Arresting TB: Pearls from Beyond the Bars!

Arresting tuberculosis: pearls from beyond the bars! 1

Arresting TB: Pearls from

Beyond the Bars!

Corrections and Public Health Working Together!

Ellen R. Murray, PhD, BSN

Southeastern National TB Center

Objectives

At the end of this presentation, participants will be able to:

• Discuss the risk factors of inmates in corrections to raise the awareness when evaluating TB programs in correctional facilities

• Illustrate how the revolving door of corrections can impact the community so providers can interrupt ongoing transmission of active tuberculosis and potential outbreaks

• List two steps in developing communication with corrections to ensure effective TB program outcomes


U.S. Incarcerated Population

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1995 1997 1998 1999 2000 2001 2002 2005 2010 2015

Jail

Prison

USDOJ. (2015). Correctional Populations in the United States, 2015.

2016

655 incarcerated/100,000 population

2.2 million incarcerated


Characteristics of Correctional Facilities

Poor Circulation

Overcrowding + Inmate

Demographics

= TB Transmission


HIV +

IV Drug Use

Homeless

Community CommunityCorrections


Health Equity – does it exist in corrections?

Prison Isolation in La Victoria Penitencia, DRJail infirmary in Tampa, Florida

Incarcerated Persons in the U.S.

• Over 6 million people were on probation, in jail or prison, or on parole at year-end 2016

− 3.2% of all U.S. adult residents − 1 in every 37 adults.

• Disproportionately high percentage of TB cases occurring among jail and prison population

Bureau of Justice Statistics Report

• 371 (4.0% of all TB cases nationwide) occurred among residents of correctional facilities in 2016

Centers for Disease Control and Prevention


*Correctional facilities include federal prisons, state prisons, local jails, juvenile correctional

facilities, other correctional facilities, or unknown type of correctional facility.

TB Cases among Residents of Correctional

Facilities Ages ≥15, 1993–2018*

TB Cases among Residents of Correctional Facilities Ages ≥15 by

Type of Facility, 2010–2018

*Includes Immigration and Customs Enforcement (ICE) detention centers, tribal jails operated by Indian reservations, police lockups (temporary holding facilities for person who have not been formally charged in court), military stockades and jails, or federal park facilities


Congregate Living, but also High Risk PopulationU.S. TB Cases by Correctional Status and TB Risk Factors*

1993-2016

0% 5% 10% 15% 20% 25% 30% 35%

Non-Injecting

Drug Use

Injecting Drug

Use

Excess Alcohol

Use

Homeless

Correctional Non-Correctional

*History of risk factor in year prior to diagnosis

CDC.gov

Facilities are Different

• Prison

− Federal

• BOP, FDC, ICE

− State

• Juvenile

− Prison

• Jail

− Local

• Local governance or state

governance

• Juvenile

− Detention Centers


Training Should Include Legal Responsibility

• Potential liability− Unidentified contacts− Medical assessment

• Legal liability− Active disease− Transmission

•

Number of cases diagnosed in corrections


History of Incarceration* Among TB Cases, Florida and Selected Counties, 2001

0%

5%

10%

15%

20%

25%

30%

STATE County A County B County C County D County E County F

12% 12%

10%

4%

7%

4% 4%

5.30%

14.40%

6.45%

0.98%

4.80%

2.46%

4.10%

12.61%

6.45%

0.98%

4.12%

1.23%

H/O Incarceration

All Corrections

Local Jail

2001 Data from TIMS

0%

5%

10%

15%

20%

25%

30%

STATE County A County B County C County D County E County F

12%

27%

10%

4%

7%

24%

4%

5.30%

14.40%

6.45%

0.98%

4.80%

2.46%4.10%

12.61%

6.45%

0.98%

4.12%

1.23%

H/O Incarceration

All Corrections

Local Jail

How Does an Inmate Move Through the System

Arrest

Jail

Court

Community Prison Other facility


Screening for TB

• Intake

− Ask questions

• Officer

• Nurse

• Other

• Sick call – questions plus symptoms

• Health Appraisal/Assessment – questions plus . . .

Treatment within Facilities

• Standards of Care− Community− Type of facility− State− World

• Medical − Similar to community− Governed by custody− Contracted (sometimes)

Screening, Sick Call, and Health Appraisals


Health Disparities

• Substance abuse

• Homelessness

• Low Socio-economic factors− “Membership in the Persistently Homeless/Rapid Cycling

cluster was associated with a 235% increase in one’s likelihood of reincarceration. . .”

Identifying Discrete Subgroups of Chronically Homeless Frequent Utilizers of Jail and Public Mental Health Services

http://journals.sagepub.com/doi/abs/10.1177/0093854816680838

Public Health vs. Corrections

Higher TB Rates in Incarcerated Populations

• At least 5-10 times higher than the general population

• Incidence rates - both active TB disease and latent infection − 20 times higher in incarcerated populations compared to worldwide

Baussano, et. al., PLoS

• Federal and state U.S. TB prison rates - 29.4 and 24.2/100,000

− compared to 6.7 per 100,000 in the general population. Inmates were more likely to have TB risk factors.

