Corrections Recommendations - *

Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC2006

Centers for Disease Control and Prevention (CDC) Division of Tuberculosis Elimination

*

Corrections Recommendations - *

Contents (1)
        - Summary of Changes from 1996 Recommendations from CDC
        - Background
        - Screening
        - Case Reporting
        - Airborne Infection Isolation
        - Environmental Controls
        - Respiratory Protection

Corrections Recommendations - *

Contents (2)
        - Diagnosis and Treatment of Latent Tuberculosis Infection (LTBI) and Tuberculosis (TB) Disease
        - Discharge Planning
        - Contact Investigation
        - TB Training and Education of Correctional Workers and Inmates
        - Program Evaluation
        - Collaboration and Responsibilities
        - References and Additional Resources

Corrections Recommendations - *

Summary of ChangesMade to the 1996 CDC Recommendations for Prevention and Control of TB in Correctional Facilities

Corrections Recommendations - *

Summary of Changes (1)
        - Target audience has been broadened to include persons working in jails and other detention facilities
        - Recommendation that screening procedures for inmates and detainees  be based on facility assessment for risk of TB is added
        - TB symptom review of all inmates and detainees at entry is emphasized

*

Corrections Recommendations - *

Summary of Changes (2)
        - Placement of all inmates and detainees with suspected TB in airborne infection isolation (AII) immediately is emphasized
        - Interferon Gamma Release Assays (IGRAs) have been added to testing recommendations 
        - Recommendations for ventilation have been added

*

Corrections Recommendations - *

Summary of Changes (3)
        - Recommendations for respiratory protection have been added
        - Treatment recommendations for TB disease and LTBI have been updated
        - Case management of inmates with TB disease and LTBI have been emphasized
        - Early discharge planning that is coordinated with local public health staff is emphasized

*

Corrections Recommendations - *

Summary of Changes (4)
        - Recommendations for US Immigration and Customs Enforcement detainees have been included
        - Collaboration between the correctional facility and public health staff is emphasized
        - Recommendations for comprehensive training programs to achieve and sustain TB control that are tailored by corrections and public health staff are added

*

Corrections Recommendations - *

Summary of Changes (5)
        - Recommendation for public health workers to be educated about the correctional environment is added
        - Program evaluation is emphasized

*

Corrections Recommendations - *

Background

Corrections Recommendations - *

Incarcerated PopulationUnited States, 1980-2008

Jail

Prison

Source: U.S. Department of Justice,   Bureau of Justice Statistics 

*

Corrections Recommendations - *

US Correctional TB Cases by Type of Correctional Facility

Corrections Recommendations - *

Disproportionately High Percentage of TB Cases Occurring in Incarcerated Persons in the US, 2003
        - 0.7% of the total US population were confined in prisons and jails
        - 3.2% of all TB cases nationwide occurred among residents of correctional facilities

*

Corrections Recommendations - *

TB Case Rates
| Location and Date          | TB Case Rate                                                                                                      |
|----------------------------|-------------------------------------------------------------------------------------------------------------------|
| United States, 1993–2006   | <10 cases per 100,000 persons(general population)                                                              |
| New Jersey,1994            | 91.2 cases per 100,000 inmates11.0 cases per 100,000 persons among all New Jersey residents                       |
| California,1991            | 184 cases per 100,000 inmates of a California prison (10 times greater than the statewide rate)                   |
| California, 1998           | 72.1 cases per 100,000 inmates in an urban jail in a high-prevalence area (10% of the county’s cases that year)   |
| New York, 1993             | 139.3 cases per 100,000 inmates, an increased rate from 15.4 during 1976–78                                       |

*

Corrections Recommendations - *

Factors Contributing to High Rate of TB in Correctional and Detention Facilities
        - Disparate numbers of incarcerated persons are at high risk for TB
        - Physical structure of facilities (e.g., close living quarters, overcrowding, inadequate ventilation)
        - Movement of inmates into and out of overcrowded and inadequately ventilated facilities

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Rationale for Updating and Strengthening TB Control and Prevention Guidelines (1)
        - Transmission of M. tuberculosis continues to be documented within correctional facilities
        - Inmates with undiagnosed TB disease place other inmates and correctional staff at risk for TB; when released they can infect members of the community
        - Immediate isolation of infectious patients can interrupt transmission of M. tuberculosis

*

Corrections Recommendations - *

Rationale for Updating and Strengthening TB Control and Prevention Guidelines (2)
        - Prompt initiation of an adequate regimen of directly observed therapy (DOT) helps ensure adherence to treatment
        - Inmates have relatively high rates of human immunodeficiency virus (HIV) and if coinfected with M. tuberculosis, are at high risk for progressing from LTBI to TB disease
        - Treatment for LTBI can prevent the development of TB disease

*

Corrections Recommendations - *

Rationale for Updating and Strengthening TB Control and Prevention Guidelines (3)
        - Inmates who have TB disease or LTBI can be treated before they are released into the community
        - The correctional setting can be a primary source of health information, intervention, and maintenance

*

Corrections Recommendations - *

Screening

Corrections Recommendations - *

Screening (1)
        - Early identification and successful treatment of persons with TB disease is the most effective means of preventing disease transmission
        - Inmates who are likely to have infectious TB should be identified and started on treatment before they are integrated with other inmates

*

Corrections Recommendations - *

Screening (2)
        - Screening programs can also detect persons with LTBI who are at high risk for progressing to TB disease 

*

Corrections Recommendations - *

Factors for Determining Screening Activities

Type of facility

Prevalence of TB infection and disease in the facility

Prevalence of TB in the inmates’ communities

Prevalence of other risk factors for TB (e.g., HIV)

Average length of stay of inmates in the facility

*

Corrections Recommendations - *

Determining the Types of Screening
        - Determined by an assessment of the risk for TB transmission within the facility (minimal or nonminimal)
        - Risk assessments for facilities should be 
        - Performed at least annually
        - Done in collaboration with the local or state health department

