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TB Notes 3, 2000
Focus on Correctional Facilities
Project to Evaluate Short-Course
Treatment of TB Infection Among Jail Inmates and Homeless Persons
New CDC/ATS guidelines for the treatment of latent
TB infection (LTBI) include a regimen consisting of 2 months of
rifampin and pyrazinamide (2RZ). Staff of DTBE initiated a project
to evaluate the program implementation of these new recommendations
as standard of care for the treatment of LTBI. The primary objective
is to demonstrate improved adherence and thus an improved completion
rate of treatment for LTBI using the 2-month regimen. Secondly,
we will evaluate the tolerance and acceptability of this regimen.
Ideal populations for short-course treatment of LTBI are those at
high risk for progression to disease, e.g., persons infected with
the human immunodeficiency virus (HIV) and recently infected with
TB, persons difficult to reach by standard public health approaches,
and persons in whom adherence and completion of therapy are unacceptably
low. Prison and jail inmates undergo extensive tuberculin skin testing
and have high rates of positive tuberculin reactivity, with very
low rates of completion of LTBI therapy. Several studies have shown
that the rate of completion among prisoners released to the community
while receiving treatment is less than 20%. The use of a short-course
regimen could be well suited to this population. In mid-1999 we
initiated a demonstration project with six large jails around the
country. To ensure high rates of completion, the project sites are
using directly observed therapy, incentives to improve adherence,
and outreach workers (ORWs) to motivate and facilitate patients'
treatment. To date, we have enrolled patients at seven jails and
three homeless shelters.
On September 20, 2000, 11 ORWs from 9 sites participating
in the 2RZ demonstration project attended a one-day meeting in Atlanta.
The purpose of the meeting was to allow the ORWs an opportunity
to learn from one another by discussing issues and situations they
confront daily. Project sites have a wide range of resources, from
a single ORW assigned to cover an entire county, to a health department's
entire staff of ORWs. The format of the meeting was a 2.5-hour focus
group (see the following summary) followed by discussion around
several topics. In addition, Khalil Sabu Rashidi from the Newark
National TB Model Center gave a presentation that drew from his
personal experiences regarding the challenges of working with difficult-to-access
populations. Participants went away with a sense of sharing and
a feeling of ownership for the project. Again we learned that outreach
is a work of dedication and thoroughness. Outreach workers are essential
team members for the project's success. The project staff held a
conference call in October to discuss data collection issues, rate
of completion of therapy, and drug toxicity, and will conduct additional
conference calls on a regular basis.
óReported by Mark Lobato, MD
Division of TB Elimination
Sharing Experiences, Insights, and Findings
from a Discussion Among TB Outreach Workers
Traditional regimens used to treat latent TB infection
(LTBI) take at least 6 months to complete, and many patients have
difficulty adhering to their treatments. To improve adherence rates,
TB programs often use outreach workers to bring services into the
patientís environment. Patients in temporary or transitory locations,
such as jail inmates and homeless persons, often have very low adherence
rates, but create special challenges for outreach.
Recently, CDC recommended a new short-course regimen
for treating LTBI: 60 daily doses (approximately 2 months) of rifampin
and pyrazinamide (2RZ). As described in the preceding article, a
new CDC project focusing on prisoners in jails and homeless persons
is evaluating the new recommendations to determine the completion
rates and examine the tolerance and acceptability of short-course
therapy. Outreach workers at each of the project sites provide patients
with the personalized support needed to complete therapy.
CDC brought together the outreach workers from the
project sites to discuss their experiences in working with patients
on the 2RZ regimen. The outreach workers shared the techniques and
strategies they use to help their patients adhere to treatment.
Their insights provided valuable information for TB program staff,
especially those working with challenging patients.
The CDC staff would like to thank Mathew Nwozuzu (New
York City, NY), Khalil Rashidi (Newark, NJ), Ozzie Renwick (Jacksonville,
FL), Dora Cotrim (San Francisco, CA), Antonio Torres (Chicago, IL),
Joann Maniscalco and Pat Kubis (Nassau County, NY) Grace Sanchez
(Denver, CO), Christopher Evans (Gulfport, MS), Tara Rogers and
Howard Pope (Fulton County, GA), and Eric Morgan (Mobile, AL) for
their participation in this focus group.
