officers, who are not viewed as being at risk in
Minnesota. Neither officers nor parolees receive
annual screening for TB.

Under no circumstances are inmates with infectious
TB released to live in the community in Minnesota.
Instead, they are placed in isolation in hospitals.
Inmates who need TB preventive therapy are referred
to a county health department. It is not a
responsibility of the parole officer in Minnesota
to determine whether or not a parolee is compliant
with treatment regimens.

Texas 

Texas law requires TB screening of inmates, staff,
and volunteers in county jails, prisons, and other
community corrections settings. Parolees living in
the community are not required to be screened for
TB, however. Employees and volunteers must be
tested for TB infection, and if they test positive,
must show proof from their own physicians that they
do not have active TB. The employee must pay the
expense of the screening test and any followup or
treatment. Inmates must be tested if they are to be
confined in any facility for more than 14 days. The
Texas Department of Health supplies the materials
for testing and treatment, and the Texas Department
of Criminal Justice provides funds for
administering the screening, further testing, and
treatment for offenders suspected of having active
TB disease. Counties share in this funding for
certain classes of inmates. TB cases must be
reported to the appropriate health authority within
3 days.

The Texas Department of Criminal Justice and the
Department of Health worked closely together to
draft the law relating to TB screening and
treatment for staff and inmates of county jails and
other correctional facilities. The implementation
of the law also necessitated close cooperation.

A TB training program is offered periodically by
health departments at the judicial district level
in Texas. So far, this training has been provided
to management staff of institutional and community
corrections agencies but not to inmates or
parolees.

------------------------------
SIDEBAR 3

How Health Departments and Community Corrections
Agencies Can Work Together

Despite the complexities involved in working out TB
control programs, the benefits for the community,
for community corrections staff, and for clients
are clear. Departments of public health, charged
with protecting the public from the spread of
disease, and faced with addressing this mission in
a population that may be particularly at risk for
developing TB, often have no systematic knowledge
about populations involved with the criminal
justice system or awareness of how to use the
information that does exist to ensure uninterrupted
compliance with TB therapy. Progress toward
achieving high rates of treatment completion can be
greatly enhanced through collaboration with
community corrections agencies. Community
corrections staff, charged with overseeing the
reintegration of offenders into the community, can
better protect themselves, their clients, and their
communities by knowing about TB, participating in
an active screening program, being aware of the TB
status of their clients, knowing whether their
clients are compliant with treatment, and
encouraging their compliance.

Health departments can provide:

o Assistance in developing and evaluating polices
and procedures (including systems for maintaining
records) for TB control.

o Training of correctional facilities staff
responsible for implementing TB control program.

o Information about TB to educate staff and the
offender population.

o Coordination of services for screening,
treatment, and prophylaxis for clients and staff of
community corrections agencies. 

o Investigation of contacts that TB patient has had
within the correctional system and in the
community.

Community corrections, in turn, can help health
departments by: 

o Referring clients with TB symptoms to TB
programs.

o Helping to ensure TB treatment compliance.

o Helping locate noncompliant clients by offering
to cross-match lists of parolees with health
department lists of noncompliant individuals (as in
New York City's pilot program). 

As health departments and correctional systems
establish linkages and begin to work together,
other areas of potential collaboration may evolve,
such as in HIV or other infectious diseases.

------------------------------

Implications

Role definitions. Disease control is outside the
normal scope of perceived responsibility and
operation for most community corrections agencies.
Like other criminal justice agencies, probation and
parole departments see their primary purpose as law
enforcement. The addition of a such a role in
coordinating and monitoring TB treatment and
compliance with medication regimens may also be
seen to increase the workload of already
overburdened and understaffed community corrections
agencies. 

However, it is in the best interests of staff who
must work closely with offenders to be aware of TB
cases and to be able to work toward protecting
their own health as well as the health of their
clients and of the public. The most important
reason for establishing a new TB control role for
community corrections staff may be to ensure their
own and their families' health.