*

Corrections Recommendations - *

Definition of a Facility’s TB Risk
| Minimal TB Risk Facility                                                                                                                                       | Nonminimal TB Risk Facility                                                                                             |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------|
| No cases of infectious TB within the last yearFew inmates with risk factors for TBFew new immigrantsEmployees of the facility are not otherwise at risk for TB | Any facility that does not meet the criteria for Minimal TB Risk should be categorized as a Nonminimal TB Risk Facility |

*

Corrections Recommendations - *

Screening MethodsSymptom Screening (1)
        - Initial screening should  be performed by 
        - Health-care professionals   whenever possible

   or
        - Adequately trained correctional officers
        - Symptom screening alone is an unsatisfactory screening mechanism for TB except for Minimal TB Risk Facilities

*

Corrections Recommendations - *

Screening MethodsSymptom Screening (2)
        - At intake, all incoming inmates should be screened for symptoms of pulmonary TB
        - During medical screening, inmates should be asked if they have
        - A history of TB
        - Ever been treated for LTBI or TB disease
        - Symptoms of TB

*

Corrections Recommendations - *

Screening MethodsSymptom Screening (3)

Suspicion of TB is high when pulmonary symptomsare accompanied by general systemic symptoms of TB
| Pulmonary Symptoms                                              | +                                                                   | Systemic Symptoms of TB |
|-----------------------------------------------------------------|---------------------------------------------------------------------|-------------------------|
| Prolonged cough ≥ 3 weeksHemoptysis (bloody sputum)Chest pain   | FeverChillsNight sweatsEasy fatigabilityLoss of appetiteWeight loss |

*

Corrections Recommendations - *

Screening MethodsSymptom Screening (4)

   All inmates who have symptoms suggestive of TB disease should immediately be placed in an AII room and receive a thorough medical evaluation including
        - TST or IGRA
        - Chest radiograph
        - Sputum examinations (if indicated) 

*

Corrections Recommendations - *

Screening MethodsSymptom Screening (5)

Symptoms suggestive of TB disease

History 

of inadequate treatment

 for TB disease

Place immediately in an AII room until patient has 

undergone a thorough medical evaluation

Infectious Should remain in isolationuntil treatment has rendered patientnoninfectious (see Discontinuationof Airborne Precautions) 
| NoninfectiousMay be released from AIIIf TB diagnosis excludedORAfter patient is improving on multidrug anti-TB treatment if suspicion for TB diagnosis remains |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|

*

Corrections Recommendations - *

Screening MethodsChest Radiograph Screening (1)
        - Can be an effective means  of detecting new cases of  unsuspected TB disease   at intake 
        - Requires fewer subsequent  visits than a TST
        - Will not identify inmates with LTBI
        - Might be appropriate for facilities that
        - House substantial numbers of inmates for short periods 
        - Serve populations at high risk for TB

*

Corrections Recommendations - *

Screening MethodsChest Radiograph Screening (2)

Factors that determine the extent to which chest radiographs are used for TB screening in a facility include

Local epidemiologic characteristics of TB disease

Inmate length of stay

Ability of staff to conduct careful histories, TST or IGRA testing, and cross-matches with state TB registries

Promptness of radiographic study and its reading (should be read within 24 hours) 

*

Corrections Recommendations - *

In facilities that do not perform screening radiographs at admission, chest radiograph should be part of initial screening for 
        - All HIV-infected patients
        - Those at risk for HIV infection, but whose status is unknown

Screening MethodsChest Radiograph Screening (3)

*

Corrections Recommendations - *

Screening Methods Chest Radiograph Screening (4) Facilities with On-site Radiographic Screening

Chest radiograph should be performedas part of intake screening

Should be read by a 

physician within 24 hours
| Persons who have radiographssuggestive of TBShould be isolated immediately and evaluated further Should receive a sputum smear and culture examination (might also be indicated for certain persons regardless of TST, IGRA, or chest radiograph results) |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

*

Corrections Recommendations - *

Screening MethodsMantoux Tuberculin Skin Test (TST) (1)
        - Most common method of  testing for TB infection
        - Is not completely sensitive  for TB disease
        - With symptom screening, may be the most practical approach to screening for TB disease in many facilities

*

Corrections Recommendations - *

 Screening MethodsMantoux Tuberculin Skin Test (TST) (2) Persons Exempt from a TST

Persons who have any of the following:
        - Documented history of a positive TST result
        - Documented history of TB disease
        - Reported history of a severe necrotic reaction to tuberculin

*

Corrections Recommendations - *

Screening MethodsMantoux Tuberculin Skin Test (TST) (3) Mantoux TST Screening
        - Intradermal injection of 0.1 mL of 5 tuberculin units (TU) of purified protein derivative (PPD) 
        - Multiple puncture tests (e.g., tine test) are not recommended
        - A trained health-care professional should
        - Place the TST
        - Interpret the reaction 48 – 72 hours after the injection 

*

Corrections Recommendations - *

Screening MethodsMantoux Tuberculin Skin Test (TST) (4) Considered a Positive TST Result in Inmates and Correctional Facility Employees
| ≥ 10 mm Induration                                      | ≥ 5 mm Induration                                                                                                                                                                                                             |
|---------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Majority of inmates and correctional facility employees | HIV infectedRecent contact of patients with TB diseaseFibrotic changes on chest radiograph consistent with previous TB diseaseOrgan transplant recipient or  other immunocompromising conditionSuspected of having TB disease |

*

Corrections Recommendations - *

Screening MethodsMantoux Tuberculin Skin Test (TST) (5) Persons with Positive TST Results

Persons with a Positive TST

No symptoms of TB diseaseShould have a 

chest radiographwithin 72 hours

Symptoms of TB disease

Should be

evaluated immediatelyand placed in an AII room 

until TB is ruled out

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Booster Reaction
        - Some people with LTBI may have negative skin test reaction when tested years after infection
        - Initial skin test may stimulate (boost) ability to react to tuberculin
        - Positive reactions to subsequent tests may be misinterpreted as a new infection

Corrections Recommendations - *

Anergy Testing
        - No longer recommended routinely for screening programs for M. tuberculosis infection in the United States
        - Has not been demonstrated to assist in diagnosing or excluding LTBI

