Arresting TB: Pearls from Beyond the Bars!
Transcript of Arresting TB: Pearls from Beyond the Bars!
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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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
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Characteristics of Correctional Facilities
Poor Circulation
Overcrowding + Inmate
Demographics
= TB Transmission
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HIV +
IV Drug Use
Homeless
Community CommunityCorrections
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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
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*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
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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
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Training Should Include Legal Responsibility
• Potential liability− Unidentified contacts− Medical assessment
• Legal liability− Active disease− Transmission
•
Number of cases diagnosed in corrections
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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
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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
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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
http://journals.sagepub.com/doi/abs/10.1177/0093854816680838
Public Health vs. Corrections
Higher TB Rates in Incarcerated Populations
• 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
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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
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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
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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:
cough dry hoarse voice throat sore
chest pain (right sided) feeling tired flu-like symptoms
laryngitis nonproductive cough productive cough
asthma sinus congestion throat scratchy
lump in right neck bronchitis pneumonia
talking in a whisper bad cold allergies
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Case History While Incarcerated in Prison (11 months)
• Prison nurse stated she did not believe the client was infectious – saw no cavities on the x-ray
− The physician agreed!
Chest Radiography in Prison• 5/3/04 CXR – abnormal – enlarged hilar
markings, otherwise Normal• 10/20/04 CXR – abnormal, bilateral
pneumonia, PCP considered
• 5/10/04 – CT scan – abnormal• 11/3/04 – CXR – abnormal, suspicious for
sarcoidosis
• Recommend bronchoscopy – refused! • 6/16/04 – CXR – abnormal
• 5/17/04 – CT scan neck – negative• 2/4/05 – CXR abnormal – bilateral
pneumonia
DORM OW
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Ex
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Evaluation of the Outbreak – 33 Cases
• Method of diagnosis− Culture – 73%
• Smear positive – 39%
− Clinical – 24%
− Provider diagnosis – 3%
• HIV status− Positive – 36%
− Negative – 61%
• Tuberculin skin test results− Positive – 67%
− Negative – 30%
− Previous positive – 3%
• Race and gender− Female – 97%
− Male – 3%
− Black – 61%
− White – 39%
2
7
6
16
13
8
10
3
19
22
4
12
9
11
23
5
18
14
17
21
24
20
15
Source Case41 Y/O B/F HIV +
2001 Case
26
25
30
28
27
3231
Both
Pleural
Pulmonary
33
1*
29 Unable to link
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Community CommunityCorrections
Case – County Jail
• 26 y.o. B/M− Very sickly looking
• Weight Loss• Cough• Fever
− Intoxicated!
• Identified in intake
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During TB Case Review . . .
Public Health Record
29 y.o. incarcerated Isolated immediately
No need for CI
Tested arresting officer and jail intake officer Both negative
Jail Medical to do case management
Will follow-up when released from jail
What Followed . . .
• Jail released the inmate after two weeks
• Inmate lost to follow-up − 4+ on sputum smear
• Found 3 months later, back in the jail & treated to completion
• After the case review one year later− According to record at HD – everything
was done per protocol− Reviewed the health record in the jail and
found the following...
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During TB Case Review . . .
Public Health Record
29 y.o. incarcerated Isolated immediately
No need for CI
Tested arresting officer and jail intake officer Both negative
Jail Medical to do case management
Will follow-up when released from jail
Jail Medical Record
29 y.o. inmate, identified at intake with symptoms of TB
Immediately removed and placed in MISO#8
With two other inmates
Inmate cooperative, coughing – will follow-up with HD
What would you do next?
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The End Result
• Contacts identified after 1 year = 67
− Frequent re-incarcerations (identified 40)
− Follow-up information 32 had TST
24(75%) were TST +
Pod A
Pod DPod C
Pod B
37 man cell
2+ TSTs
17 man cell Ǿ Conversions
39 man cell 22+ TSTs
56% conversions
16 man cell
2+ TSTs but Ǿ conversionsTB Patient
Gaming Table
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Opportunities to Impact Patient Outcomes
• Think TB!
• Treat TB if HIV infected
• During risk assessments, ask patients about prior incarceration
• Work collaboratively with state/local Health Department TB program (and correctional facility staff)
• Provide patient education − Signs and symptoms of active TB− Treatment completion
• Consult the TB experts when needed! 1-800-4TB-INFO
Opportunities for Change
• Captive audience
− Training and education
− Focused areas for education, studies
− Opportunities for Release Planning
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Questions?
Ellen R. Murray, PhD, BSN, RN
Nurse Consultant/Training Specialist
Southeastern National Tuberculosis Center
(352) 273-9385