Tb Control Corrections

8/17/2019 Tb Control Corrections

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Tuberculosis Control inTuberculosis Control in

Correctional FacilitiesCorrectional Facilities

Heidi Behm, RN, MPHHeidi Behm, RN, MPH

Acting TB Controller Acting TB Controller

Tuberculosis ControlTuberculosis Control

Oregon Department of HumanOregon Department of Human

er!iceser!ices


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A Small Disclaimer…A Small Disclaimer…

This presentation willThis presentation willNOTNOT teach youteach youeverything there is to know abouteverything there is to know about

tuberculosis or even tuberculosis controltuberculosis or even tuberculosis controlin correctional facilitiesin correctional facilities


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TB 101TB 101

Caused byCaused by M. tuberculosis M. tuberculosis Tuberculosis is airborne, not on “things”.Tuberculosis is airborne, not on “things”. Latent TB infection is not contagious (noLatent TB infection is not contagious (no

symptoms, TST+, CXR normal)symptoms, TST+, CXR normal) TB disease can occur in any body partTB disease can occur in any body part Most cases of pulmonary TB disease areMost cases of pulmonary TB disease are

infectiousinfectious

Symptoms of pulmonary TB are cough,Symptoms of pulmonary TB are cough,hemoptysis, fever, weight loss, night sweatshemoptysis, fever, weight loss, night sweats


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Individuals at High Ris !or TBIndividuals at High Ris !or TB

HIV/AIDSHIV/AIDS Recent immigration (5 years)Recent immigration (5 years) History of TBHistory of TB Recent close contact to person with TBRecent close contact to person with TB

iseaseisease In!ection"r#g #se (ID$)In!ection"r#g #se (ID$) Dia%etesDia%etes Imm#nos#ppressi&e therapy (chronic steroiImm#nos#ppressi&e therapy (chronic steroi

#se' T alpha inhi%itor)#se' T alpha inhi%itor) Hematologic malignancy or lymphomaHematologic malignancy or lymphoma *hronic renal fail#re*hronic renal fail#re S#%stantial weight loss or maln#tritionS#%stantial weight loss or maln#trition

History of gastrectomy or !e!#noileal %ypassHistory of gastrectomy or !e!#noileal %ypass


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"h# Care about TB$"h# Care about TB$

Oregon Administrative Rules (OARS)Oregon Administrative Rules (OARS)333-019-0041333-019-0041

Each Facility specified below shall formallyEach Facility specified below shall formally assess theassess therisk of tuberculosis transmissionrisk of tuberculosis transmission among staffamong staff (professional and volunteer), residents,(professional and volunteer), residents, inmatesinmates, and, andpatients at least annually and shallpatients at least annually and shall follow appropriatefollow appropriatetuberculosis screening recommendationstuberculosis screening recommendations as outlined inas outlined inthe relevant publication or as otherwise approved bythe relevant publication or as otherwise approved by

DHS:DHS: Correctional Facilities: "Controlling TB in CorrectionalCorrectional Facilities: "Controlling TB in CorrectionalFacilities," published by the Centers for DiseaseFacilities," published by the Centers for DiseaseControl and PreventionControl and Prevention


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From the Headlines…From the Headlines…

Ramsey County sued over handling of inmateRamsey County sued over handling of inmatewith TBwith TB At least 80 former inmates and 30 countyAt least 80 former inmates and 30 countyemployees were later found to have the infection,employees were later found to have the infection,according to the class-action lawsuit.according to the class-action lawsuit.

County Jail Failing to Test Prisoners forCounty Jail Failing to Test Prisoners forTuberculosis as Required by Department ofTuberculosis as Required by Department ofHealthHealth

A Denver parolee claims he got tuberculosis inA Denver parolee claims he got tuberculosis inthe Arapahoe County Jail or the state prison inthe Arapahoe County Jail or the state prison inCanon City.Canon City.


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TB in Corrections A!!ectsTB in Corrections A!!ects

the Communit#the Communit#

Corrections employees are exposed andCorrections employees are exposed andinfected. May develop active TB diseaseinfected. May develop active TB disease

Employees live in the community, mayEmployees live in the community, mayinfect family and friendsinfect family and friends

Inmates may move frequently in and outInmates may move frequently in and out

of systemof system


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"h# is TB a %roblem in"h# is TB a %roblem in

Corrections$Corrections$

Inmates have histories that put them atInmates have histories that put them atgreater risk for TB exposuregreater risk for TB exposure

(homelessness, IVDU)(homelessness, IVDU) Inmates are frequently in poor health andInmates are frequently in poor health andget sick (and contagious) with TB diseaseget sick (and contagious) with TB disease

much quicker (HIV, poorly nourished)much quicker (HIV, poorly nourished)


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"h# is TB a %roblem in"h# is TB a %roblem in

Corrections &Continued'$Corrections &Continued'$

Structure of facilities makes transmissionStructure of facilities makes transmissionlikely (close living conditions, poorlikely (close living conditions, poorventilation)ventilation)

Frequent movement of inmates makes TBFrequent movement of inmates makes TB

control hardcontrol hard


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"hat to do$"hat to do$

Prevention and Control of Tuberculosis inPrevention and Control of Tuberculosis inCorrectional and Detention Facilities:Correctional and Detention Facilities:Recommendations from CDCRecommendations from CDC

July 7, 2006 / 55(RR09);1-44 July 7, 2006 / 55(RR09);1-44


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"hat(s in the )uidelines$"hat(s in the )uidelines$

ScreeningScreening

(trying to find people with latent TB(trying to find people with latent TB

infection and TB disease)infection and TB disease) ContainmentContainment (making sure others don’t(making sure others don’tget TB if someone is infectious)get TB if someone is infectious)

CollaborationCollaboration


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Ris Assessment and ScreeningRis Assessment and Screening

Risk Assessment determines how muchRisk Assessment determines how muchscreening should be done andscreening should be done andenvironmental controlsenvironmental controls

Performed annuallyPerformed annually

Conducted in collaboration with LocalConducted in collaboration with Local

and State Health Departmentsand State Health Departments


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Categories o! RisCategories o! Ris

1-1-Minimal risk facilityMinimal risk facility

(not much TB or risk of, many in Oregon)(not much TB or risk of, many in Oregon)

2-2-Nonminimal TB PrisonNonminimal TB Prison 3-3-Nonminimal TB JailNonminimal TB Jail


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*inimal Ris Facilit#

o cases of infectio#s TBo cases of infectio#s TB occ#rreocc#rre

withinwithin the facility #ringthe facility #ring past yearpast year acilityacility oes notoes not ho#se s#%stantialho#se s#%stantial

n#m%ers of inmates withn#m%ers of inmates with ris"ris"factorsfactors for TBfor TB (HIV' homeless'(HIV' homeless'

IVD$)IVD$)

acilityacility oes not ho#se s#%stantialoes not ho#se s#%stantialn#m%ers ofn#m%ers of ne# immigrantsne# immigrants


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Ris FactorsRis Factors

andand

+Substantial ,umbers-$+Substantial ,umbers-$ Substantial=significant amountSubstantial=significant amount

>70%>70% of the inmate population have riskof the inmate population have riskfactors and/or are new immigrants yourfactors and/or are new immigrants yourfacility isfacility isNOTNOT minimal riskminimal risk

Risk factors include: IVDU, HIV or otherRisk factors include: IVDU, HIV or otherimmunocompromised state, diabetes, recentimmunocompromised state, diabetes, recentexposure to TB,exposure to TB,immigration to U.S. fromimmigration to U.S. fromhigh incidence area within past 5 yearshigh incidence area within past 5 years


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http://images.google.com/imgres?imgurl=http://www.odmp.org/patch.php%3Fid%3D1482%26s%3D150&imgrefurl=http://www.odmp.org/agency/1482-grant-county-sheriffs-department-oregon&usg=__RAK4hYvBtKXj9UsgXxcD6O1dSws=&h=150&w=150&sz=9&hl=en&start=3&tbnid=liZl3ed-heuQbM:&tbnh=96&tbnw=96&prev=/images%3Fq%3Dgrant%2Bcounty%2Bjail%2Boregon%26gbv%3D2%26hl%3Den%26sa%3DGhttp://images.google.com/imgres?imgurl=http://www.correctional-patches.com/city-county/or_malheur_co_corrections.jpg&imgrefurl=http://www.correctional-patches.com/city-county.html&usg=__kT8BVjnHQ3fXMTQcBS00d2FSr7g=&h=338&w=316&sz=73&hl=en&start=6&tbnid=JVsa2Et0SJY9YM:&tbnh=119&tbnw=111&prev=/images%3Fq%3Dmalheur%2Bcounty%2Bjail%26gbv%3D2%26hl%3Denhttp://www.flickr.com/photos/saknussem/2105424773/


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Screening i! *inimal RisScreening i! *inimal Ris

ScreenScreen all inmatesall inmateson intakeon intake for symptoms of TBfor symptoms of TB(questionnaire and observation)(questionnaire and observation)

ScreenScreen all inmatesall inmates on intakeon intake for risk factorsfor risk factors

(questionnaire and observation)(questionnaire and observation) HIV+, immunocompromisedHIV+, immunocompromised need aneed aCXRCXRononintakeintake

IfIfTB risk factorTB risk factor present, need apresent, need aTB skin testTB skin test

(TST),(TST),quantiferonquantiferon (QFT) or(QFT) orCXRCXR within 7 dayswithin 7 daysof arrival.of arrival.

