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U.S. Department of Health and Human Services

  

Controlling TB In Correctional Institutions (1995)

Case Studies

Case Study #1

The Hard Rock Correctional Facility is a medium-security prison housing male inmates in a rural area of the South. It currently has an inmate population of 1,589 and a design-rated capacity of 1,500. The housing of the main prison unit is composed of seven wings, located off a main administrative corridor. Hard Rock's infirmary, which is located in the administrative corridor, has no respiratory isolation rooms. Each wing contains 100 two-person cells arranged on two tiers; in addition, there are 80 single-occupancy cells for maximum security and administrative segregation. Two satellite facilities containing 50 beds each are used to house inmates on work release to neighboring farms.

On May 5, 1995, John Walker entered Hard Rock for the second time. (He had previously served a 2-year sentence.) Walker had a negative reaction to the tuberculin skin test. He reported a persistent cough, but ascribed it to his heavy smoking. No further medical evaluation was done, and Walker was placed in a two-person cell on the upper tier of Wing D.

On June 9, Walker complained that he had been coughing up blood and had chest pains and difficulty sleeping. He was referred to the medical unit, where a chest x-ray was performed (showing an infiltrate in the left upper lobe) and a sputum specimen was collected. He was transferred to the infirmary.

On June 16, a report of a positive AFB smear was mailed in from the facility's contracting laboratory. While reviewing Walker's medical file from his previous incarceration (in 1987), staff found that Walker had had a positive skin test result (17 mm) on entry and had weighed at least 40 pounds more than his current weight.

Medical staff called the county health department for help referring Walker to a facility with a TB isolation unit. They discovered that Walker had been reported to the health department as a TB suspect in March, when he was admitted to a neighboring city hospital. Walker had started TB medications but left the hospital against medical advice and subsequently could not be located. The hospital lab reported a culture positive for M. tuberculosis on a specimen submitted on March 25.

Questions:

  1. What problems contributed to delays in identifying and isolating this potentially infectious case of TB? How could these problems have been avoided?
  2. What steps does Hard Rock need to take in carrying out a contact investigation?
  3. Skin-testing of contacts revealed the following:
    • 16 of 43 inmates on the upper tier of Wing D had positive skin-test results (37%)
    • 6 of 12 staff working on the upper tier of Wing D had positive skin-test results (50%)
    • 2 of 3 inmates housed in the infirmary had positive skin-test results (67%)
    • 3 of 7 staff working in the infirmary had positive skin-test results (43%)

    How should these data be interpreted? What should the next step be?

Answers

Case Study #2

The Wayback County Jail is located in the northwestern United States, near a large metropolitan city where the health department has recently reported increased incidence rates of AIDS and tuberculosis in the community. Built with a design-rated capacity of 510, Wayback now has an average daily population of more than 600 inmates and will soon have more than 700. The facility was initially opened in 1913 with additional major construction occurring in the 1980's. The older housing is poorly lit and ventilated; the newer expansion consists of eight self-contained pods. The expansion relies heavily on the direct supervision philosophy of reducing inmate traffic within the jail: the only time an inmate leaves a pod is to go to court or the main medical facility, or to be transported to another facility (or released). No isolation units are located at this facility.

Wayback employs 300 persons, 200 of whom are correctional officers. Security staff work under three supervisory groups: one assigned to the old jail, one assigned to pods 1 through 4, and the other to pods 5 through 8. In addition, several persons work in the administrative section of the building: 9 administrators, 24 clerical and office support workers, and 48 professional, counseling, and education personnel. Nineteen maintenance and upkeep workers are assigned to various areas of the facility and rotate assignments periodically.

Skin-test data for employees (1994) reveal the following:
 

  Prior PPD Negative
Unit Total Prior PPD+
(a)
Total
(b)
Tested and Read
(c)
PPD Converted
(d)
Conversion Rate
(d/c)
Pods 1-4 70 7 63 63 2 3.2%
Pods 5-8 70 8 62 60 1 1.6%
Old Jail 76 6 70 69 8 11.4%
Administrative 84 7 77 77 1 1.3%
Total 300 28 272 269 12 4.5%

 
 

Prior PPD Negative

Category Total Prior PPD+
(a)
Total
(b)
Tested and Read
(c)
PPD Converted
(d)
Conversion rate
(d/c)
Administrative 9 1 8 8 0 0.0%
Security 200 18 182 180 9 5.0%
Clerical 24 3 21 21 0 0.0%
Professional 48 2 46 46 1 2.2%
Maintenance 19 4 15 14 2 14.3%
Total 300 28 272 269 12 4.5%

Questions:

  1. How should these data be interpreted? What additional information should the TB control official collect?
  2. Wayback's TB control official and the city health department decide to conduct an evaluation of this possible transmission problem. What should the objectives of this investigation be?

Answers

Case Study #3

The Willie Maquet State Prison is a medium security prison housing male and female inmates, located in a large metropolitan area in the Midwest. The facility is extremely overcrowded; the design-rated capacity is 624, but the population recently has averaged 800 male offenders and 100 female offenders. The facility offers a large substance abuse treatment program and is the regional center for on-site specialty clinics for three other state prisons. This facility has a large population of handicapped and physically impaired inmates, as well as a large geriatric population (10% of inmates are 60 years of age or older). There are 57 HIV-infected patients receiving medications for HIV-related illnesses (e.g., aerosolized pentamidine); approximately 12% of inmates are known to be or suspected of being HIV-infected.

The following information was been collected for the first half of 1995 (reporting period January through June 1995):

Treatment for Inmates with TB Disease

Patients diagnosed during period

TB suspects: 4
Starting treatment: 4
Diagnosis confirmed: 4
Case rate: 444 per 100,000 inmates

Follow-up of patients diagnosed during 1994

Completing treatment: 100%

Note: 2 inmates started TB treatment between January and June of 1994. One remained in the facility and had completed treatment by the end of June 1995. One was released while still on treatment and successfully referred to the local health department.

Infection Control

Smear-positive cases: 3
TB isolation rooms available: 1

TB Infection in Staff

Skin-test positive persons at beginning of period: 27 of 292 (9.2%)
Skin-test conversions at end of period: 8 of 265 previously skin-test negative persons
Conversion rate: 3.0%

TB Infection in Inmates

Skin-test positive persons: 125 (19.8%)
Skin-test conversions: not available
Conversion rate: not available

Preventive Therapy (PT) for Infected Inmates

Patients starting PT during reporting period: 46
Follow-up of patients starting PT during 1994
Completing PT: 79% of 38 inmates

Note: 6 inmates who started PT between January and June 1994 were released or transferred out before completing therapy.

Follow-up of Inmates Released or Transferred Out
 

Status Inmates with TB Disease Inmates with TB Infection
Transferred Out 0 4
Successfully referred to receiving facility 0 4 (100%)
Released 1 2
Successfully referred to health department 1 (100%) 0 (0)%

Question:

  1. What components of Willie Maquet State Prison's TB control program could be improved? How might this be done?

Answers

Answers to Case Studies

Case Study #1

  1. What problems contributed to delays in identifying and isolating this potentially infectious case of TB? How could these problems have been avoided?

    Inadequate medical and clinical history: at entry on May 5, a more careful screening for symptoms might have picked up Walker's substantial weight loss. If questioned thoroughly about his medical history at that time, Walker might have revealed his previous skin-test result or hospitalization and treatment for TB.

    Lack of an organized TB database: if the facility had an organized database (preferably in electronic form), Walker's previous skin-test result might have been found and prompted further evaluation of his cough.

    Failure to determine if case had been previously reported: if registry cross-matching had been available from the county health department, Hard Rock might have found out sooner that Walker had TB disease. In the absence of cross-matching, correctional staff could have telephoned the county health department for information and consultation if they had suspected Walker's history of TB treatment.

    Failure to place patient in isolation room when indicated: when Walker was referred to the medical unit on June 9, his symptoms were strongly suggestive of TB and he should have been referred to an isolation facility. Instead, he was kept in the infirmary, exposing staff who were caring for him or working in the adjacent corridor. When the smear results were reported positive for AFB on June 16, Walker should have been immediately referred to a local hospital with a TB isolation room; the administrative segregation cell is not adequate for this purpose. Medical staff at Hard Rock should receive training and education in recognizing symptoms suggestive of TB and in appropriate procedures for infection control.

    Slow reporting methods by laboratory: the laboratory results should have been phoned or faxed to the facility and the physician of record, not mailed; this caused a delay of several days.

    Lack of a collaborative agreement with the health department: Hard Rock should delegate a medical staff person to take the lead in controlling TB within the facility. That person should collaborate with the county health department to develop a written agreement for information exchange, consultation, and technical assistance. The Hard Rock TB control official could then work with the health department to improve TB control efforts.

  2. What steps does Hard Rock need to take in carrying out a contact investigation?

    Because Walker's AFB smear was positive, he should be considered infectious. Within the Hard Rock facility, the first place to start is Wing D, where Walker was incarcerated for 5 weeks while he was symptomatic. Walker's cellmate, the inmates in neighboring cells, and staff who worked on the same tier are at the highest risk of infection. Staff who work in the infirmary and inmates who stayed in the infirmary while Walker was held there should also be tested.

    If skin test data shows evidence of transmission, the investigation should be broadened to include other inmates in Wing D, as well as staff who work in the administrative corridor. The county health department should identify and evaluate any community contacts Walker had prior to his incarceration in May. Staff and inmates in the satellite facilities do not need to be tested unless they worked or were housed in Wing D or the administrative corridor while Walker was potentially infectious. The county health department should help determine who should be tested, based on skin-test conversion rates among Walker's closest contacts and environmental factors such as air flow in the wings and administrative corridor.

