R e s e a r c h i n B r i e f

U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

DEPARTMENT OF JUSTICE

OFF ICE OF JUSTICE PROGRAMS

BJA NI J OJJDP BJS OVC

National Institute of Justice

Jeremy Travis, Director July 1996

continued . . .

Issues and Findings

Discussed in this Brief: Results of

a 1994 survey cosponsored by NIJ

and CDC to determine the existing

dimensions of the TB problem in

correctional facilities housing

adults and the prevention and

control strategies being used to

address it. The survey followed up

on a similar survey in 1992-93 and

sought information on infection

and disease occurrence (including

skin test conversions, coinfection

with HIV, and drug-resistant and

multidrug-resistant (MDR) TB);

tuberculosis screening; isolation,

treatment, and preventive therapy;

and discharge policies. The study

also examined legal issues.

Key issues: Prison and jail officials

confront the need to curb the

spread of tuberculosis infection

and disease in correctional facilities

that house high-risk inmates frequently under crowded, poorly

ventilated conditions. In addition,

they face the problem of preventing recently released inmates with

infectious TB disease from infecting

members of the communities to

which they return. Detecting all

cases of TB infection or disease

within a facility is difficult because

of such problems as:

● Coinfection with HIV resulting in

false negative TB skin tests.

● High turnover and short lengths

of stay in jails, making it impossible

to administer and read TB skin

tests for all inmates.

by Karen Wilcock, Theodore M. Hammett, Rebecca Widom, and Joel Epstein

Many prisons and jails present optimal

conditions for the spread of tuberculosis

(TB), a disease that was resurgent in the

United States in the 1980’s and early

1990’s.1

 Correctional facilities house men

and women who often come from those

segments of the community with high

rates and risk of TB because of such factors as poverty, poor living conditions,

substance abuse, and HIV/AIDS. Overcrowding in a correctional facility increases the potential for close and

repeated contact with an active case of

Tuberculosis in Correctional

Facilities 1994–95

TB. The significant health problem posed

by TB is further exacerbated by two factors.

First, because of immunosuppression, persons coinfected with TB and HIV may not

be reactive on a tuberculin skin test and

thus elude detection; persons with unidentified or incompletely treated TB can remain

infectious for a long time, further spreading

infection and the disease. Second, recent

prison outbreaks of multidrug-resistant tuberculosis (MDR-TB) raise the threat of an

often untreatable disease spreading in a

closely confined population.

CDC Recommendations

ontrolling TB in Correctional Facilities

(1995), a new CDC publication, is based on

the latest recommendations of the Advisory

Council for the Elimination of Tuberculosis

(ACET) for the prevention and control of TB

in correctional facilities. Designed for use by

correctional medical staff, correctional facility

administrators, health department staffs,

and anyone responsible for providing training and guidance in implementing TB control policies, the ACET recommendations

cover needs of both short- and long-term

correctional facilities. This resource is intended to encourage collaboration between

health departments and their jurisdictions’

correctional facilities. Specific assistance is

provided through case studies, screening algorithms, treatment tables, and sample

forms for information management.

Copies may be ordered by calling 404–639–

1819, faxing 404–639–8628, or writing:

Information & Technology Services

National Center for HIV, STD, and

TB Prevention

Mailstop E–06

Centers for Disease Control and Prevention

1600 Clifton Road, N.E.

Atlanta, GA 30333

Please provide name, organization, address

with a ZIP code, and a daytime phone.

C
2

R e s e a r c h i n B r i e f

Table 1: TB Infection in Inmates 1994

State/Federal Systems

Percentage of Inmates Number of Number of Percent of

with positive PPD Systems (%) PPD Positive PPD Positivea

Less than 5.0% 12 (24%) 2,006 2.2

5.0–10.9% 10 (20%) 8,532 6.7

11.0–20.0% 5 (10%) 16,232 14.0

More than 20% 4 (8%) 42,148 25.7

Did not report 20 (39%) N/A –

Total 51 (101%)b 68,918 13.8

City/County Systems

Less than 5.0% 6 (21%) 232 2.2

5.0–10.9% 0 – –

11.0–20.0% 3 (10%) 14,238 15.8

More than 20% 0 – –

Did not report 20 (69%) N/A –

Total 29 (100%)b 14,470 6.9

a

 The percent positive was calculated by dividing the reported number of positive skin tests in

each category by the reported number of inmates who were given a skin test at intake in each

category, and then multiplying the result by 100. b Due to rounding, numbers do not add up to 100 percent.

R e s e a r c h i n B r i e f

Issues and Findings

continued . . .

Key findings: The survey revealed

the following with regard to TB

infection:

● In 31 State prison systems, 14

percent of inmates had positive

tuberculin skin test results at intake.

● In 51 Federal/State systems surveyed, 25 reported a total of 5,609 TB

skin test conversions in the 2 years

prior to the survey.

● Coinfection with TB and HIV increased among male inmates in some

systems since the 1992–93 NIJ/CDC

survey, but data on female inmates

generally were not provided.

Findings on TB disease included the

following:

● The number of inmates with TB

disease under treatment declined

since 1992-93.

● The use of CDC-recommended

negative-pressure rooms to isolate infectious inmates from the rest of the

prison population increased.

● Directly observed therapy (DOT) for

TB disease became more widespread

in correctional systems; directly observed preventive therapy (DOPT) also

increased.

