Correctional facilities becoming TB reservoirs

CDC issues new guidelines to prevent spread into community

The nation’s prisons and jails are rapidly becoming tuberculosis reservoirs, giving the otherwise stalled TB epidemic an avenue to strike back into communities, health officials are warning.

To meet the threat, comprehensive new guidelines for TB infection control in correctional facilities have been issued by the Atlanta-based Centers for Disease Control and Prevention’s Advisory Council on the Elimination of Tuberculosis (ACET).1 The ACET guidelines emphasize the importance of early identification and isolation of infected inmates as well as measures to screen and protect correctional employees.

’It is starting to be recognized internationally [that] jails and prisons are essentially reservoirs for TB,” says Jeffery Starke, MD, ACET chairman and associate professor of pediatrics at the Baylor College of Medicine in Houston. ’There is also recognition that communities themselves have done precious little to support [TB control] in prisons and jails. We have really paid a price for that.”

With overall national declines in reported TB cases in recent years, the dramatic resurgence that began in the mid-1980s has been blunted by infection control measures in hospitals and public health efforts, such as directly observed therapy. However, the shifting epidemiology of TB finds as many as 50% of new cases occurring in clusters that reflect recent transmission in a single setting, Starke says. Such clusters — which often involve repeated exposures to a single undiagnosed active case — have been found in such settings as homeless shelters, bars, and apartment complexes.

’The quintessential example of that is prisons and jails,” he says.

Correctional settings amplify and accelerate TB in part because they house a very susceptible population, including those with HIV infection and others immune suppressed through poor nutrition and alcohol and drug abuse, Starke notes. Accordingly, the prevalence of TB among inmates remains high, with estimates ranging from 14% to 25%, ACET reports. The trend is worrisome because an increasing number of people either work in or are confined to correctional facilities.

According to ACET, in 1980, one of every 453 U.S. residents was incarcerated; by the end of 1993, that ratio had grown to one of every 189 residents. From 1980 through 1994, the number of prisoners in federal and state correctional facilities more than tripled and now numbers more than 1 million people. Many more are held for short stays and released from jails, with ACET citing a figure of 9.9 million released from jails in 1991. Inmates who develop active TB disease after their release might infect others, including young children who are especially vulnerable, the committee emphasized, noting that more than half the men and two-thirds of incarcerated women report having children.

’I can’t give you exact numbers, but I can trace a fair percentage of my [pediatric patients] with active TB to contacts who spent time in prison or jail,” Starke says. ’They either got infected or even developed active TB in prison or jail and then infected people in their [home] environment.”

Likewise, correctional-facility employees are at risk for occupational exposure to TB, and they may in turn pose a threat to their families if active TB ensues. In that regard, the ACET guidelines urge that all new correctional employees be medically evaluated, including initial and annual TB skin testing for those who do not have a documented history of a positive skin-test result.

All correctional facilities — even those in which few TB cases are expected to occur — should designate someone with experience in infection control, occupational health, and engineering to be responsible for the TB infection control program in the facility, ACET advises. In that regard, independent or hospital-based infection control consultants can work with municipalities or private prison systems to assist in interpreting and implementing the guidelines, Starke notes.

’This is really TB 101 for prisons and jails,” Starke says. ’If they do it — and I think it’s doable — they will go a long way toward controlling TB problems in their facilities.”

Much as in hospitals, a series of exposures due to an unsuspected TB case is likely to be the most problematic situation for a correctional facility.

’Every once in a while we get somebody that is bused into to us — sent over because they are obviously sick for some reason, but they have not had a full medical evaluation, and they come in coughing,” explains Cathe Beebe, BSN, infection control professional at Augusta State Prison in Grovetown, GA. ’If we find out we do have a [TB] exposure, we have to double back and track down the driver, any other inmates on the bus, and also let their home institution know.”

With 34 TB isolation rooms and an affiliated hospital, the correctional facility regularly accepts TB cases from other state facilities. At any given time, there are about 15 inmates in rule-out TB isolation, and between 80 and 90 on maintenance medications, Beebe says. Those on isolation must have three negative sputum tests and a minimum of two-weeks medication before returning to the prison population.

’If they refuse any of their TB medications, they automatically come back in, and we start back at square one with them,” Beebe says.

Yet Augusta State’s comprehensive control programs and isolation facilities are more of the exception than the rule in corrections, particularly in jail systems with frequent turnover of inmates and inadequate engineering controls.

’Jails have an incredibly rapid turnover with very high volume,” Starke says. ’For instance the Harris County Jail in Houston — which at any given time houses about 5,000 inmates — has about 100,000 total admissions during the year. The average length of stay is really just a few days, so it’s long enough for TB to be transmitted, but it is very difficult to institute any kind of a screening program because that takes time.”

In such situations, screening for classic TB symptoms like persistent cough and weight loss is more practical than administering TB skin tests which will likely be lost to follow-up before they can be read and recorded, Starke says. Another option is using X-rays. But in any case, arrangements for isolation or transfer must be in place for screening to have full benefit, he says. Less expensive alternatives to negative pressure isolation rooms include using portable high efficiency particulate air (HEPA) filter units and/or ultra violet lights, he adds. In general, infection control consultants working with correctional facilities should use the guidelines in doing a preliminary risk assessment of the correctional facility and then consider options for prevention and control.

Reference

1. Centers for Disease Control and Prevention. Prevention and control of tuberculosis in correctional facilities: Recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR 1996; 45(No.RR-8) 1-27.