Those in the facility < 7days don’t need testing!Those in the facility < 7days don’t need testing!


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,on.*inimal Ris

Cases ofCases ofinfectious TBinfectious TB occurred in theoccurred in thefacility in thefacility in thepast yearpast year

Facility housesFacility housessubstantial numberssubstantial numbers(>70%) of inmates with risk factors(>70%) of inmates with risk factors for TBfor TB Facility housesFacility housessubstantial numberssubstantial numbers(>70%) of new immigrants(>70%) of new immigrants


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Screening ,on.*inimalScreening ,on.*inimal

Screen all inmatesScreen all inmates on intakeon intake for symptomsfor symptoms of TBof TB

(questionnaire and observation)(questionnaire and observation)

ScreenScreen all inmatesall inmates on intakeon intakefor risk factorsfor risk factors of TBof TB (questionnaire and observation)(questionnaire and observation) All inmatesAll inmates need a TB skin test (TST), quantiferonneed a TB skin test (TST), quantiferon

(QFT) or CXR within 7 days(QFT) or CXR within 7 days of arrivalof arrival HIV/AIDS, immunocompromised need a CXR onHIV/AIDS, immunocompromised need a CXR onintakeintake

ThoseThosein the facility < 7days don’t need testingin the facility < 7days don’t need testing!!


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/mlo#ee Screening/mlo#ee Screening

Applies to all facilitiesApplies to all facilities

All employeesAll employees must be screened on hire formust be screened on hire for

symptoms of TBsymptoms of TB All employeesAll employees who don’t have a previouswho don’t have a previouspositive need apositive need atwo step TB test OR singletwo step TB test OR single

QFTQFT


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Annual ScreeningAnnual Screening

Previously negative employees should bePreviously negative employees should betested annuallytested annually

Previously negative long-term inmatesPreviously negative long-term inmates

should be tested annuallyshould be tested annually If previously positive, a symptom checkIf previously positive, a symptom checkonly. Don’t repeat the CXRonly. Don’t repeat the CXR

Minimal risk may not need annualMinimal risk may not need annualscreening. Consult.screening. Consult.


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FA on ScreeningFA on Screening

What if an inmate or employee says they’reWhat if an inmate or employee says they’repositive, but there’s no documents?positive, but there’s no documents? GiveGive

them a TST or QFT. Document it well! If theythem a TST or QFT. Document it well! If they

are positive, a CXR is needed.are positive, a CXR is needed. What is Quantiferon (QFT)?What is Quantiferon (QFT)?

A blood test for latent TB infectionA blood test for latent TB infection

What’s considered a positive TST?What’s considered a positive TST?

>>10 for most,10 for most, > 5 if HIV+, recent contact, etc.5 if HIV+, recent contact, etc.


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*easuring TST*easuring TST

RecordRecordindurationinduration (bump) only(bump) only

MeasureMeasuretransversetransverse (across arm)(across arm)

Record: Date given, date read, mm, + or –Record: Date given, date read, mm, + or –


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Treating 2TBITreating 2TBI

Ideally, all inmates who have LTBIIdeally, all inmates who have LTBIshouldshould be offered treatment. be offered treatment.

In jails this might not be possibleIn jails this might not be possible

May prioritize treatment for high riskMay prioritize treatment for high riskgroups (HIV+)groups (HIV+)

Work with local health department toWork with local health department to

ensure completion of treatment afterensure completion of treatment afterreleaserelease


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ContainmentContainment


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Signs and S#mtoms o! TBSigns and S#mtoms o! TB

Cough for more than three weeksCough for more than three weeks

Coughing up bloodCoughing up blood

Unexplained weight lossUnexplained weight loss Night sweatsNight sweats

FeverFever

Feeling tiredFeeling tired

Not everyone with TB looks really sick…Not everyone with TB looks really sick…


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Sounds eas#3 right$Sounds eas#3 right$