● As part of discharge planning, most

correctional systems referred to local

health department TB programs those

inmates who had not completed

treatment prior to release or parole.

● However, validation survey results

revealed that some facilities were not

following their systems’ TB treatment

and control policies.

Target audience: Corrections officials, public health officials, State and

local policymakers.

To determine the scope of the TB problem

in prisons and jails, the National Institute

of Justice (NIJ) and the Centers for Disease Control and Prevention (CDC) have

cosponsored national surveys of tuberculosis and tuberculosis control in correctional

facilities in conjunction with surveys of

HIV/AIDS.2

 This Research in Brief presents results from the eighth survey of

State/Federal prison systems and city/

county jail systems, conducted in 1994.

A more complete discussion of basic clinical information and the history of TB in correctional facilities can be found in the

previous report,3

 as well as in CDC’s published guidelines (see “CDC Recommendations”). Some comparisons between the

results of the 1994 survey with those of the

1992–93 survey are possible, although the

1994 survey was not an exact replication of

the previous effort.

Survey method

As in earlier NIJ/CDC surveys, questionnaires were sent to 88 correctional systems, including the Federal Bureau of

Prisons, all 50 State correctional systems, and 37 large city and county jail

systems. The State/Federal response rate

was 100 percent; 78 percent of the large

city and county jail systems provided information, although the data provided

were sometimes incomplete. Questionnaires were answered primarily by correctional health services personnel, but

in some cases, certain sections were answered by other correctional administrators. Respondents relied on sources such

as internal management information system data and written policies and procedures to complete the survey forms. To

ensure a high response rate, telephone

followup was carried out over a 6-month

period; respondents were also telephoned if key responses on a returned

questionnaire were left blank or required

clarification.

In addition to the basic survey, a validation survey (an abbreviated version of

the main questionnaire covering only

key policy issues) was sent to 50 larger
R e s e a r c h i n B r i e f

3

Table 2: Skin Test Conversions Among Inmates

State/Federal Systems City/County Systems

Skin Test Number Total Number Total

Conversions of Systems Number of of Systems Number of

in Past 2 Years (%) Conversions (%) Conversions

0 6 (12%) 0 4 (14%) 0

1–10 6 (12%) 21 1 (3%) 1

11–100 6 (12%) 221 1 (3%) 17

More than 100 7 (14%) 5,367 0 –

Did not report 26 (51%) N/A 23 (79%) N/A

Total 51 (101%)a 5,609 29 (99%)a 18

a

 Due to rounding, numbers do not add up to 100 percent.

facilities in 14 State systems and the

Federal Bureau of Prisons. An effort

was made to achieve representativeness on some broad dimensions (e.g.,

men’s and women’s facilities, maximumand medium-security facilities).

TB infection among inmates

Survey results indicate that TB infection continues to be a frequently observed phenomenon among inmates in

correctional facilities, but only a small

percentage of infected persons ever

develop active disease. The prevalence of infection serves as an indicator of how much disease activity is in a

population and also identifies potential

candidates for preventive therapy.

Correctional systems were asked to report the number of inmates who tested

positive at intake during the 2 years

preceding the survey (see table 1).

Standard purified protein derivative

(PPD) skin tests administered at intake produced positive reactions in

more than 68,000 State/Federal and

over 14,000 city/county inmates, according to survey responses. Twelve

State/Federal prison systems reported

that from 0 to 5 percent of prisoners

were TB-positive at intake, and four

State/Federal systems reported that

more than 20 percent of incoming prisoners had positive tests. Rates of positive skin tests at intake ranged from 0

to 27 percent (with a mean of 8.9 percent) among males tested in State/Federal systems; for females, positive

rates at intake ranged from 0 to 25

percent (with a mean of 6.7 percent).

The few city/county jail systems reporting on PPD results indicated that

the percentage of inmates positive at

intake ranged from 0 to 16 percent

(with a mean of 6.1 percent) among

men and from 0 to 17 percent (with a

mean of 4.3 percent) among women.

The fact that 39 percent of State/Federal systems and 69 percent of city/

county systems reported no data on

PPD positivity is important from a

policy standpoint because an effective

TB control strategy depends fundamentally on the presence of a sound

data base.

Skin test conversions. A single positive PPD test result indicates past TB

exposure and an infection of unknown

duration. Sometimes a change in skin

test reaction, or conversion from negative to positive, occurs between

screening intervals. Conversions, either among inmates or staff, indicate

the likely transmission of infection

from one or more active cases within

the same facility. Long-term inmates

and all staff with negative skin test reactions should be retested annually.

For short-term inmates, such as those

in city/county jails, it is less likely that

two TB skin-tests can be performed

during incarceration.

Conversions among inmates. Correctional systems were asked how many

inmates had skin test conversions in

the 2 years prior to the survey (see

table 2); however, since data were not

sought on the number of inmates with

initial negative test results who were

tested for TB infection twice in the

past 2 years, conversion rates could

not be calculated.

Six State/Federal prison systems reported no skin test conversions among

inmates during the 2 years preceding

the 1994 survey, while 19 systems reported having documented evidence of

skin test conversions in which both

negative and positive test results were

obtained during the inmate’s confinement in that system. Seven State/Federal systems reported having over 100

such conversions. Two city/county jail

systems had documented conversions

among inmates. However, 51 percent

of State/Federal systems and 79 percent of city/county systems provided

no information on inmate skin-test

conversions.

Twenty-five State/Federal prison systems reported a total of 5,609 PPD

conversions for the 2 years prior to the

1994 survey. Only six city/county jail

systems provided conversion information in 1994; of the 18 documented

conversions they reported, 17 occurred

within a single system. This large

number of conversions in a single jail

system may have been discovered

through a contact investigation, although systems were not asked to

elaborate on the circumstances of PPD

testing.
4

R e s e a r c h i n B r i e f

Table 3: Skin Test Conversions Among Staff

State/Federal Systems City/County Systems

Skin Test Number Total Number Total

Conversions of Systems Number of of Systems Number of

in Past 2 Years (%) Conversions (%) Conversions

0 10 (20%) 0 4 (14%) 0

1–10 6 (12%) 21 8 (28%) 36

11–100 3 (6%) 85 1 (3%) 26

No response 32 (63%) N/A 16 (55%) N/A

Total 51 (101%)a 598 29 (100%) 62

a

 Due to rounding, numbers do not add up to 100 percent.

Conversions among staff. Twenty State/

Federal prison systems reported a total

of 598 conversions, and 13 city/county

jail systems reported 62 conversions.

Fourteen systems reported having no

staff with PPD conversions (see table 3).

Many systems failed to report the number of documented skin test conversions

among staff during the 2 years preceding

the survey. This is because the usual

practice is for staff to be tested outside

of the prison or jail system, and the

prison or jail system does not always receive records of their tests and results. It

is important for the designated TB control person in each correctional system

to collect this information, in order to

monitor and evaluate TB screening and

containment.

Coinfection with HIV

Systems were asked to report the number of PPD-positive inmates for the 2

years preceding the survey who were

also HIV-positive. This question was

posed as the last in a hierarchical series in 1994:

• How many inmates had been skintested at intake during the previous 2

years?

• How many of those tested were

PPD-positive?

• How many of the PPD-positive inmates were also HIV-positive?

Among prisoners in State/Federal systems with both TB and HIV test results, approximately 11 percent were

TB-positive. Of these PPD-positive

prisoners, 9 percent were coinfected.

In city/county jail systems, 0.3 percent

of PPD-positive prisoners were also

HIV-positive.

Many systems were unable to provide

data on TB and HIV coinfection, particularly for women inmates. Reports

were available for male inmates from

19 State/Federal prison systems and

from 14 such systems for women.

Three city/county jail systems provided this information for men, and

two provided it for women. Seven

State/Federal systems reported no instances of coinfection among male

PPD-positive inmates. In five State/

Federal systems, fewer than 1 percent

of PPD-positive men were also HIVpositive; in five other systems, from 1

to 10 percent of male inmates were

coinfected, and over 10 percent of

PPD-positive men were also positive

for HIV in two systems. Eight State/

Federal systems reported no cases of

coinfection among females with positive PPD tests; two systems reported

that between 1 and 10 percent of PPDpositive women were also positive for

HIV, and four systems reported that

more than 10 percent of women were

both PPD- and HIV-positive.

The 1992–93 survey had also asked

systems to report on coinfection, but

not in a hierarchical framework—as

used in 1994; in addition, systems

were not asked in 1992–1993 to provide information on intake. As a result,

the 1992–1993 and 1994 surveys are

not directly comparable in this respect. Sixteen State/Federal systems

responded to this question in both surveys; three reported a decrease in

coinfections, seven reported the same

number for both surveys, and six reported an increase. A total of 87

coinfections in State/Federal systems

were reported in 1992–93; in 1994,

the number of coinfected at intake was

1,581. New York reported the largest

number of coinfected inmates in both

surveys, with 34 in 1992–93 and

1,512 in 1994.

One city/county jail system reported

0.2 percent coinfection for men; the

other two responding jail systems reported that 8 and 42 percent, respectively, of male TB-positives were also

HIV-positive. For females, both reporting city/county jail systems indicated that no cases of coinfection had

been found.

TB disease among inmates

The survey asked correctional systems

whether any prisoners currently in the

system were under treatment for TB

disease (excluding Mycobacterium

avium, a tuberculous infection causing

neurologic complications that is often

associated with AIDS). The majority of

systems reported having between 0

and 10 cases of TB under treatment, as

shown in table 4. Total populations for
R e s e a r c h i n B r i e f

5

the correctional systems in each category are presented to establish a context for these figures. The total

numbers for the various systems were

reported as of May 1, 1994 (they can,

therefore, be used as a midyear total

population estimate), while information on the number of prisoners under

treatment was often drawn from

records having various dates. For the

51 State/Federal systems, reporting

dates ranged from December 1993

(one system) to mid-December 1994.

Dates for city/county systems ranged

from the end of January 1994 to late

September 1994. Some data are missing, particularly for women. For example, a system may have reported

cases of TB disease for men and not

for women, meaning either that there

were no cases for women or that the

count was simply unavailable. Many

systems indicated they had no cases

for men or women. As a result, the

data do not provide a solid basis for

calculating formal TB case rates.

State/Federal systems reported 663

cases under treatment in the 1994

survey, compared to 805 in 1992–93.

Four State/Federal systems did not

provide this information in 1994; two

of these had reported no cases in

1992–93, and the others had reported

4 and 12 cases, respectively. In

1992–93, 372 cases were under treatment in city/county systems, while

the 1994 survey indicated 256 such

cases. The fact that seven systems

provided no case numbers in 1994,

compared to four in the earlier survey, may account for part of the discrepancy in figures for city/county

jails. At least one of this round’s

nonresponding systems indicated in

the earlier survey that it had a large

number of cases under treatment.

