TB plus HIV cause big trouble for prison, jail in two Southern states
TB plus HIV cause big trouble for prison, jail in two Southern states
In SC, an outbreak; in GA, a court order to shape up
The days when outbreaks of multidrug-resistant disease swept through institutional settings have been distanced by the passage of almost a decade. But recent events suggest that when it comes to TB and HIV making mischief in jails and prisons, the past isn’t past at all.
In an HIV-only unit inside a South Carolina men’s prison, a TB outbreak last year resulted in 34 cases — 31 inside the prison and the remaining three outside. In the community, contact investigators had to track down more than 100 men who had been released by the time the outbreak was discovered. Even after complex treatment regimens for active HIV-infected cases have been completed, state TB experts note that two years of monitoring remain for prisoners who were exposed.
Last spring, as South Carolina TB controllers were still mopping up the mess, a district court judge in Atlanta ruled that TB control measures and HIV care for prisoners in the Fulton County jail were dangerously inadequate and must be improved. "Everyone recognizes that we have a bad situation," noted U.S. District Judge Marvin H. Shoob. A settlement was reached earlier this year between the jail and inmates.
Both situations highlight the dangers of housing groups of people segregated by HIV status or, as was the case in the Atlanta jail, crowding together prisoners at risk for HIV and TB, especially when necessary safeguards against the spread of infectious diseases are lacking.
Both situations also show how important it is for public health authorities to stay in close touch with prisons and jails, experts say. Even then, they add, there are no guarantees.
In South Carolina, the outbreak in the Broad River Men’s Correctional Institution in Columbia was discovered last year in early fall, says Carol Pozsik, RN, MPH, chief of the TB control division for the state health department. (See related story, p. 80.)
Trouble began when an older man on the HIV unit complained of stomach problems and poor appetite. He also mentioned some respiratory symptoms, which the health care staff at the prison didn’t seriously, Pozsik says.
As it happened, the prisoner with the stomach complaints devoted lots of time to religious activities, such as Bible study, with fellow inmates. Known to be a longtime tuberculin skin-test reactor, he’d attempted prophylaxis twice before but had failed to complete it. When the health care staff at the prison offered it again, once more he refused.
In hindsight, Pozsik conceded, it’s clear someone at the prison should have attended more closely to the man’s respiratory complaints. She says the staff did the best they could under less-than-ideal circumstances. "There are so many health-related issues with the inmates — everything from cancer to ingrown toenails. You name it," she says.
Mammoth contact investigation
Later, federal TB experts surmised the man probably had been infectious for several months before someone realized what was happening. He may even have fallen into the category of "hyper-transmitter," some would later say.
By the time the diagnosis had been clinched, more than 100 men on the unit had already finished their sentences and been released. Early in the contact investigation, Pozsik remembers getting a call from a hospital in another part of the state. A nurse preparing a history on a patient being admitted with TB symptoms discovered her patient had just come from the prison’s HIV unit.
The nurse rushed to call Pozsik. "’We’ve heard you all are having some trouble down there,’" she said. "’We think we’ve got one of the ones you’re looking for.’" The man turned out to be the first of three cases eventually found in the community.
Almost all the rest of the 100 inmates released into the community also were found, though not as easily as the case in the hospital. "We were looking for people who didn’t want to be found, of course," Pozsik says. "They’d been watched long enough already." In the end, all but about six were tracked down. "They’ve either moved to other states, or, as far as we can tell, just disappeared off the face of the earth," she adds.
Back on one wing of the HIV unit, TB control experts were witnessing extravagant reactions to tuberculin skin tests. Of 90 men on the index case’s wing, 73 men reacted, says Pozsik. "We were seeing reactions more than 20 millimeters in size, with oozing, running sores," she recalls. "When I saw the size of those reactions, that’s when I knew we were in big, big trouble."
Most of the inmates were placed on prophylaxis, but liver function difficulties, often related to hepatitis C infections, kept some from completing it. Others, because of their antiretroviral regimens, couldn’t take the short-course, rifampin- containing regimen. Managing treatment regimens for men on combination therapy was a nightmare, adds Pozsik. "It was very complex, very complicated."
It’s hard to overestimate the impact of community contact investigations on local and state public health, she adds. "In many places, the work load doubled. And, of course, we still have people coming out, over and above the original 100."
At the height of the investigation, the Centers for Disease Control and Prevention lent several people to help out, but the lion’s share of the work fell, inevitably, on the backs of the state field staff. "And of course they’ve already got work of their own," Pozsik adds.
Recounting the investigation at a recent meeting of the Advisory Council for the Elimination of Tuberculosis (ACET), Pozsik says she looked around the room and noticed rows of faces frozen in expressions of horror. "This is the kind of thing that could happen to any one of us," she says. "I think everyone in the room knew that."
Conditions improve after lawsuit settlement
In Atlanta’s Fulton County jail, where estimates place the number of HIV-infected inmates at any given time at about 150, a different set of circumstances set the stage for the spread of infectious disease.
According to a lawsuit brought against the jail (along with other defendants, among them the city’s large indigent-care public hospital), inmates were routinely crowded into holding tanks for days a time before TB skin tests could be given. Once skin tests were implanted, they often were not read in a timely fashion, the lawsuit says. As for negative-pressure rooms, no one knew whether the units were functional or not, says Tamara Serwer, JD, staff attorney for the chief plaintiff, an Atlanta-based prisoners’ advocacy group called the Southern Center for Human Rights.
"If someone with obvious symptoms of TB came in, they were sent out [to Grady Hospital]," says Serwer. "But a correctional officer would have to be the one to notice. Meanwhile people were sitting in the holding tank for days."
Worse, HIV-infected inmates admitted on a regimen of antiretroviral therapy and protease inhibitors typically found that once in jail, they were denied access to their medications, says Serwer. Grady Hospital’s infectious disease clinic did provide good care for inmates with HIV, she adds, but in a fashion that could hardly be called timely. "It would take six to eight weeks before patients would get seen," she says. "They’d get no medications in the interim. No one knew or cared that people taking antiretrovirals can’t be suspended like that."
As the lawsuit was being prepared, Grady Hospital, buffeted by financial problems, declared it would no longer provide care to jail inmates with HIV. That left the jail without any care for HIV-infected inmates for a period of two months.
Delays and other problems related to the care of HIV-infected inmates did occur, but the main cause was severe overcrowding, not intentional neglect, says Capt. David Chadd, public information officer for the Fulton County Sheriff’s Department. The jail was designed to hold 1,400 people, but at times, it held as many as 4,300, Chadd says. At the time the lawsuit was filed, occupancy stood at about 2,250, he reports. "With that much overcrowding, you’re going to have people who come in who are sick," he says.
Since the settlement was reached, both the health care service and the administration at the jail have changed hands, Chadd notes. "We’re striving hard to address the problems and to make conditions acceptable to the lawyers and the judge," he explains.
Serwer says an infectious-disease specialist now works on site at the jail, seeing inmates twice weekly. A physician assistant helps out, and a system of nurse case management has been instituted.
(Editor’s note: To read the text of the amended complaint, visit the following Web site: www.schr.org/ news/news_hiv.htm.)
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