Texas prisons mend ways via tough jail TB screening

Houston’s jail even adds portable chest X-rays

There was a time when "Texas prison" was a synonym for "good place to catch TB." That time has come and gone, prison officials declare. They credit the change to good compliance with a statute passed in 1993 that requires every jail with more than 100 beds to screen all inmates for TB who are there for more than 14 days.

Widespread compliance with the statute has made a huge dent in TB caseloads in Texas prisons, amounting to a decline in cases of more than 70% since 1994, says Michael Kelley, MD, chief of preventive medicine for the state’s Department of Criminal Justice. As a result, TB case rates in state prisons are about the same as in the city of Houston — a much brighter prospect than in days gone by. Annual skin-test conversion rates in Texas prisons are down dramatically as well, he adds, from a high of more than 6% to 1.4% now.

Screening program a success

Because on average, two-thirds of a given jails’ inmates will have checked out before 14 days have elapsed, many of them still return to the community without having been screened, Kelley concedes. But none go on to prison without first having been screened. "So the screening requirement may not have as great an impact on the community, but it’s had a fantastic impact on the prisons," says Kelley.

Interestingly, the wording of the 1993 statute is a bit vague. It mandates "testing for TB" but doesn’t say exactly how or at what point during the 14 days the testing has to be done.

At the Harris County jail in Houston, that vagueness inspired debate about particulars, says Bobby Davis, RN, CCHP, director of nursing at the Harris County jail in Houston. Did the statute mean a TB skin test, a chest X-ray, or both?

"We debated it with the Texas Department of Health," says Davis. Jail officials also studied requirements of the National Commission on Correctional Healthcare, which mandates some kind of TB check upon intake (simply asking about any possible TB symptoms is enough), as well as a PPD skin test done in conjunction with a health assessment performed on the 14th day.

In the end, the jail, which had just gotten a chunk of money from state legislators worried about severe overcrowding in the correctional system, decided to go whole-hog. They took the new funding and used it to turn one corner of a cellblock into 47 negative-pressure rooms, then bought a digital chest X-ray machine.

Now, inmates are X-rayed as soon as they’re booked. The 70-mm images, stored on a disk, are read by a technician in another building. "The tech doesn’t do any guesswork," says Davis. "Anything that looks even slightly suspicious, that person goes immediately to isolation."

Along with the chest X-ray, intake workers do a health history, asking open-ended questions designed to elicit information about a history of TB or symptoms of current disease. Again, any signs that look suspicious land the inmate in isolation. Then, for those still cooling their heels in jail by day 14, there’s a physical exam conducted by a nurse, which includes a skin test for everyone without a record of a positive skin test. Those who test positive are placed on isoniazid.

All this makes good economic sense as well as good public health policy, given the jail’s size. "We book between 250 and 300 people a day, or about 100,000 a year," says Davis. "We’re the third-largest jail in the country, right behind Los Angeles county, and the second-largest accredited jail in the country."

With 8,300 inmates booked in, Davis estimates he’s got 10 to 12 inmates in his isolation unit and about 420 on treatment for latent TB infection.