*

Corrections Recommendations - *

Bacille Calmette-Guerin (BCG)
        - Used worldwide as a vaccine against TB
        - Cannot distinguish between TST reactions caused by BCG and those caused by natural mycobacterial infection, but ≥ 20-mm induration is usually NOT caused by BCG
        - TST is not contraindicated for persons vaccinated with BCG
        - The same criteria for interpretation of TST results are used for both BCG vaccinated and nonvaccinated persons 

*

Corrections Recommendations - *

Screening MethodsInterferon Gamma Release Assays (IGRAs) (1)
        - Diagnostic tool for M. tuberculosis infection, including both TB   disease and LTBI
        - Should be used with risk assessment, radiography, and other diagnostic evaluations

*

Corrections Recommendations - *

Screening MethodsIGRAs (2)
        - As with TST, cannot distinguish between LTBI and TB disease
        - Available data indicate that IGRAs are as sensitive as TST for detecting TB disease and more specific than TST for detecting LTBI 
        - IGRAs can be used in all situations that currently use the TST

*

Corrections Recommendations - *

Screening MethodsIGRAs (3)Types of IGRAs
        - QuantiFERON®-TB Gold  test (QFT-G)
        - QuantiFERON®-TB Gold-  In-Tube test (QFT-GIT)
        - T-Spot TB test

Corrections Recommendations - *

Screening MethodsIGRAs (4) Advantages of IGRAs
        - Results can be obtained after a single patient visit (possible cost-benefit)
        - Variability associated with skin-test reading can be reduced because “reading” is performed in a qualified lab
        - IGRA tests are not affected by previous BCG vaccination (eliminates unnecessary treatment for false-positives)
        - IGRA tests do not affect the result of future IGRA tests (no boosting occurs)

*

Corrections Recommendations - *

Screening MethodsIGRAs (5)Limitations of IGRAs
        - Phlebotomy is needed 
        - Blood specimens need to be processed within 12 – 16 hours of collection
        - Limited number of laboratories can process the test
        - Many health care workers lack clinical experience in interpreting test results

*

Corrections Recommendations - *

Use of Local Health DepartmentTB Registry to Assist with Screening Inmates (1)
        - Correctional facilities and local health departments should collaborate to ensure effective TB screening in the correctional setting
        - During screening, inmates may provide inaccurate information due to forgetfulness, confusion, or deliberate misrepresentation

*

Corrections Recommendations - *

Use of Local Health DepartmentTB Registry to Assist with Screening Inmates (2)
        - Correctional facilities and health departments should perform cross-matches using the local TB registry and search for aliases, birth dates, maiden names, and other personal information for TB suspects
        - Readily accessible records of previous TB history, drug susceptibility, treatment, and compliance are useful when dealing with patients with suspected TB

*

Corrections Recommendations - *

Initial ScreeningInmates in Minimal TB Risk Facilities

AIl inmates 

Evaluate upon entry for symptoms of TB

TB symptoms 

Evaluate immediately to rule out infectious TB disease and keep in an AII room until they are evaluated

 (or transported to a facility that has an AII room) 

Infectious Inmates should remain in 

isolation until treatment has 

rendered them noninfectious

No TB symptoms but risk factors 

Provide additionalscreening within 7 days of arrival
| NoninfectiousMay be released from AIIIf TB diagnosis excludedORAfter patient is improving on multidrug anti-TB treatment if suspicion for TB diagnosis remains |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|

*

Corrections Recommendations - *

Initial ScreeningInmates in Nonminimal TB Risk Prisons

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

Infectious Inmates should remain in 

isolation until treatment has 

rendered them noninfectious

No TB symptoms 

Require further screening within 7 days of arrival

TB symptoms 

Evaluate immediately to rule out infectious TB disease and keep in an AII room until they are evaluated

 (or transported to a facility that has an AII room) 
| NoninfectiousMay be released from AIIIf TB diagnosis excludedORAfter patient is improving on multidrug anti-TB treatment if suspicion for TB diagnosis remains |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|

*

Corrections Recommendations - *

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

All inmates Evaluate upon entry for symptoms of TB 

Positive results Inmates should remain in 

isolation until treatment has 

rendered them noninfectious

No TB symptoms 

Require further screening within 7 days of arrival

TB symptoms 

Evaluate immediately to rule out infectious TB diseaseand keep in an AII room until they are evaluated(or transported to a facility that has an AII room) 
| NoninfectiousMay be released from AIIIf TB diagnosis excludedORAfter patient is improving on multidrug anti-TB treatment if suspicion for TB diagnosis remains |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|

*

Corrections Recommendations - *

Inmates in Nonminimal TB Risk Jails and Other Short-Term Detention Facilities (2)
        - Primary purpose of screening in correctional settings is to detect TB disease
        - TST or IGRA screening is often not practical for the purpose of initiating LTBI therapy because of the high rate of turnover and short lengths of stay

*

Corrections Recommendations - *

Inmates in Nonminimal TB Risk Jails and Other Short-Term Detention Facilities (3)
        - Treating LTBI in the jail setting is most effective if resources dedicated to discharge planning and reliable access to community-based treatment are available
        - Some interventions (e.g., education and incentives) can lead to 
        - Improvements in linking released detainees to post-release medical care 
        - An increase in the likelihood that LTBI treatment will be completed

*

Corrections Recommendations - *

Screening Persons in Holding or Booking Facilities

All personsProvide TB symptom screening at the time of entry

TB symptoms 

Immediately isolate

and transfer to a facility or hospital that has an AII room and 

evaluate for TB disease 

*

Corrections Recommendations - *

Screening New Employees in All Correctional and Detention Facilities

All new employees Evaluate at time of hiring with medical history related to TB and a physical examination for TB disease

No documented history of a positive TST or IGRA result

Should receive a TST or IGRA

(Those not tested during the preceding 12 months

should receive two step TST or single step IGRA)

Positive TST or IGRA result Should have a chest radiograph 

and a medical evaluation

No TB disease Consider for LTBI treatment

TB disease Should be told NOT to work until no longer infectious

*

Corrections Recommendations - *

Other Persons Who Need to Be Screened
        - People who are neither inmates nor employees but who visit high-risk facilities on a regular basis should be considered for screening (e.g., food handlers, service workers, volunteers,  and those providing religious ministries)
        - Screening should follow the same procedures as for employees

