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
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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
Arresting tuberculosis: pearls from beyond the bars! 2
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
Arresting tuberculosis: pearls from beyond the bars! 3
Characteristics of Correctional Facilities
Poor Circulation
Overcrowding + Inmate
Demographics
= TB Transmission
Arresting tuberculosis: pearls from beyond the bars! 4
HIV +
IV Drug Use
Homeless
Community CommunityCorrections
Arresting tuberculosis: pearls from beyond the bars! 5
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
Arresting tuberculosis: pearls from beyond the bars! 6
*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
Arresting tuberculosis: pearls from beyond the bars! 7
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
Arresting tuberculosis: pearls from beyond the bars! 8
Training Should Include Legal Responsibility
• Potential liability− Unidentified contacts− Medical assessment
• Legal liability− Active disease− Transmission
•
Number of cases diagnosed in corrections
Arresting tuberculosis: pearls from beyond the bars! 9
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
Arresting tuberculosis: pearls from beyond the bars! 10
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
Arresting tuberculosis: pearls from beyond the bars! 11
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
• 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
Arresting tuberculosis: pearls from beyond the bars! 12
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 tuberculosis: pearls from beyond the bars! 13
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
Arresting tuberculosis: pearls from beyond the bars! 14
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: