Transcript No Slide Title

TB Prevention and Control
in Correctional and
Detention Facilities
Mark Lobato, MD
Division of TB Elimination
Centers for Disease
Control and Prevention
Corrections Connections
Forming Partnerships to Stop TB
April 26-27 and May 11, 2007
What’s New? (1)
• Broadens definition of corrections to
include detention facilities
• Uses a risk assessment approach
• Recommends all inmates receive
symptom screening
• Suggests testing by TST or QFT-Gold
What’s New? (2)
• Highlights importance of collaboration,
education, and evaluation
• Emphasizes case management
• Expands environmental controls section
and adds a section on respiratory
protection
• Recognizes the role of ICE in screening
the foreign born in the U.S.
TB Testing
• TST should be done within 7 days
• If TST positive, CXR done within 72 hours
• HIV-infected persons require a CXR
Facility Risk Assessment
Minimum Risk Facility
• Zero TB cases in last year
• Not a “high-risk” population (HIV, IDU)
• Not large numbers of foreign born
• Employees not otherwise at risk for TB
• All other facilities are non-minimal risk
Individual Risk Assessment
Minimum Risk Facility
• Inmates with TB symptoms require
immediate isolation in an AII room
• Individuals in minimum-risk facilities
require further evaluation if
• clinical condition or risk factor for TB
• HIV
• require CXR
Non-Minimum Risk Facility
• Review symptoms at entry
• immediately place symptomatic in a AII room
• TB test (TST, QFT-G, CXR) within 7 days
• CXR for HIV infected or immunosuppressed
• Consider therapy for positive test results
TB Screening: > Minimal Risk Facility
Entry
Screen for
symptoms
TB
Symptoms
Present?
Yes
Isolate and
evaluate
No
Obtain medical History
Previous TST +
documented?
No
Yes
If treatment not
completed, CXR
and evaluate
TB Screening: > Minimal Risk Facility
No previous TST+ documented
TST* or
QFT-G
TST+ or
QFT-G?
Yes
CXR and
evaluate
Yes
CXR and
evaluate
No
HIV+ or at
risk for HIV but
status unknown?
No
Retest periodically
In long-term facilities
*2-step testing recommended for
Initial testing in facilities that
perform periodic TST testing
Recommendations
• Report suspect cases by all entities including
federal facilities to local or state HD
• Screen all incoming inmates at entry with at
least a TB symptom review
• Perform risk assessment
• Isolate TB suspects immediately
• Plan for discharge early
• Provides a special section on ICE detainees
New and Renewed Emphasis
• Summarizes treatment for TB and latent
TB infection
• Expands on collaboration between health
departments and medical staff
• Emphasizes contact investigations
• Provides details for evaluation of TB
control activities
• Offers guidance on training and
education
Airborne Infection Isolation (AII)
• Initiate TB AII precautions for any patient who
• Has signs and symptoms of TB disease
• Has not completed treatment
• Has not previously been determined noninfectious
When to Discontinue AII
• Discontinue AII when infectious TB is unlikely
• Another diagnosis is made
• Patient has 3 negative AFB sputum smears
• If patient has 3 negative AFB smear results
• Release after starting 4 anti-TB drugs
• Patient improving clinically
LTBI - Treatment
• Prioritize patients
• Preferred treatment 9 months INH
• Daily or biweekly (DOT)
• Other regimens
• 4 months rifampin
• NOT 2 months of pyrazidamide and rifampin
• Drug resistance
Collaboration
• Requires formal mechanisms
• Designated liaisons
• Regular meetings
• Written agreements
• Case management
• Discharge planning
• Contact investigations
Case Management
• Care should be individualized
• Management should be coordinated with
health department
• Most inmates released before treatment is
completed
• Evaluate outcomes
Jails – A Community Institution
Shelter
Soup
Kitchen
Homeless
Clinic
Hospital Clinic
Jail
Detention -Center
Discharge Planning
• Requires coordination between
corrections and public health
• Begin as soon as possible
• Interview by health department should
occur before release
Contact Investigations
• Goal is to interrupt TB transmission
• Collaboration with public health essential
• Scope of investigation depends on
• Site of TB disease (pulmonary, laryngeal)
• AFB smear status (smear positive)
• “Index of suspicion”