*

Corrections Recommendations - *

Periodic Screening of Inmates and Employees
        - Long-term inmates and all employees who have a negative baseline TST or IGRA result should have follow-up testing at least annually
        - Persons who have a history of a positive test result should be screened for symptoms of TB disease at least annually
        - Annual chest radiographs are unnecessary for the follow-up evaluation of infected persons

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Use of Data to Refine Policies and Procedures
        - Collect and analyze data on the effectiveness of the facility screening policies and procedures
        - Refine policies and procedures based on the data

*

Corrections Recommendations - *

Case Reporting

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Reporting Drug Susceptibility Results

Report drug susceptibility results to 
        - The state or local health department for use in monitoring rates of drug resistance
        - All health departments managing the infectious person’s contacts to help determine the LTBI treatment regimen

*

Corrections Recommendations - *

Isolation in an Airborne Infection Isolation (AII) Room

Corrections Recommendations - *

Initiation of TB Airborne Precautions

Signs or symptoms of TB disease

Documented TB diseaseand has NOT completed treatmentor has NOT been determined previously to be noninfectious

Or

Initiate for any patient with the following:

*

Corrections Recommendations - *

Remaining in an AII Room

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

*

Corrections Recommendations - *

Discontinuation of Airborne Precautions for Suspected TB

Infectious TB is considered unlikely 

AND

Another diagnosis is made that explains the clinical syndrome

The patient has 3 negative acid-fast bacilli (AFB) sputum-smear results
        - Should be collected 8–24 hours apart
        - At least one should be an early morning specimen
        - If AFB sputum negative and suspicion for TB remains, should be started on 4 drugs before release from AII room

Or

*

Corrections Recommendations - *

Environmental Controls

Corrections Recommendations - *

Environmental Controls (1)
        - Should be implemented when the risk for TB transmission persists despite efforts to screen and treat infected inmates
        - Used to remove or inactivate M. tuberculosis in areas in which the organism could be transmitted

*

Corrections Recommendations - *

Environmental Controls (2)
        - Primary environmental controls
        - Control the source of infection with local exhaust ventilation
        - Secondary environmental controls
        - Control airflow to prevent contamination of air adjacent to the source or clean air using a high-efficiency particulate air (HEPA) filter or ultraviolet germicidal irradiation (UVGI)

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Respiratory Protection

Corrections Recommendations - *

Considerations for Selection of Respirators

Respiratory protection is used 
        - When administrative and environmental controls alone have not reduced the risk for infection with M. tuberculosis to an acceptable level
        - For specific settings and situations
        - Entering AII rooms
        - Transporting infectious inmates
        - Participating in cough-inducing procedures

*

Corrections Recommendations - *

Respirators

N-95 Particulate Respirator

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

www.cdc.gov/niosh

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Key Elements of a Respiratory Protection Program
        - Assignment of responsibility
        - Training
        - Fit testing

*

Corrections Recommendations - *

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

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

*

Corrections Recommendations - *

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

Transporting in a vehicle that is NOT an ambulance
        - Ventilation system should bring in as much outdoor air as possible
        - Set ventilation system to noncirculating
        - Isolate the cab from the rest of the vehicle if possible
        - Place patient in the rear seat

*

Corrections Recommendations - *

Precautions for Transporting Patients Between Correctional or Detention Facilities (3)

Transporting in a vehicle that is NOT an ambulance
        - Drivers and other persons should wear at least an N95 disposable respirator
        - If the patient has signs or symptoms of infectious TB, the patient should wear a surgical or procedure mask during transport, in waiting areas, or when others are present

*

Corrections Recommendations - *

Diagnosis and Treatment of Latent Tuberculosis Infection and Tuberculosis Disease

Corrections Recommendations - *

TB Disease Symptoms
        - Persistent cough (≥ 3 weeks)
        - Hemoptysis (coughing up blood) 
        - Night sweats
        - Weight loss
        - Anorexia
        - Fever

*

Corrections Recommendations - *

Diagnostic Tests for TB Disease and LTBI
        - TST
        - IGRA
        - Chest radiograph
        - Laboratory examination of sputum samples or other body tissues and fluid

*

Corrections Recommendations - *

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

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

*

Corrections Recommendations - *

*  Except for persons in whom 5 mm is considered positive: 

Persons infected with HIV

Persons who are recent contacts of patients with TB disease

Persons with fibrotic changes on chest radiograph consistent with previous TB disease

Organ transplant recipients and patients with other immunocompromising conditions (e.g., persons receiving >15 mg/day of prednisone for 1 month)

Persons suspected of having TB disease

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

*

Corrections Recommendations - *

Special Considerations in Interpreting the TST

Interpretation may be complicated by 
        - Vaccination with BCG
        - Anergy
        - Boosting effect

*

Corrections Recommendations - *

Correctional Staff and Inmates who Refuse Testing forM. tuberculosis Infection
        - Educate the person on the importance of routine screening of correctional facility staff and inmates
        - If the person continues to refuse a TST, offer an IGRA test (and vice versa)

*

Corrections Recommendations - *

IGRA Test Results and Interpretation
| Laboratory Interpretation | Clinical Interpretation                                                                                                                                                   |
|---------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Positive IGRA result      | M. tuberculosis infection likely; medical evaluation indicated                                                                                                            |
| Negative IGRA result      | M. tuberculosis infection unlikely but cannot be excluded, especially when illness is consistent with TB disease and likelihood of progression to TB disease is increased |
| Indeterminate IGRA result | Not possible to determine likelihood of M. tuberculosis infection from blood sample supplied                                                                              |

*

Corrections Recommendations - *

Interpreting Chest RadiographsPersons with Suspected Pulmonary TB (1)
        - Multiple types of abnormalities  strongly suggest pulmonary  TB disease:
        - Upper-lobe infiltration
        - Cavitation
        - Pleural effusion
        - Infiltrates can be patchy or nodular and observed in the apical or subapical posterior upper lobes or superior segment of the lower lobes