Drug-resistant TB among inmates. Tuberculosis disease that is resistant to

the leading medications poses very serious problems for correctional facilities.

Resistant strains of TB can be transmitted to others. If a TB strain is resistant

to only one drug, others from the list of

the most effective treatments can be selected; however, if a strain is resistant to

both isoniazid (INH) and rifampin

(RMP), the two most widely used and

effective anti-TB drugs, then treatment

options are seriously reduced. In both

surveys, a similar number of systems reported about the same numbers of drugresistant TB cases; however, systems

were not asked to provide information

on cumulative inmate cases of drug-resistant TB disease in 1994, as they had

been in 1992–93.

Of the 35 cases with any drug resistance reported to the 1994 survey (as

shown in table 5), 24 (69 percent) were

cited as being resistant to both INH

and RMP. Although based on relatively small numbers, this proportion

is much higher than that found in a nationwide survey conducted by the

CDC, where 24 percent (114/472) of

cases with any drug resistance were

resistant to both INH and RMP.4

TB control policies

TB is an airborne disease, transmitted

via droplet nuclei (e.g., the dried residue of droplets from sneezes or

coughs) from patients who have pulmonary or laryngeal TB and who

cough, laugh, spit, or otherwise emit

sputum containing the TB bacteria

(called Mycobacterium tuberculosis).

TB can be transmitted through repeated exposure in crowded, poorly

ventilated environments; it does not

require intimate contact. Priority TB

control activities, as identified by

CDC5

 are:

• Rapidly identifying, reporting, isolating, and initiating appropriate

therapy for active and potentially infectious cases of TB.

Table 4: Inmates Under Treatment for Active TB Disease

State/Federal Systems City/County Systems

Inmates Currently

Under Treatment Total Total

for TB Disease Systems Cases Inmatesa Systems Cases Inmatesa

0 cases 14 0 105,314 11 0 18,548

1–10 cases 23 85 297,231 12 45 55,998

11–50 cases 6 177 180,804 3 77 22,246

51–100 cases 3 268 152,051 2 134 41,103

More than 100 cases 1 133 23,817 0 0 0

Did not report 4 N/A 76,589 1 N/A 18,478

Total 51 663 835,806 29 256 156,373

a

 Total Inmates reflect reported prison populations as of May 1, 1994. Current cases were reported as of the last recorded information available. These dates varied widely.
6

R e s e a r c h i n B r i e f

Table 5. Current Inmate Cases of Drug-Resistant TB Disease

State/Federal Systems City/County Systems

Current Number Number of Number Number

Inmate Cases of Systems Cases of Systems of Cases

0 40 0 23 0

1–10 8 18 4 4

More than 10 1 13 – –

Did not report 2 N/A 2 N/A

Total 51 31 29 4

• Ensuring the continuity and completion of therapy through direct observation and other adherence-enhancing

strategies.

• Rapidly identifying and evaluating

contacts of infectious TB cases and

initiating preventive therapy for infected persons.

• Identifying persons with TB infection at high risk for developing active

TB and ensuring that they complete a

full course of preventive therapy.

CDC’s specific guidelines for TB control in correctional facilities are designed to help these facilities avoid the

spread of TB and diminish the numbers of cases that are exported to the

community as prisoners are released.

The CDC guidelines have recently been

updated and include recommendations

for both long- and short-term facilities,

thus providing more specific guidance

for jails as well as for prisons.6

Screening policies and practices

CDC guidelines for TB screening. Several types of screening for TB are used

in correctional facilities. Symptom

screening involves checking for signs

and symptoms of TB through a systematic interview that inquires about persistent, productive cough; chest pain;

coughing up blood; fever, chills, and

night sweats; loss of appetite and

weight loss; and tiring easily, especially during the preceding 6 weeks.

Symptom screening should be performed as soon as possible. During the

regular medical evaluation, inmates

should be asked whether they have

had TB disease, been treated, or received preventive therapy for TB.

A second screening procedure involves the PPD (purified protein

derivative) or Mantoux tuberculin skin

test. The PPD is injected under the

skin and, after 48 to 72 hours, interpreted by an experienced reader, who

measures the diameter of the swollen

area that can be felt around the injection site and records the result in millimeters. Chest radiographs are also

used in screening for TB disease when

the incidence or prevalence of TB is

high and the time required for skin

testing makes that method impractical

or may delay the isolation of infectious

persons. Generally, a posterioranterior view of the chest is taken.

For all facility types, CDC recommends TB symptom screening of incoming inmates. Inmates who are

found to have symptoms of TB should

be isolated and further evaluated. For

short-term facilities serving populations at low risk for TB, this is the only

recommended screening. To fall in this

category, facilities would have no existing cases and draw inmates from

communities that have had no TB

cases within the previous year. Some

small facilities in rural areas may meet

this definition.

CDC recommends more than symptom

screening in short-term facilities with

high-risk populations. Prisoners who

stay long enough should be tuberculin

skin-tested within 14 days of arrival if

their medical records do not include a

documented positive skin test result.