  3. Skin-testing of contacts revealed the following:
    • 16 of 43 inmates on the upper tier of Wing D had positive skin-test results (37%)
    • 6 of 12 staff working on the upper tier of Wing D had positive skin-test results (50%)
    • 2 of 3 inmates housed in the infirmary had positive skin-test results (67%)
    • 3 of 7 staff working in the infirmary had positive skin-test results (43%)

    How should these data be interpreted? What should the next step be?

    This represents a high proportion of skin-test positive contacts. The conversion rate can be calculated after discounting persons who had a documented positive skin-test result before this exposure occurred. For example, if 6 of the 16 skin-test positive inmates on Wing D had documented positive skin-test results, then the conversion rate in this group is

    (16 - 6)/(43-6) or 10/37 = 27%

    This is a very high conversion rate, and would warrant further skin-testing on Wing D and possibly on the administrative corridor as well. Again, the county health department should help determine who should be tested.

    All skin-test positive persons should be evaluated for TB disease and, if disease is ruled out, considered for preventive therapy. In addition, any immunosuppressed persons who were potentially exposed while Walker was symptomatic should receive a thorough medical evaluation and should begin preventive therapy if TB disease is ruled out. Inmates or staff who were exposed but are no longer in the facility should be identified by Hard Rock so that the local TB program or other correctional facilities involved can locate and skin-test these persons.

Case Study #2

  1. How should these data be interpreted? What additional information should the TB control official collect?

    The skin test conversion rates in maintenance (14.3%) and security personnel (5.0%) are quite high when compared with rates in other groups . An unusually high conversion rate (11.6%) is also evident in the old jail. This situation may indicate a need for further epidemiologic investigation, based on

    • the occurrences of skin-test conversions in staff members (especially in security officers and maintenance staff)
    • the occurrence of possible person-to-person transmission of M. tuberculosis (especially likely in the old jail)

    This may have been a situation in which an inmate or staff member with TB disease was not promptly identified and isolated, thus exposing other persons in the facility to M. tuberculosis.

    Wayback's TB control official would want to interview those persons whose skin-test reaction has recently converted in order to determine more precisely their work locations and to question them about symptomatic persons. The TB control official would also want to review the medical records of inmates treated in the medical facility during or before 1992; in addition, TB screening data from inmates on entry might provide some helpful information. Wayback officials should consult with the county health department for assistance in analyzing this data and evaluating possible transmission in the facility.

  2. Wayback's TB control official and the county health department decide to conduct an evaluation of this possible transmission problem. What should the objectives of this investigation be?

    The general objectives of this investigation are as follows:

    • to determine the likelihood that transmission of and infection with M. tuberculosis has occurred in the facility
    • to determine the extent to which M. tuberculosis has been transmitted
    • to identify those persons who have been exposed and infected, enabling them to receive appropriate clinical management and treatment
    • to identify factors that could have contributed to transmission and infection and to implement appropriate interventions
    • to evaluate the effectiveness of any interventions that are implemented and to ensure that exposure to and transmission of M. tuberculosis have been terminated

    Wayback officials should consult with the health department for technical assistance in carrying out such an investigation and recommended policy changes to avoid future transmission problems. For more detailed information on conducting a problem evaluation and revising the facility's TB control plan, refer to section II-K of the CDC's "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Facilities, 1994." (36)

Case Study #3

  1. Willie Maquet has a good success rate with the treatment of inmates diagnosed during 1994. However, the case rate for newly diagnosed cases is high and may indicate prob- lems with intake screening or transmission within the facility. The TB control official may want to review records of all recent TB patients to determine

    • whether they were identified as infected or symptomatic through intake screening
    • whether their disease could be prevented by appropriate therapy
    • how long they were symptomatic before TB was suspected
    • whether treatment was promptly initiated
    • whether the single TB isolation room available is adequate for Willie Maquet's needs

    Skin-test conversions among staff could indicate a transmission problem, especially if they occur among several persons who work in the same area. No data were presented on preventive therapy among staff; the TB control official at Willie Maquet should monitor the initiation and completion of preventive therapy in this group.

    No data on skin-test conversions among inmates are available. Long-term inmates should be receiving a repeat skin test annually; conversion rates in inmates can be used to help identify transmission problems. It is not clear on what basis inmates are starting preventive therapy. The TB control official should determine if appropriate priority is being given to high-risk groups. A preventive therapy completion rate of 79% is less than desired for an incarcerated population, especially in a facility with a high rate of HIV infection. Prison medical staff may want to review the records of inmates not completing preventive therapy to identify problems and correct policies and procedures, if necessary. In analyzing completion of preventive therapy, staff should consider looking at the results for immunosuppressed patients separately to make sure this high-priority group receives high priority.

    Finally, the follow-up of inmates on preventive therapy who are released into the community could be improved. Willie Maquet's TB control officer may need to arrange a collaborative agreement with the local health department to coordinate a successful transfer of patients, their records, and their locating information. Many health departments have arranged for outreach workers to visit inmates before their release to establish a rapport with the inmates and develop follow-up plans for continuation of therapy.

 


Released October 2008
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