MacNeil, et al., AJPH, 2005


Quezon City Jail - Manila

Studies Looking at Outbreaks

• Characteristics of Tuberculosis Cases that Started Outbreaks in the United States, 2002-2011

Haddad, M.B., Mitruka, K., Oeltmann, J.E., Johns, E.B., and Navin, T.R. (2015). EID 21(3); 508-10

− Prolonged infectious period− Lack of knowledge− Lack of/poor screening


Arresting TB:

Best Practices for

Controlling TB in

Corrections

Outbreak! The Epidemiology

of an Outbreak in

Corrections

Contact Investigation Begins

• 39 y.o. B/F

• PMH

− Substance abuse

− Diabetes

− HIV-negative

− Asthma

• Diagnosed with TB

• 4/8/05 – from sputum collected at local hospital emergency room

− Sputum

• Smears 4+, 4+, 3+

• Culture positive

• Sensitivities – Pansensitive

• Infectious period

− Original – 2/8/05 – 4/8/05

− After Review

• 2/8/04 to 4/8/05

• History somewhat inaccurate

− Information from patient

• “Released from prison three months prior”

• “No symptoms at that time”

− No further follow-up done by local health department immediately


Incarceration History

Dates of Incarceration

County Jail State Prison• In and out of jail 3 times

TST – 20 mm

• 2004 CXR – stated “WNL” no active disease

• Increased hilar markings, otherwise “normal”

4/27/04 to 3/25/05

TST – 30 mm

Infectious period

?? 2/8/04 to 3/25/05 ??

Sick Calls Identified from Chart Review

• Numerous complaints and medical encounters− Did not appear to be related – all dealt with separately− 38 sick calls and medical encounters with complaints of:

cough dry hoarse voice throat sore

chest pain (right sided) feeling tired flu-like symptoms

laryngitis nonproductive cough productive cough

asthma sinus congestion throat scratchy

lump in right neck bronchitis pneumonia

talking in a whisper bad cold allergies


Case History While Incarcerated in Prison (11 months)

• Prison nurse stated she did not believe the client was infectious – saw no cavities on the x-ray

− The physician agreed!

Chest Radiography in Prison• 5/3/04 CXR – abnormal – enlarged hilar

markings, otherwise Normal• 10/20/04 CXR – abnormal, bilateral

pneumonia, PCP considered

• 5/10/04 – CT scan – abnormal• 11/3/04 – CXR – abnormal, suspicious for

sarcoidosis

• Recommend bronchoscopy – refused! • 6/16/04 – CXR – abnormal

• 5/17/04 – CT scan neck – negative• 2/4/05 – CXR abnormal – bilateral

pneumonia

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Evaluation of the Outbreak – 33 Cases

• Method of diagnosis− Culture – 73%

• Smear positive – 39%

− Clinical – 24%

− Provider diagnosis – 3%

• HIV status− Positive – 36%

− Negative – 61%

• Tuberculin skin test results− Positive – 67%

− Negative – 30%

− Previous positive – 3%

• Race and gender− Female – 97%

− Male – 3%

− Black – 61%

− White – 39%

2

7

6

16

13

8

10

3

19

22

4

12

9

11

23

5

18

14

17

21

24

20

15

Source Case41 Y/O B/F HIV +

2001 Case

26

25

30

28

27

3231

Both

Pleural

Pulmonary

33

1*

29 Unable to link


Community CommunityCorrections

Case – County Jail

• 26 y.o. B/M− Very sickly looking

• Weight Loss• Cough• Fever

− Intoxicated!

• Identified in intake


During TB Case Review . . .

Public Health Record

29 y.o. incarcerated Isolated immediately

No need for CI

Tested arresting officer and jail intake officer Both negative

Jail Medical to do case management

Will follow-up when released from jail

What Followed . . .

• Jail released the inmate after two weeks

• Inmate lost to follow-up − 4+ on sputum smear

• Found 3 months later, back in the jail & treated to completion

• After the case review one year later− According to record at HD – everything

was done per protocol− Reviewed the health record in the jail and

found the following...


During TB Case Review . . .

Public Health Record

29 y.o. incarcerated Isolated immediately

No need for CI

Tested arresting officer and jail intake officer Both negative

Jail Medical to do case management

Will follow-up when released from jail

Jail Medical Record

29 y.o. inmate, identified at intake with symptoms of TB

Immediately removed and placed in MISO#8

With two other inmates

Inmate cooperative, coughing – will follow-up with HD

What would you do next?


The End Result

• Contacts identified after 1 year = 67

− Frequent re-incarcerations (identified 40)

− Follow-up information 32 had TST

24(75%) were TST +

Pod A

Pod DPod C

Pod B

37 man cell

2+ TSTs

17 man cell Ǿ Conversions

39 man cell 22+ TSTs

56% conversions

16 man cell

2+ TSTs but Ǿ conversionsTB Patient

Gaming Table


Opportunities to Impact Patient Outcomes

• Think TB!

• Treat TB if HIV infected

• During risk assessments, ask patients about prior incarceration

• Work collaboratively with state/local Health Department TB program (and correctional facility staff)

• Provide patient education − Signs and symptoms of active TB− Treatment completion

• Consult the TB experts when needed! 1-800-4TB-INFO

Opportunities for Change

• Captive audience

− Training and education

− Focused areas for education, studies

− Opportunities for Release Planning


Questions?

Ellen R. Murray, PhD, BSN, RN

Nurse Consultant/Training Specialist

Southeastern National Tuberculosis Center

(352) 273-9385

[email protected]

Documents

Arresting TB: Pearls from Beyond the Bars!