*

Corrections Recommendations - *

Interpreting Chest RadiographsPersons with Suspected Pulmonary TB (2)
        - Radiographic presentation of pulmonary TB in HIV-infected persons may be atypical
        - In these persons, apical cavitary disease is less common than in HIV-uninfected patients
        - More common findings include infiltrates in any lung zone, mediastinal or hilar adenopathy, or in rare cases, a normal chest radiograph

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Specimen Collection (1)
        - Collect at least 3 sputum specimens 
        - 8–24 hours apart
        - At least 1 specimen in the early morning
        - Preferably in a sputum induction booth or an AII room
        - Outdoors in resource-limited settings
        - Observed by a health-care professional if possible

*

Corrections Recommendations - *

Specimen Collection (2)
        - Instruct patients how to produce an adequate sputum specimen
        - For patients who are unable to produce an adequate sputum specimen, induce by inhalation of an aerosol of warm hypertonic saline

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Laboratory Examination (1)
| Feature                           | Sputum Smear                                                        | Culture                                                                                                                                             |
|-----------------------------------|---------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------|
| Time                              | Usually within 1day                                                 | Usually within 28 days                                                                                                                              |
| Basis of procedure                | Look for AFB on slide under microscope                              | Look for colonies of tubercle bacilli or other mycobacteria on culture media in incubator                                                           |
| Significance of test              | Detection of  mycobacteria                                          | Definitive identification of specific mycobacteria species necessary for confirmation of TB and for drug susceptibility                             |
| Significance of a negative report | Patient is less likely to be infectious Does NOT exclude TB disease | No live tubercle bacilli found in the specimen.Does not rule out TB disease (live tubercle bacilli may be in other specimens and/or in the patient) |

*

Corrections Recommendations - *

Laboratory Examination (2)
| Feature                           | Sputum Smear                                                                                                  | Culture                                           |
|-----------------------------------|---------------------------------------------------------------------------------------------------------------|---------------------------------------------------|
| Significance of a positive report | Patient is more likely to be infectious (if AFB are tubercle bacilli)AFB could be nontuberculous mycobacteria | Confirms diagnosis of TB disease                  |
| Report positive results           | Within 24 hours of collection                                                                                 | Within 24 hours of notation of a positive culture |

*

Corrections Recommendations - *

Drug-Susceptibility Tests
        - Perform on initial isolates  from all patients with TB   disease
        - Repeat if
        - Sputum specimens continue to be culture-positive 3 months after initiation of treatment
        - A patient’s culture that had converted to negative subsequently reverts to positive 

*

Corrections Recommendations - *

Drug-Susceptibility Testing
        - When results are available, adjust the treatment regimen accordingly
        - Medical providers treating patients with drug-resistant TB disease should seek expert consultation and collaborate with the local health department for treatment decisions

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Candidates for Treatment of LTBI (Correctional Facility Staff and Inmates) (1)
        - High-risk groups with a ≥ 5 mm TST result, regardless of age:
        - HIV-infected persons
        - Recent contacts of a TB patient
        - Persons with fibrotic changes on chest radiograph consistent with previous TB disease
        - Patients with organ transplants and other immuno-compromising conditions who receive the equivalent of ≥ 15 mg/day of prednisone for ≥ 1 month 

*

Corrections Recommendations - *

Candidates for Treatment of LTBI (Correctional Facility Staff and Inmates) (2) 
        - All others with a ≥ 10 mm TST result
        - Positive IGRA result

*

Corrections Recommendations - *

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

* See footnotes on next slide
| Drugs      | Duration (mos) | Interval | No. of Doses | Rating (Evidence) †   |
|------------|----------------|----------|--------------|-----------------------|
| HIV -      | HIV +          |
| Isoniazid  | 9              | Daily    | 270          | A (II)                | A (II) |
| Twice wkly | 78             | B (II)   | B (II)       |
| Isoniazid  | 6              | Daily    | 180          | B (I)                 | C (I) |
| Twice wkly | 52             | B (II)   | C (I)        |
| Rifampin * | 4              | Daily    | 120          | B (II)                | B (III) |

*

Corrections Recommendations - *

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

*  Substitution of rifabutin for rifampin might be indicated in HIV-infected patients taking certain antiretroviral medications because drug-drug interaction might be less frequent when rifabutin is used

†	Ratings are based on modification of the U.S. Public Health Service rating system (American Thoracic Society, CDC. Targeted tuberculin testing and treatment of latent TB infection) 

A = Preferred

B = Acceptable alternative

C = Offer when A and B   cannot be given

I =   Randomized clinical data

II =  Data from clinical trials that  are not randomized or were   conducted in other populations

III = Expert opinion

*

Corrections Recommendations - *

Contacts of Patients withDrug-Susceptible TB Disease (1)
        - Contacts of patients with drug-susceptible TB disease who once tested negative but subsequently have a positive TST result (i.e., ≥ 5 mm) should be evaluated for treatment of LTBI
        - Majority of persons who are infected will have a positive TST result within 6 weeks of exposure
        - Retest those who have initial negative TST result 8–10 weeks after exposure

*

Corrections Recommendations - *

DOT for LTBI Patients
        - LTBI patients who should receive DOT
        - All patients on intermittent treatment
        - Use DOT with daily dosing of LTBI treatment whenever feasible
        - Patients with highest priority for DOT
        - Persons with HIV infection
        - Recent contacts of infectious patients with pulmonary TB 

Corrections Recommendations - *

Contacts of Patients withDrug-Susceptible TB Disease (2)
        - Consider the following high-risk groups for LTBI treatment: 
        - HIV-infected persons (regardless of TST result or previous LTBI treatment history)
        - Persons receiving immunosuppressive therapy (regardless of TST result or previous LTBI treatment history)
        - Persons with a known documented (previous to current exposure) positive TST result if they have not been previously treated

*

Corrections Recommendations - *

Contacts of Patients with Drug-Resistant TB Disease (3)
        - Treatment for LTBI caused by drug-resistant M. tuberculosis organisms is complex 
        - Should be conducted in consultation with the local health department TB control program and persons with expertise in the medical management of drug-resistant TB
        - Will require waiting for drug-susceptibility testing results

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Initial Drug Regimens for Culture-Positive Pulmonary TB Caused by Drug-Susceptible Organisms (1)