Those with TB symptoms or with positive tuberculin skin tests should be

given radiographs and medical evaluations. Any inmates known to be HIVpositive or to be at high risk for HIV

should be given a radiograph as part of

the initial screening process. CDC

suggests that large jails may want to

consider using onsite radiography for

all prisoners.

CDC recommends that while long-term

facilities also begin with symptom

screening, they should give a skin test

to each asymptomatic inmate without a

documented prior positive result. An

inmate with positive PPD results

should be given a radiograph and

evaluated; an inmate who tests PPDnegative but is HIV-positive or at high

risk for HIV also should be given a radiograph and evaluated. Annual PPD

tests are recommended for inmates

who have negative tests.

Screening recommendations for staff

include an evaluation of medical history during the physical exam performed at hiring and mandatory

tuberculin skin-testing for those without a documented positive skin-test result. Staff members who have not been

tested for 12 months or more should be

retested. Any staff member with symptoms suggestive of TB should be sent
R e s e a r c h i n B r i e f

7

Table 6. Screening Inmates for TB Disease

State/Federal Systems City/County Systems

Current Number Percent of Number Percent

Inmate Cases of Systems Systems of Systems of Systems

Screening

All individuals 44 86% 24 83%

All known HIV+ 1 2 2 7

Other 2 4 2 7

Missing/none 4 8 1 3

Total 51 100% 29 100%

Method

Minifilm

X-ray 7 14% 6 21%

Table 7. Screening Inmates for TB Infection

State/Federal Systems City/County Systems

Current Number Percent of Number Percent of

Inmate Cases of Systems Systems of Systems Systems

Screening

All individuals 50 98% 19 66%

All HIV+ 42 82 19 66

All close contacts

of active TB cases 42 82 23 79

Missing/none 1 2 0 –

Screening Frequency

At intake 51 100 20 69

At intake

and annually 46 90 12 41

At release 2 4 1 3

home until infectious TB has been ruled

out. A staff member who has positive

test results should be given a radiograph

and a medical evaluation. Further, staff

members should be told that if they are

immunosuppressed for any reason, they

should consult their personal physicians

for additional followup.

Screening practices. Prison and jail systems were asked to report on screening

practices for TB infection and disease.

Tables 6 and 7 show the responses to

questions about who is screened and

how frequently. Of the 51 State and Federal prison systems, 44 (86 percent) reported screening all incoming inmates

for TB disease. Of the 29 responding

city and county jail systems, 24 (83 percent) reported screening all inmates at

intake.

Thirty-three facilities in 13 systems

responded to the validation study on

this issue and revealed that not all facilities followed system policy with respect to screening for TB disease. Ten

of the systems that participated in the

validation study reported screening all

incoming inmates for TB disease, but

only 85 percent of the 26 facilities in

these 10 systems reported carrying out

this policy.

Screening inmates for TB infection is

more common than screening for TB

disease in State/Federal correctional

systems. Of the 51 State/Federal

prison systems, 50 reported screening

all incoming inmates for TB infection,

and 44 stated that this policy was

mandatory. Of the 29 city/county jail

systems, 19 (66 percent) reported testing all incoming inmates, and 14 indicated that this was mandatory. All

systems in the validation study reported testing all incoming inmates for

TB infection, and all of the facilities in

these systems reported carrying out

this policy. For 11 of the systems in

the validation study, testing of all

incoming inmates was mandatory, and

82 percent of the facilities in these systems complied. In 1992–93, systems

were asked if inmates were routinely

tested for TB infection at least annually,

while in 1994, they were asked if they

were tested at intake and at regular intervals thereafter. Forty State/Federal

systems reported annual testing in

1992–93, and 46 systems reported testing at intake and regular intervals thereafter in 1994.

Housing policies and practices

A primary TB control measure is the isolation of infectious cases to prevent

spreading the disease to other inmates.

The most common and recommended

isolation measure in prisons and jails

is use of negative-pressure isolation

rooms (i.e., isolation rooms with ventilation that does not flow into the general ventilation system) either in the

infirmary or in a community hospital.

As shown in table 8, 61 percent of

State/Federal systems reported using
8

R e s e a r c h i n B r i e f

Table 8. Housing of Inmates With Confirmed or Suspected TB Disease 1994

State/Federal Systems City/County Systems

Number Percent of Number Percent of

of Systems Systems of Systems Systems

Housing Placement

General population:

Double cells 1 2% 2 7%

Single cells 1 2 2 7

Separate unit 3 6 1 10

Prison/jail infirmary

Wards 1 2 0 –

Single rooms 13 25 6 28

Negative-pressure

 isolation rooms 31 61 14 48

Community hospital

Negative-pressure

isolation rooms 30 59 15 52

Duration of isolation

About 3 days 0 – 2 7

About 2 weeks 4 8 4 14

Until symptoms

disappear 7 14 5 17

Until 3 negative

sputums on

consecutive days 39 76 21 72

No isolation 5 10 2 7

negative-pressure isolation rooms in

the prison infirmary, and 59 percent of

these systems reported using negativepressure rooms in community hospitals. When the two categories are

combined, 65 percent of State/Federal

systems reported using negativepressure rooms in the infirmary, community hospitals, or both. Of city/

county jail systems, 48 percent reported using negative-pressure rooms

in jail infirmaries, and 52 percent reported using negative-pressure rooms

in community hospitals. When the categories are combined, 66 percent of

city/county jail systems reported using

negative-pressure rooms in one or the

other location, or in both.