Lack of knowledge. Clarification of roles is not
the only challenge. Lack of information and
knowledge is another significant barrier to the
effective involvement of community corrections
staff in TB control. Parole and probation officers
may know very little about TB or its means of
transmission. They may not have information about
resources to which they can refer their clients for
care and treatment. Indeed, they may not be aware
of available anti-TB medications. Further,
community corrections staff may not be aware of the
importance of treatment compliance, or of any of
the other dimensions of TB control on which they
may be able to have some impact in their day-to-day
work with their clients. Education and training
programs are needed to address these gaps in
knowledge.

Particular problems of probation. There can be
little discharge planning with regard to
probationers except for those who spend pretrial
time in jail. Universal TB screening of
probationers and followup diagnostic workups on
suspect cases of TB disease would provide
information as to the medical needs of clients, but
such a policy would be costly to implement. Given
these obstacles, probation agencies are likely to
receive little if any information on the medical
needs of their clients.

Interagency cooperation. Interagency communication
and information sharing are extremely important in
effective discharge planning and community
followup. However, medical records and information
on TB status often do not accompany prisoners as
they leave their institutions. Probationers and
parolees living on their own in the community may
see no reason to divulge information concerning
their TB status. Health-related information is
generally considered confidential, and working out
a system involving medical release forms and
practices that protect the privacy of clients may
pose an additional difficulty for community
corrections agencies. As correctional programs and
health departments begin to work together, the
whole area of confidentiality must be carefully
considered.

Close inter- and intra-agency collaboration is
needed for the integration of TB control into the
accepted mission of community corrections. This
takes time, effort, and commitment from all
participants. The fact that public health and
criminal justice agencies may have very different
perceptions of their roles and responsibilities may
pose difficulties as potential collaborations are
explored. In the States where TB control programs
in community corrections already exist, the health
department has usually played a key role in
offering training and developing materials for use
in inservice education, as well as providing
screening and treatment services for clients and
staff.

The role of community corrections staff in TB
control must be defined. This can be difficult, as
a number of possibilities exist, each of which may
have its own supporters within an agency. Community
corrections staff may assist health departments by
trying to locate clients who are non-compliant with
treatment. They may also be given a significant
role in enforcing treatment compliance if
noncompliance is specified as a parole violation.
Providing referrals for care may constitute another
level of involvement for community corrections
staff. Offering incentives for seeking and
complying with treatment may also be considered for
inclusion in a TB control effort. Such incentives
may include additional services provided in a
caring manner, as well as vouchers for
transportation or food. Approaches combining
incentives and threatened sanctions may work best.
It is a delicate balance, a key to which is winning
the confidence of clients that both the incentives
and the sanctions will be forthcoming as
appropriate.

Community corrections agencies have services to
offer health departments in an attempt to achieve
better TB control (see "How Health Departments and
Community Corrections Can Work Together"). To the
extent that they use these services, they can
reduce the probability of infection among their own
staff and reduce the spread of disease in the
surrounding community. In the case of repeat
offenders, they can also minimize the
reintroduction of TB into correctional populations.

The potential impact that these agencies can have
is of course shaped by the dimensions of the TB
problem in their own jurisdictions. Even where the
prevalence of TB is low, however, an isolated case
of TB in prison can lead to an outbreak; and if
controls like screening are in place, at least some
level of protection is available. Where the
prevalence of TB is high, such as in New York City
and other major metropolitan centers, and known
cases of active TB reenter the community each year,
the involvement of community corrections programs
is even more critical in controlling the spread of
the disease.

Notes

1 Valway, S.E., S.B. Richards, J. Kovacovich, R.B.
Greifinger, J.T. Crawford, and S.W. Dooley, 1994.
"Outbreak of Multi-Drug-Resistant Tuberculosis in a
New York State Prison," 1991. American Journal of
Epidemiology 140:113-122.

2 Centers for Disease Control and Prevention, 1995,
in press. "Prevention and Control of Tuberculosis
in Correctional Facilities: Re-commendations of the
Advisory Council for the Elimination of
Tuberculosis." Morbidity and Mortality Weekly
Report.