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

*

Corrections Recommendations - *

Initial Drug Regimens for Culture-Positive Pulmonary TB Caused by Drug-Susceptible Organisms (2)(Footnotes)

Source: Modified from American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR 2003; 52(No. RR-11):1-80

*  Substitution of rifabutin for rifampin might be indicated in HIV-infected patients taking certain antiretroviral medications because drug-drug interaction might be less frequent when rifabutin is used

†  May be discontinued if the infecting organism is confirmed to be susceptible to isoniazid and rifampin

§	Not recommended for HIV-infected patients with CD4+ T-lymphocyte cell counts of <100 cells/mm3. Additional information is available at http://www.cdc.gov/nchstp/tb/tb_hiv_drugs/toc.htm

*

Corrections Recommendations - *

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

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

*

Corrections Recommendations - *

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

*	Patients with cavitation on initial chest radiograph and positive cultures at completion of 2 months of therapy should receive a 7-month (31 wks; either 217 doses [daily] or 62 doses [twice wkly]) continuation phase

†	Ratings are based on modification of the U.S. Public Health Service rating system (American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR 2003;52 [No. RR-1]:1-80) 

A = Preferred

B = Acceptable alternative

C = Offer when A and B   cannot be given

I =   Randomized clinical data

II =  Data from clinical trials that are   not randomized or were    conducted in other populations

III = Expert opinion

*

Corrections Recommendations - *

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

§	 Human immunodeficiency virus (HIV)-negative

¶	 HIV-infected

**  Substitution of rifabutin for rifampin might be indicated    in HIV-infected patients taking certain antiretroviral  medications because drug-drug interaction might be  less frequent when rifabutin is used

††	 Not recommended for HIV-infected patients with CD4+    T-lymphocyte cell counts <100 cells/mm3. Additional  information is available at  www.cdc.gov/nchstp/tb/tb_hiv_drugs/toc.htm.

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Discharge Planning

Corrections Recommendations - *

Discharge Planning

Correctional facilities’ discharge planning process should include

Collaborating with public health and other community health-care professionals

Ensuring continuity of case management

Evaluating discharge-planning procedures and modifying procedures as needed to improve outcomes

*

Corrections Recommendations - *

Collaboration Between Correction Facilities and Public Health Officials for Discharge Planning (1)

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

*

Corrections Recommendations - *

Collaboration Between Correction Facilities and Public Health Officials for Discharge Planning (2)

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

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Components of Discharge Planning (1)
        - Initiate discharge planning early
        - Provide case management
        - Obtain detailed contact information 
        - Assess and plan for substance abuse and mental health treatment and other social services

*

Corrections Recommendations - *

Components of Discharge Planning (2)
        - Make arrangements for post-release  follow-up
        - Make provisions for unplanned release and unplanned transfers
        - Provide education and counseling

*

Corrections Recommendations - *

DOT for TB Disease or LTBI in the Correctional Setting
        - Provides an opportunity for educating and counseling inmates
        - Establishes a routine of medication administration (this may enhance adherence after release)

*

Corrections Recommendations - *

Community-Based Case Management After Release (1)
        - Case-management strategies begun in the correctional facility should be continued after release for former inmates with
        - Confirmed or suspected TB disease
        - LTBI who are at high risk for progression to TB 

*

Corrections Recommendations - *

Community-Based Case Management after Release (2)
        - Incentives combined with education and counseling optimize both short-and long-term adherence
        - Case management results in improved LTBI treatment completion rates if cultural differences and patient-defined needs are addressed

*

Corrections Recommendations - *

Discharge Planning for Immigration and Customs Enforcement Detainees (1)
        - Persons with TB disease detained by Immigration and Customs Enforcement (ICE) officers are a potential public health threat because they are
        - Typically highly mobile
        - Likely to leave and reenter the United States before completion of TB therapy
        - At high risk for interrupting treatment

*

Corrections Recommendations - *

Discharge Planning for Immigration and Customs Enforcement Detainees (2)
        - Ensuring treatment of such detainees is important to the national strategy to eliminate TB in the United States
        - Correctional facility staff should identify patients who are ICE detainees when reporting TB cases to local and state health departments

Corrections Recommendations - *

Contact Investigation

*

Corrections Recommendations - *

Overview of TB Contact Investigation (1)
        - Overall goal is to interrupt transmission of M. tuberculosis
        - Ongoing transmission is prevented by

Identifying, isolating, and treating persons with TB disease

Identifying infected contacts of the source patient and secondary patients and providing them with a complete course of treatment for LTBI

*

Corrections Recommendations - *

Overview of TB Contact Investigation (2)
        - The contact investigation can serve to 
        - Educate corrections staff and inmates about the risk, treatment, and prevention of TB in correctional facilities
        - Inform staff and inmates regarding the importance of engaging in recommended TB-control practices and procedures within the correctional system
        - Emphasize the importance of completion of therapy for persons with TB disease and LTBI

*

Corrections Recommendations - *

Overview of TB Contact Investigation (3)
        - Requires a multidisciplinary team
        - Health departments can help in planning, implementing, and evaluating a TB contact investigation
        - Data collection and management is an essential component and requires a systematic approach to collecting, organizing, and analyzing TB-associated data

*

Corrections Recommendations - *

Overview of TB Contact Investigation (4)
        - Two correctional information systems critical to the efficient conduct of a contact investigation:

An inmate medical record system containing TST results and other relevant information

An inmate tracking system

*

Corrections Recommendations - *

TB Transmission Factors (1)
| Characteristics | High Likelihood of Transmission                                                                                                    |
|-----------------|------------------------------------------------------------------------------------------------------------------------------------|
| Source Patient  | AFB smear-positive Cavitary diseaseDelayed diagnosis                                                                               |
| Contacts        | AgeInfants and children < 4 years of ageImmunosuppression HIV infectedOther forms of immune suppressionOther medical conditions |

Corrections Recommendations - *

TB Transmission Factors (2)
| Characteristics | High Likelihood of Transmission                                                                                                                                                      |
|-----------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Exposure        | Air volume Low air volumeConfined spaceVentilationConfined air with little or no ventilationRecirculated air without HEPA filtrationDuration of exposureLonger and frequent exposure |