When asked to describe their job activities, all reported
delivering LTBI medicines to patients in the patientís own environment:
jails, shelters, or the community after release from jail or when
leaving a shelter. Most outreach workers watch patients swallow
their pills daily during the week, and allow the patient to self-administer
the medicines on weekends. In addition to delivering medicine, outreach
workers may place and read tuberculin skin tests, remind patients
of health care appointments, and provide transportation to attend
clinic. Further, they maintain records on patients and serve as
liaisons, coordinating with TB control staff, other health providers,
and staff at the prison facility or shelter.
All outreach workers see their primary role as helping
patients adhere to and complete LTBI treatment, which requires building
trust and establishing effective communication. Because patients
may suspect that the outreach worker is a law enforcement official,
the workers are always direct with patients in informing them that
they work for the TB control program and not the facility. Dressing
casually and "using the patientís language" reinforce
the message that the patient can trust the outreach worker. The
workers stress confidentiality and repeatedly tell patients that
they will not share information with legal authorities. The workers
arrange in advance for a separate, private room to meet with patients.
In community settings, outreach workers scan their environment for
less public settings, and act discreetly, greeting their patients
as friends rather than in an official capacity.
Continually, the outreach workers emphasized the need
to "show the patient that you respect and care about them."
Given that these patients, prisoners, and homeless people often
receive little respect, the outreach workersí respect establishes
a core for the relationship. Outreach workers show their concern
by listening to them patiently and calming fears by tying in the
benefit of completing treatment. To help patients overcome the stigma
associated with TB, personal stories are shared, such as those about
the workerís family.
Communicating with patients who are not native English
speakers can be a challenge. One outreach worker is bilingual, and
other outreach workers have fellow staff members who can serve as
translators when needed. Learning several key phrases in the patientís
language was suggested as a way to help build trust. AT&T telephone
translation services are also a resource for overcoming language
differences (for information on this service, call 1-800-752-0093,
extension 196, or visit the Web site www.att.com/languageline).
Once communication challenges have been solved, the
outreach workers continually educate the patients about TB and LTBI.
Several outreach workers noted that citing "worst-case scenarios"
of people who developed TB served to emphasize the need for treatment.
To explain the complexity of LTBI, one worker explains to patients
that the germ is "sleeping." Given the status of these
patients, the workers educate the patients that they are not "guinea
pigs," and will be respected throughout the study.
After rapport is built, outreach workers maintain
regular contact; "just being there for the patient, and taking
time with them" is essential. Showing concern for the patientís
overall well-being by assisting patients access additional health
and social services reinforces trust. Helping patients enroll in
substance abuse treatment programs is critical to increasing adherence.
In addition, to help motivate patients, outreach workers report
using incentives, such as food coupons, and enablers (e.g., transportation
vouchers or bus tokens).
Maintaining contact requires knowing the patientís
location throughout the treatment period. While the outreach workers
in this project initially meet and enroll their patients in correctional
facilities or in shelters, many patients will leave or be released
before treatment is complete. At the start, some patients give false
names and incorrect addresses, not trusting the outreach worker.
Recognizing this challenge, outreach workers regularly review contact
information with patients to learn possible aliases and alternate
addresses, and over time, as trust builds, more accurate names and
addresses are given. When patients cannot be located from the outreach
workersí information, coordination with law enforcement staff, parole
officers, or INS officials may help locate the patients. One worker
reported having great success by involving younger patientsí parents
in maintaining contact. Only when a patient cannot be located for
over a month will most outreach workers close a case as "lost,"
although one worker noted her program closes cases in 2 wks.