3 Hammett, T.M., L. Harrold, 1994. Tuberculosis in
Correctional Facilities. Washington, D.C.: U.S.
Government Printing Office.

4 Centers for Disease Control and Prevention, 1994.
Core Curriculum on Tuberculosis: What the Clinician
Should Know. Washington, D.C.: U.S. Government
Printing Office, page 42.

5 Ibid.

6 Centers for Disease Control and Prevention, 1993.
"Tuberculosis Prevention in Drug-Treatment Centers
and Correctional Facilities--Selected U.S. Sites
1990-1991." Morbidity and Mortality Weekly Report
42:210-213.

7 Cantwell, M.G., D.E. Snider, G.M. Cauthen, I.M.
Onorato, 1994. "Epidemiology of Tuberculosis in the
United States, 1985 Through 1992." Journal of the
American Medical Association 272:535-539.

8 Ibid.

9 Ibid.

10 Cairns, G., (New York City Department of
Health), 1994. Presentation at meeting of National
Institute of Justice working group on Tuberculosis
Control in Community Corrections, Bethesda,
Maryland, May 19, 1994.

Karen Wilcock is an analyst, Theodore M. Hammett is
a vice president, and Dale G. Parent is an
associate with Abt Associates Inc.

Prepared under contract number OJP-89-C-009 from
the National Institute of Justice, Office of
Justice Programs, U.S. Department of Justice.
Points of view in this document are those of the
authors and do not necessarily reflect the official
position of the U.S. Department of Justice.

The National Institute of Justice is a component of
the Office of Justice Programs, which also includes
the Bureau of Justice Assistance, Bureau of Justice
Statistics, Office of Juvenile Justice and
Delinquency Prevention, and the Office for Victims
of Crime.

NCJ 153 211

------------------------------
SIDEBAR 4

Selected Recent NIJ Publications in Corrections and
Health

Listed below are some recent NIJ publications
related to issues of corrections and health.  These
publications can be obtained free, except where
indicated, from the National Criminal Justice
Reference Service (NCJRS): telephone 800-851-3420,
or email askncjrs@ncjrs.aspensys.com, or write
NCJRS, Box 6000, Rockville, MD 20849-6000. 

Please note that when free publications are out of
stock, they are available in xerox copies for a
minimal fee or through interlibrary loan. They are
also usually  available on the NCJRS Bulletin Board
System or on the Department of Justice Internet
gopher site for downloading. Call NCJRS for more
information. 

McDonald, Douglas, Managing Prison Health Care and
Cost, NIJ Issues and Practices, March 1994, NCJ
152768.

National Institute of Justice, National Institute
of Justice Journal, #228, December 1994, JR000228.
(This issue features articles on health and
justice.)

Hammett, Theodore M., 1992 Update: HIV/AIDS in
Correctional Facilities, NIJ/Centers for Disease
Control and Prevention, NIJ Issues and Practices,
January 1994, NCJ 143398.

Hammett, Theodore M., Tuberculosis in Correctional
Facilities, NIJ/Centers for Disease Control and
Prevention, NIJ Issues and Practices, January 1994,
NCJ 143399.

McDonald, Douglas C., and Michelle Teitelbaum,
Managing Mentally Ill Offenders in the Community:
Milwaukee's Community Support Program, NIJ Program
Focus, March 1994, NCJ 145330.

Rubin, Paula N., The Americans With Disabilities
Act and Criminal Justice: Providing Inmate
Services, NIJ ADA Bulletin, Research in Action,
July 1994, NCJ 148139.

Kellerman, Arthur L., M.D., M.P.H., Understanding
and Preventing Violence: A Public Health 
Perspective, Research in Progress Seminar, VHS
Videotape, NCJ 152238, $19.00, includes postage and
handling. (This videotape is one of a series of six
currently available tapes featuring well-known
scholars describing current criminal justice
research studies; call NCJRS for more information.)