Corrections Recommendations - *

Decision to Initiate a Contact Investigation (1)
        - Make decisions to conduct contact investigations on a case-by-case basis
        - Conduct contact investigations in conjunction with the public health department

*

Corrections Recommendations - *

Decision to Initiate a Contact Investigation (2)
        - Conduct contact investigations in the following circumstances:
        - Suspected or confirmed pulmonary, laryngeal, or pleural TB with cavitary disease on chest radiograph or positive AFB smears (sputum or other respiratory specimens)
        - Suspected or confirmed pulmonary (noncavitary) or pleural TB with negative AFB smears (sputum or other respiratory specimens) and a decision has been made to initiate TB treatment

*

Corrections Recommendations - *

Principles for Conducting the Contact Investigation (1)
        - Stratify identified contacts by their duration and intensity of exposure to the source patient
        - Classify HIV-infected and other immunosuppressed contacts as the highest priority group for screening and initiation of LTBI therapy, regardless of duration and intensity of exposure

*

Corrections Recommendations - *

Principles for Conducting the Contact Investigation (2)
        - Immediately screen groups of contacts identified with the greatest degree of exposure, follow with repeat testing at 8–10 weeks if the initial TST or IGRA is negative
        - Calculate the infection rate to assess the level of TB transmission

*

Corrections Recommendations - *

Principles for Conducting the Contact Investigation (3)
        - Make decisions to expand the contact investigation to groups with less exposure on the basis of the calculated infection rate 
        - If no evidence of transmission is observed, do NOT expand the investigation
        - If transmission is occurring, expand the investigation incrementally to groups with less exposure
        - Include corrections and medical staff in the contact investigation, depending on their exposure risks

*

Corrections Recommendations - *

Contact Investigation Stepwise Procedures (1)

Notify correctional management officials

Conduct a source patient chart review

Interview the source patient

Define the infectious period

Convene the contact investigation team

Update correctional management official

Obtain source case inmate traffic history

Tour exposure sites

*

Corrections Recommendations - *

Contact Investigation Stepwise Procedures (2)

Prioritize contacts

Develop contact lists

Conduct a medical record review on each high-priority contact

Evaluate HIV-infected contacts for TB disease and LTBI promptly

Place and read initial TST or perform IGRA on eligible contacts

Make referrals for contact evaluation

*

Corrections Recommendations - *

Contact Investigation Stepwise Procedures (3)

Calculate the infection rate and determine the need to expand the investigation

Place and read follow-up TST or perform follow-up IGRA

Determine the infection/transmission rate

Write a summary report

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Medical Evaluation of All Contacts

AIl contacts

Interview for symptoms of TB disease using a standard symptom questionnaire

TB symptoms 

Receive a chest radiograph and a complete medical evaluation by a physician, regardless of TST or IGRA status

No TB symptoms but  risk factors 

Provide additionalscreening within 7 days of arrival

HIV statusis unknown 

Consider HIV testing
| InfectiousInmates should be isolated in an AII room if infectious TB is suspected by chest radiograph or clinical findings Symptomatic staff should not be permitted to work) |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

*

Corrections Recommendations - *

Medical Evaluation of ContactsInmates With Documented Previous Positive TST or IGRA Result

AIl inmates with documented previous positive TST or IGRA Result 

Interview for symptoms of TB disease using a standard symptom questionnaire

TB symptoms 

Receive further evaluation

(e.g., chest radiograph for persons with respiratory symptoms)

No TB symptoms

Need no further follow-up, other than consider for routine treatment of LTBI (if not completed in the past)

*

Corrections Recommendations - *

        - HIV-infected contacts should
        - Be interviewed for symptoms
        - Have a TST or IGRA
        - Have a chest radiograph
        - Complete a course of treatment for LTBI (once TB disease has been ruled out) regardless of the TST or IGRA result

Medical Evaluation of Contacts HIV-Infected Inmates (1)

*

Corrections Recommendations - *

        - Treatment should be initiated even for persons with a history of previous treatment of LTBI or TB disease because of the possibility of re-infection
        - Those with a history of a negative TST or IGRA result should have a TST or IGRA done at baseline and again in   8–10 weeks

Medical Evaluation of Contacts HIV-Infected Inmates (2)

*

Corrections Recommendations - *

        - Conduct mandatory TST or IGRA testing of all previously negative (HIV and TST or IGRA) inmate contacts at baseline (unless previously tested within 1–3 months of exposure)
        - Repeat testing 8–10 weeks from the most recent contact with the source patient 

Medical Evaluation of Contacts HIV-Negative Inmates with Previous Negative TST or IGRA

*

Corrections Recommendations - *

        - Offer treatment for LTBI (unless medically contraindicated) to
        - Persons whose TST or IGRA result converts to positive

Or
        - Persons with newly documented positive TST or IGRA results
        - Inmate contacts who refuse medically indicated treatment for LTBI should be monitored regularly for symptoms

Medical Evaluation of Contacts TST and IGRA Converters

*

Corrections Recommendations - *

Tuberculosis Training and Education of Correctional Workers and Inmates

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Training and Education in Correctional Facilities
        - In-facility, preservice training or orientation should include training and education on M. tuberculosis for people who spend significant time in correctional facilities, and can include
        - Correctional workers
        - Volunteers
        - Inmates
        - Other persons
        - TB training should be provided at least annually thereafter

*

Corrections Recommendations - *

Initial Training and Education for All Correctional Workers (1)

For all correctional workers* include
        - M. tuberculosis transmission signs, symptoms, diagnosis (difference between LTBI and TB disease), and prevention
        - Importance of following up on inmates or correctional workers demonstrating signs or symptoms of TB disease
        - Initiation of AII precautions for inmates with suspected or confirmed TB disease

* Level and detail will vary according to job responsibilities

*

Corrections Recommendations - *

Initial Training and Education for All Correctional Workers (2)

For all correctional workers* include 
        - Policies and indications for discontinuing AII precautions
        - Basic principles of LTBI and TB disease treatment
        - TB disease in immunocompromised persons