In a large correctional facility, an inmate went to medicalIn a large correctional facility, an inmate went to medicalreporting a cough and fatigue. It was flu season- everyonereporting a cough and fatigue. It was flu season- everyonehad a cough! Came back 2 weeks later, still coughing withhad a cough! Came back 2 weeks later, still coughing withslight fever. Given ABX. Came back 1 week later. Sameslight fever. Given ABX. Came back 1 week later. Same

complaint. Given ABX and a TB test. TB test was negative.complaint. Given ABX and a TB test. TB test was negative.Continued to cough… 6 weeks later was transferred toContinued to cough… 6 weeks later was transferred toanother facility and diagnosed with TB disease.another facility and diagnosed with TB disease.

Over 400 contacts were identified. Many were not located.Over 400 contacts were identified. Many were not located.

Could this happen in your facility?Could this happen in your facility?

How do you “catch” chronic coughers?How do you “catch” chronic coughers?


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"hat to do i! #ou susect TB"hat to do i! #ou susect TB

Call State TB program or local healthCall State TB program or local healthdepartment for help!department for help!

Better to be safe than sorry…Better to be safe than sorry…

If you have negative pressure, use it.If you have negative pressure, use it. If no negative pressure, put patient in maskIf no negative pressure, put patient in mask(surgical) and remove from others. Staff should(surgical) and remove from others. Staff should

wear N95. PREPARE TO TRANSFER PATIENTwear N95. PREPARE TO TRANSFER PATIENTOUT.OUT. All this should be in your infection control planAll this should be in your infection control plan


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CollaborationCollaboration

CorrectionsCorrections

Local Health DepartmentLocal Health Department

State TB ControlState TB Control

Building relationships before there’s aBuilding relationships before there’s a

problem is a good idea…problem is a good idea…


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I! #ou susect TB…I! #ou susect TB…

If either an inmate or employee isIf either an inmate or employee issuspected or confirmed to have active TBsuspected or confirmed to have active TB

disease you must report this to the localdisease you must report this to the localhealth departmenthealth department


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"h# reort$"h# reort$

The State and local health department will helpThe State and local health department will helpyou:you:

-coordinate care upon discharge-coordinate care upon discharge

-assist you in the facility contact investigation-assist you in the facility contact investigation

-assist you in organizing and analyzing contact-assist you in organizing and analyzing contact

datadata

-ensure contacts who have been released or are-ensure contacts who have been released or areno longer employed are screenedno longer employed are screened


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Summar# %ointsSummar# %oints

Each facility must determine if minimal orEach facility must determine if minimal ornonminimal risknonminimal risk

All facilities need to assess every inmate for riskAll facilities need to assess every inmate for riskfactors and TB symptoms on arrivalfactors and TB symptoms on arrival

All facilities will screen some inmate with TSTsAll facilities will screen some inmate with TSTsor QFTs…amount of screening depends on riskor QFTs…amount of screening depends on risklevellevel

All facilities should provide CXRs to inmatesAll facilities should provide CXRs to inmates

who are severely immunocompromisedwho are severely immunocompromised Focus testing efforts on inmates in facilityFocus testing efforts on inmates in facility

> 7days> 7days


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Summar# %oints ContinuedSummar# %oints Continued

All facilities should screen for risk factors, signsAll facilities should screen for risk factors, signssymptoms and test new employees on hiresymptoms and test new employees on hire

Annual screening of employees and long termAnnual screening of employees and long terminmates is advisedinmates is advised

Knowing the signs/symptoms of TB and actingKnowing the signs/symptoms of TB and actingpromptly is criticalpromptly is critical

If your facility doesn’t have negative pressure,If your facility doesn’t have negative pressure,you need a back up plan. This should beyou need a back up plan. This should be

outlined in your facilities infection control planoutlined in your facilities infection control plan The State TB program and your local healthThe State TB program and your local healthdepartment are here to helpdepartment are here to help


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ResourcesResources

Oregon TB ControlOregon TB Control [email protected]@state.or.us

971-673-0169971-673-0169

Local Health Department DirectoryLocal Health Department Directoryhttp://www.oregon.gov/DHS/ph/lhd/lhd.shtmlhttp://www.oregon.gov/DHS/ph/lhd/lhd.shtml

Summary of GuidelinesSummary of Guidelineshttp://www.oregon.gov/DHS/ph/tb/docs/correctionssum.pdfhttp://www.oregon.gov/DHS/ph/tb/docs/correctionssum.pdf

CDC GuidelinesCDC Guidelines

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm

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