These 1994 NIJ/CDC survey results

show some important changes since

1992–93. Where just under one-third

of prison and jail systems reported using negative-pressure rooms for all inmates with potentially infectious TB in

the earlier survey, in 1994 the proportion reporting the exclusive use of

negative-pressure rooms had more

than doubled.

In 1994, 76 percent of prison systems

and 72 percent of jail systems reported

isolating inmates until three negative

sputums had been collected on consecutive days. (The current CDC recommendation is that three consecutive

sputums be collected on different days

and, additionally, that the patient must

be on effective therapy and improving

clinically.) Fourteen of the 39 prison

systems reporting this practice also

mentioned using other indicators to

determine duration of isolation, as did

6 of 21 jail systems. In 1992–93, 82

percent of prison systems and 64 percent of jail systems had reported isolating inmates until they could

produce three successive daily negative sputum smears.

The validation study showed that approximately two-thirds of the facilities

in systems that reported policies for

isolating TB cases in negative-pressure rooms agreed that this was their

practice. Ten of the 13 systems in the

validation study indicated that inmates

were isolated until three negative sputum smears were collected, and 68

percent of the facilities in these systems followed this practice. These results suggest that significant minorities

of facilities are admittedly not following recommended TB control procedures—despite their systems’ policies

calling for such measures.

Treatment policies and

practices

Current CDC guidelines7 recommend

that the initial course of treatment for

TB disease for most patients should include four drugs: INH, RMP, pyrazinamide (PZA), and either ethambutol

(EMB) or streptomycin (SM). PZA and

SM should not be used in pregnant

women. If there is little possibility of

drug resistance (i.e., the primary INH

resistance rate in the community is

less than 4 percent, and the patient

has had no previous treatment for TB,

is not from a country with a high

prevalence of drug-resistant TB, and

has had no known exposure to a patient with drug-resistant TB), then the
R e s e a r c h i n B r i e f

9

first three of the drugs listed can be

used. In persons with positive smears

or cultures at the beginning of therapy,

response to treatment should be monitored by smear and culture at least

monthly until the results are negative.

Directly observed therapy (DOT) is

recommended for all inmates.

As shown in table 9, 94 percent of

State/Federal prison systems reported

employing DOT for all inmates receiving treatment for TB disease, as did 90

percent of city/county jail systems. In

1992–93 only 77 percent of prison

systems and 84 percent of jail systems

reported using DOT for all inmates under treatment for TB disease. Validation study results showed a 90-percent

agreement between facilities and systems with respect to DOT for inmates

under treatment.

The majority of HIV-negative inmates

were treated for at least 6 months for

TB (the CDC-recommended treatment

duration) in 1994 (78 percent for

State/Federal systems and 66 percent

for city/county systems). In 1992–93,

77 percent of both prison and jail systems reported treating HIV-negative

inmates for at least 6 months. Fortynine percent of State/Federal systems

and 48 percent of city/county systems

reported treating coinfected inmates

for 9 or more months in 1994, while

more than 60 percent of both prison

and jail systems had reported this

policy in 1992–93. It should be noted

that in 1994, the CDC recommended

that treatment duration be changed to

6 months for drug-susceptible,

coinfected persons responding adequately to therapy.8

INH preventive therapy

Most asymptomatic but infected inmates should be given preventive

therapy with INH to reduce their likelihood of developing active disease.9

CDC recommends that, once active

disease has been ruled out, all PPDpositive persons who are non-HIVinfected be considered for at least 6

months of INH (300 mg daily or 900

mg twice weekly) and dually infected

persons be considered for 12 months

of prophylaxis.10

CDC also recommends that all preventive therapy be directly observed.11 This

is particularly important since people on

preventive therapy are asymptomatic

and may never have experienced TB

symptoms, a circumstance that offers

little incentive for them to adhere to a

lengthy course of medication. The 1994

survey results on preventive therapy

practices are presented in table 10.

As was the case for TB disease treatment, an increased percentage of prison

systems reported in the 1994 survey that

directly observed prevention therapy

(DOPT) was provided for all inmates

with TB infection (76 percent vs. 67 percent in 1992–93). Nine of the 51 State/

Federal systems that reported not using

DOPT in the earlier survey reported its

use in 1994. However, four prison systems that did not use DOPT in 1994 had

reported employing it in 1992–93. The

percentage of jail systems using DOPT

for all infected inmates was approximately the same.