* Level and detail will vary according to job responsibilities

*

Corrections Recommendations - *

Required Training for Correctional Workers in Facilities with AII Rooms

For all correctional workers in facilities equipped with AII rooms include
        - Use of administrative and engineering controls and personal protective equipment
        - Respiratory protection program

*

Corrections Recommendations - *

Enhanced Training and Education for Correctional Workers inHigh-Risk Facilities (1)
        - Signs and symptoms of TB disease
        - Transmission of TB disease
        - TB infection-control policies (including instruction on and location of the facility’s written infection-control policies and procedures, exposure control plan, and respiratory protection plan)

*

Corrections Recommendations - *

Enhanced Training and Education for Correctional Workers inHigh-Risk Facilities (2)

If a contact investigation is conducted because of suspected or confirmed infectious TB include
        - Contact investigation guidelines
        - Method used to determine a contact’s risk for infection and prioritization for evaluation and treatment
        - Noninfectiousness of persons with TB disease who have responded to therapy and have submitted 3 AFB-negative sputum smear results
        - Patient confidentiality issues

*

Corrections Recommendations - *

Training and Education of Public Health Department Staff (1)

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

*

Corrections Recommendations - *

Training and Education of Public Health Department Staff (2)

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

*

Corrections Recommendations - *

Training and Education of Inmates

Using appropriate terms for education level and language include
        - General TB information (provided at the time of admission or when being screened for TB)
        - The meaning of a positive TST or IGRA result and treatment options for LTBI
        - Comprehensive TB education, including infectiousness and treatment for inmates being confined with suspected or confirmed TB disease
        - The importance of completing treatment for inmates with LTBI or TB disease

*

Corrections Recommendations - *

Program Evaluation

Corrections Recommendations - *

Six Steps for Monitoring and Evaluation of a TB Prevention and Control Program
        - Identifying collaborators
        - Describing the TB-control program
        - Focusing the evaluation to assess facility TB risk and performance
        - Collecting and organizing data
        - Analyzing data and forming conclusions
        - Using the information to improve the TB program

*

Corrections Recommendations - *

Identifying Collaborators
        - TB control requires collaboration of
        - Correctional system
        - Health departments
        - Other community agencies
        - Early engagement of collaborators
        - Ensures that evaluation will yield most useful information for stakeholders
        - Promotes mutual cooperation for constructive change
        - Each program should have a designated person responsible for data quality and program evaluation 

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Focusing the Evaluation to Assess Risk and PerformanceRisk Assessment (1)

Each facility should annually assess its level of TB risk and include the following indicators:  
        - Burden of disease
        - Community rates of TB disease
        - Number of cases of TB disease in the facility during the preceding year
        - Number and percentage of staff and inmates with LTBI 

*

Corrections Recommendations - *

Focusing the Evaluation to Assess Risk and PerformanceRisk Assessment (2)

Each facility should annually assess its level of TB risk and include the following indicators:  
        - Facility transmission
        - Number and percentage of staff and inmates with TST conversion and reasons for conversion
        - Number of TB exposure incidents (contact investigations)
        - Evidence of person-to-person transmission

*

Corrections Recommendations - *

Performance Measurement for Improving Quality Examples
        - Timeliness of screening and isolation
        - Treatment
        - Continuity of care

*

Corrections Recommendations - *

Assessment of Collaboration(conduct annually)

Each facility should
        - Assess its relationship with local and state public health departments in  
        - Screening
        - Containment
        - Assessment
        - Meet with respective public health staff to review facility 
        - TB risk
        - Policies 
        - Compliance with environmental control and respiratory protection recommendations 

*

Corrections Recommendations - *

Collecting and Organizing Data  (1)
        - Data sources
        - Review medical records 
        - Annually, for facilities that house persons with confirmed or suspected TB disease (including low-risk facilities)
        - Quarterly, for facilities with numerous cases 

*

Corrections Recommendations - *

Collecting and Organizing Data (2)
        - Information infrastructure
        - Health professionals responsible for TB control should have access to
        - Complete medical records
        - Database of essential TB-related activity and measurements

*

Corrections Recommendations - *

Collecting and Organizing Data (3)
        - Information infrastructure
        - Retrievable aggregate record system is essential 
        - For tracking all inmates
        - For assessing the status of persons who have TB disease and LTBI 
        - Electronic medical databases can provide additional benefits

*

Corrections Recommendations - *

Analyzing Data and Drawing Conclusions
        - In a multifacility correctional system, compile data for each facility separately and in aggregate
        - Analyze data against standards which can be defined externally or internally as established by the program collaborators
        - Use data to develop recommendations for program improvement
        - Share evaluation and recommendations with program staff, administrators, and partners, including the local health departments

*

Corrections Recommendations - *

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

*

Corrections Recommendations - *

Collaboration and Responsibilities

Corrections Recommendations - *

Liaisons for TB-Associated Efforts
        - Correctional facilities   and health departments  should each designate  liaisons
        - Liaisons should be either responsible for, or familiar with, TB control
        - Liaisons should hold regular meetings with correctional facility and health department staff to discuss TB-control efforts

*

Corrections Recommendations - *

Roles and Responsibilities That Require Collaboration Between Correctional Facilities and Health Departments (1)
        - Screening and treatment of inmates for LTBI and TB disease
        - Reporting of TB disease
        - Follow-up of inmates with symptoms or abnormal chest radiographs
        - Medical consultation regarding persons with confirmed and suspected TB disease

*

Corrections Recommendations - *

Roles and Responsibilities That Require Collaboration Between Correctional Facilities and Health Departments (2)
        - Contact investigations for reported TB cases
        - Continuity of treatment and discharge planning for persons with TB disease and LTBI
        - Training and education of correctional facility staff
        - Evaluation of screening and case management
        - Facility risk assessment

*

Corrections Recommendations - *

References and Additional Resources

Corrections Recommendations - *

References

MMWR ArticleVolume 55, No. RR-09 1-44 July 7, 2006 

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

www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm?s_cid=rr509a1_e

*

Corrections Recommendations - *

Additional Resources

For additional information on TB, visit the CDC Division of Tuberculosis Elimination Website at

http://www.cdc.gov/tb

*