While the outreach workers shared their techniques
and tips on how to promote patient adherence, they cautioned that
every patient is different and strategies had to be individualized
to work. Underlying each success is perseverance and hard work,
but not every case can be a success. The outreach workers often
have high caseloads and competing priorities and often do not have
enough time to devote to the most challenging situations. Some patients
will not communicate honestly, some are lost to follow-up, and some
refuse treatment. Data and records on patients are often missing
or incorrect, and occasionally the cooperation of other professionals,
such as certain jail personnel, is missing. But, despite these challenges,
the outreach workers remain enthusiastic about their jobs. Armed
with a sense of humor, patience, and compassion, each worker is
committed to helping their patients complete their LTBI short-course
óReported by Maureen Wilce, MS
Division of TB Elimination
Florida Corrections TB
On July 27 and 28, 2000, I had the opportunity to
participate in the Florida Corrections TB Program Workshop, which
was held in Fort Pierce, Florida. The workshop brought together
approximately 85 individuals from health departments, jails, and
the Department of Corrections in Florida to increase their awareness
of issues surrounding TB prevention and control among the incarcerated
The Florida Corrections TB Program is currently cosponsored
by the Florida Department of Health (DOH) and the Florida Department
of Corrections, the Florida Sheriff's Association, and the American
Lung Association. The group members currently hold quarterly meetings,
and use one meeting a year for a 2-day workshop; the meeting I attended
was their annual workshop. The meeting was hosted by the St. Lucie
County Sheriff's Office and the Indian River Community College.
Graydon Sheperd, Chief of the Florida DOH Bureau of
TB and Refugee Health, was part of a DOH panel. The title of his
presentation was "The State of the State - TB." A TB skin
test certification course, for which trainers included Jo-Ann Arnold
and Ellen Murray (nurses with the DOH), was among the break-out
Other speakers included Max Salfinger, the Director
of Laboratories for the New York State Department of Health; representatives
from the Florida Department of Corrections; staff from other DOH
bureaus (HIV/AIDS and STD); staff from A.G. Holley Hospital; private
physicians; and a representative from the social services division
of the Salvation Army.
Presenting the key note address, I outlined the CDC
recommendations for correctional facilities emphasizing screening,
containment, assessment, and continuity of care.This proved to be
a good introduction of the key points to consider. In the address,
I stressed the barriers and facilitators to effective TB prevention
and control in correctional settings. In my talk, I also provided
national statistics on TB in correctional facilities and reviewed
the reasons why correctional facilities and incarcerated populations
are at high risk for TB. The discussion which followed focused on
how to overcome barriers and develop specific strategies. Heather
Duncan, a DTBE field staff public health advisor, also attended
the meeting and gave a presentation entitled "TB: What Is My
CDCís participation demonstrated our support for Florida's
efforts. The Florida Corrections TB Program, and this workshop specifically,
are good examples of the collaboration necessary to best address
TB in the incarcerated population. In addition to general sessions
presenting medical, legal, psychosocial, administrative, and programmatic
issues regarding TB and HIV in corrections in Florida, breakout
sessions provided the opportunity for the medical directors, nurses,
correctional administrators, security staff, and program managers
in attendance to have more detailed discussion and training on tuberculin
skin testing, personal respiratory protection, and development of
TB control plans including risk assessments.
óReported by Lauri B. Bazerman, MS
Division of TB Elimination
TB Training Videos for Correctional and Health
The Texas Department of Health, with a grant from
the U.S. Department of Justice, has developed five training videos
based on the edited presentations from the satellite broadcast "TB
Control in Correctional Facilities." The titles and running
times are as follows:
Preventing TB in Correctional Facilities (22:00
TB Screening and Diagnosis (28:50 minutes)
Safely Transporting Inmates with TB (14:00 minutes)
Creating a Plan to Control TB (21:30 minutes)
Ins & Outs of Contact Investigation (32:21
You can purchase videos either singly for $7 or as
a set of five for $30. These prices include shipping. To order,
you will need to obtain an order form by calling the Texas Department
of Health TB Elimination Division at (512) 458-7447 or by sending
an e-mail to email@example.com.
No orders can be processed without an order form.
óReported by Phyllis Cruise
Texas TB Control Program