According to the validation study,

reports from systems and facilities as

to who received preventive therapy

were somewhat inconsistent. Ten of 13

systems in the validation study stated

they practiced DOPT, while 88 percent of the reporting facilities in those

10 systems claimed to administer

DOPT to all inmates. Most (12 of the

13 in the validation study) systems reported that all inmates under 35 years

Table 9: Treatment of Inmates with TB Disease

State/Federal Systems City/County Systems

Number of Percent of Number of Percent of

Systems Systems Systems Systems

Duration of Therapy

HIV+ Inmates

9 months or more 25 49% 14 48%

Other 17 33 13 45

None specified 7 14 1 3

Missing 2 4 1 3

HIV-inmates

6 months or more 40 78 19 66

Other 5 10 9 31

None specified 3 6 0 –

Missing 3 6 1 3

Directly Observed

Therapy

All inmates 48 94 26 90

Selected inmates 3 6 3 10

None 0 – 0 –

Total 51 100% 29 100%
10

R e s e a r c h i n B r i e f

Table 10: INH Preventive Therapy for Inmates

State/Federal Systems City/County Systems

Number of Percent of Number of Percent of

Systems Systems Systems Systems

Inmates Offered

Preventive Therapy

All PPD-positive

inmates 30 59% 10 35%

All PPD-positive

under 35 years 36 71 19 66

HIV-infected

inmates regardless

of PPD result 11 22 2 7

HIV-infected

and PPD-positive 38 75 23 79

With anergy 28 57 17 59

All close contacts

with TB disease 19 37 12 41

Only close contacts

with PPD-positive 22 43 14 48

Recent skin test

converters 37 74 19 66

Duration of Therapy

At least 12 months

for HIV-positive 41 80 18 66

At least 6 months

for HIV-negative 49 96 24 83

Directly Observed

Therapy

All inmates 39 76 24 83

Some inmates 9 18 4 14

None 2 4 1 3

Missing 1 2 0 –

Total 51 100% 29 100%

of age with positive skin tests received

preventive therapy, and 72 percent of

facilities in those systems agreed. Nine

of the 13 systems in the validation

study reported that they gave preventive therapy to recent converters, to all

inmates with positive reactions—whatever their age, and to all coinfected inmates. The concurrence rates for

facilities in these systems were 83 percent, 55 percent, and 78 percent.

Eight systems in the validation study

stated that they administered preventive therapy to all HIV-positive inmates who demonstrated anergy (i.e.,

no response to the skin test); only 45

percent of the facilities in these systems reported doing this. Four systems

in the validation study said they administered therapy to all close contacts of a TB case; the agreement rate

from facilities in these systems was 58

percent.

Discharge policies

Systems were asked about discharge

planning for inmates with TB disease

or infection who had not finished their

course of therapy prior to discharge or

parole. Most systems (94 percent of

State/Federal systems and 100 percent

of city/county systems) reported that

they referred inmates to local health

department TB programs on release.

Many systems also informed health departments about inmates and provided

locating information (86 percent of

State/Federal and 97 percent of city/

county systems). Relatively few systems went as far as scheduling appointments for inmates (32 percent of

State/Federal and 38 percent of city/

county systems). Validation study results showed that all 13 systems said

they referred inmates to health departments, and 88 percent of facilities in

those systems agreed; 12 systems reported that they informed health departments about inmates, and 81

percent of facilities agreed. However,

five systems reported that they scheduled appointments for inmates, but

only 30 of the facilities in those systems confirmed this practice.

The 1994 survey did not include specific questions on environmental controls, nor were questions posed

concerning education and training. Systems were asked to indicate whether

they would like to receive assistance

from the public health department on a

number of different aspects of TB control. Over 30 systems expressed an interest in receiving help with educational

programs/materials and with discharge

planning. Other types of assistance were

of interest as well, but to a smaller number of systems.

Legal issues

Correctional officials may be concerned

about liability with respect to the transmission and treatment of TB in their facilities. Additional discussion on this
R e s e a r c h i n B r i e f

11

topic can be found in the report on the

1992-93 survey.12 Recently adjudicated

cases have centered on two issues:

• Failure to protect inmates from acquiring TB or provide adequate treatment or

care.

• Failure to respect individuals’ constitutional rights by instituting a mandatory

TB testing program.

Six instances alleging the first type of

failure have been reported. In a case in

a Federal District Court in Wyoming,

Blumhagen v. Sabes13, a prisoner

claimed that following the discovery of

an active case of TB, prison officials had

the entire prison population screened for

the disease but failed to quarantine or

isolate the sick inmate. Followup tests or

proper procedures to control the spread

of the disease were not performed, and

the prison population was not monitored.

The District Court found that the prisoner’s allegations amounted to differences

of opinion about proper medical treatment

and not “the type of subjective indifference to the medical needs of the prisoners

that the controlling cases require.” The

court’s decision in Blumhagen acknowledged the decision in DiGidio v. Pung14

(holding that “a consistent pattern of

reckless or negligent conduct is sufficient

to establish deliberate indifference”) but

distinguished the ruling and held that

it need not be followed. The Blumhagen

decision also noted that the court had

found no decisions holding that “speculative harm in future is sufficient to

meet” the “serious medical need” requirement. Finally, the court noted that

the plaintiffs may have a claim for malpractice and that Wyoming had waived

its sovereign immunity.

Three cases in Texas also revolved

around issues of adequate protection of

inmates from TB. Two of these are pending against the Harris County Sheriff,

while a third case was dismissed. James

H. King v. Johnny Klevenhager [sic],

Sheriff, et al.,

15 involves a plaintiff’s

“civil suit for medical negligence.” The

plaintiff alleges that, while housed in the

Harris County Jail during 1992, he received inadequate medical attention,

was subjected to intolerable living conditions due to overcrowding, and was exposed to tuberculosis. Preston Briggs v.

Jerry Eversole et al.,

16 another pro se

case, involves a plaintiff’s “complaint for

violation of civil rights pursuant to 42

USC § 1983.” In his pleadings the

plaintiff claims that, since his incarceration in the Harris County Jail in January

1993, his civil rights have been violated.

Among his claims are assertions that he

was unreasonably exposed to tuberculosis from other inmates, that he was injured on an ongoing basis because of the

inadequate flow of air in the jail, and

that he received inadequate medical attention. In a case that was dismissed,

John Friedel and Dorcas Friedel v. Sheriff Johnny Klevenhagen et al.,

17 the

plaintiff alleged that he contracted tuberculosis while in prison, that the disease was never properly diagnosed, and

that he was never treated for his TB.

Two cases in Massachusetts dealt with

the issue of violating inmates’ civil rights

through mandatory testing programs.

The primary issue in Langton v. Commissioner of Correction,

18 was whether

prison officials are authorized to compel

inmates to submit to TB testing under

State law. The inmates argued that the

defendants had no authority to force

them to submit to the TB test. In Massachusetts, the State Legislature had mandated specifically that, during each

prisoner’s physical exam, special attention be given to determining the presence of communicable diseases,

particularly pulmonary tuberculosis.

The Appeals Court ruled that the Commissioner of Correction has the responsibility to maintain security, safety, and

order at all State correctional facilities.

The court further ruled that, although an

inmate’s incarceration does not divest

him of the right of privacy and interest

in preserving his bodily integrity, it does

limit those constitutional rights when the

State’s interests in prison security and

inmate health are at issue. Furthermore,

the court said that disciplinary procedures implemented to deal with inmate

refusals to take the TB test were lawful.

On the other hand, a Federal District

Court judge in New York recently

ruled that the State correctional department must return to the general population a person who had been held in

“medical keeplock” (solitary confinement) for 3-1/2 years because he refused a PPD test. Skin testing is

mandatory for New York State inmates,

but this prisoner refused the test on the

grounds that it violated the tenets of his

Rastafarian religion. In an affidavit, the

inmate stated that “accepting artificial

substances into the body constitutes a

sin and shows profound disrespect to

our creator.” The court held that the inmate, “in choosing to undergo the conditions of medical keeplock for a

period of over 3-1/2 years, had shown

remarkable conviction for what he

stated are his religious beliefs.”19

Implications for policy and

practice

These recent legal cases, as well as concerns about the spread of TB within correctional facilities—and, ultimately,

beyond, as released inmates return to

their communities–indicate the need for

continuing attention to prison health

policies and practices. The study found

that although policies for the prevention,

treatment, and control of tuberculosis
12

R e s e a r c h i n B r i e f

Prepared under contract OJP-89-C-009 to Abt

Associates Inc. from the National Institute of

Justice, Office of Justice Programs, U.S. Department of Justice. Findings and conclusions

of the research reported here are those of the

authors and do not necessarily reflect the official position or policies of the U.S. Department

of Justice.

This research was conducted by

Abt Associates Inc. The study

team consisted of: Karen Wilcock,

associate; Theodore M. Hammett,

vice president; Rebecca Widom,

research assistant; and Joel

Epstein, analyst.

NCJ 157809

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.

have been mandated by legislatures or

stipulated as corrections systems policies, some facilities did not comply.

Incarceration may also represent a

unique public health opportunity to

provide long-term, directly observed

therapy to persons with TB disease

and directly observed preventive

therapy to those who might otherwise

go untreated. Following CDC guidelines, strong TB prevention, treatment,

and control programs in correctional

facilities can help contain the spread

of TB within the greater community.

Notes

1. Hammett, T. and L. Harrold, Tuberculosis in Correctional Facilities, Issues and Practices, National

Institute of Justice and Centers for Disease Control

and Prevention, 1994.

2. Ibid.

3. Ibid.

4. Alan Bloch et al., “Nationwide Survey of DrugResistant Tuberculosis in the United States,” Journal

of the American Medical Association, March 2,

1994, 271:665-671.

5. CDC, Screening for tuberculosis and tuberculous

infection in high risk populations: recommendations

of the Advisory Council for the Elimination of Tuberculosis,” Morbidity and Mortality Weekly Report,

44(No. RR-11):19-34, 1994.

6. CDC, Controlling Tuberculosis in Correctional Facilities, Atlanta 1995.

7. Ibid.

8. ATS/CDC, “Treatment of Tuberculosis and Tuberculosis Infection in Adults and Children,” Am J

Respir Crit Care Med, 149:1359-74, 1994.

9. ATS/CDC, “Control of Tuberculosis in the United

States,” Am Rev Respir Dis, 146:1623-1633, 1992.

10. ATS/CDC, “Treatment of Tuberculosis and Tuberculosis Infection in Adults and Children.”

11. CDC, “Prevention and Control of Tuberculosis in

Correctional Facilities: Recommendations of the Advisory Council for the Elimination of Tuberculosis.”

12. Hammett and Harrold, Tuberculosis in Correctional Faclities, chapter 10.

13. Blumhagen v. Sabes, 834 F. Supp. 1347, 1353

(D. Wyo. 1993).

14. DiGidio v. Pung, 920 F. 2nd 525 (8th Cir. 1990).

15. James H. King v. Johnny Klevenhager [sic],

Sheriff, et al., No. 93-52770.

16. Preston Briggs v. Jerry Eversole et al., No. H–

93–1485.

17. John Friedel and Dorcas Friedel v. Sheriff

Johnny Klevenhagen et al., No. 93–58890.

U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

Washington, D.C. 20531

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18. Langton v. Commissioner of Corrections, 614

N.E. 2d 1002 (Mass. App. Ct. 1993).

19. McKinley, James C. Jr., “Isolation Ends for Prisoner Who Refused Testing for TB,” New York Times,

August 22, 1995, p. B5.