TB Prevention and Control in Correctional and Detention Facilities Mark Lobato, MD Division of TB Elimination Centers for Disease Control and Prevention Corrections Connections Forming Partnerships to Stop TB April and May 11, 2007

What’s New? (1) Broadens definition of corrections to include detention facilities Uses a risk assessment approach Recommends all inmates receive symptom screening Suggests testing by TST or QFT-Gold

What’s New? (2) Highlights importance of collaboration, education, and evaluation Emphasizes case management Expands environmental controls section and adds a section on respiratory protection Recognizes the role of ICE in screening the foreign born in the U.S.

TB Testing TST should be done within 7 days If TST positive, CXR done within 72 hours HIV-infected persons require a CXR

Facility Risk Assessment Minimum Risk Facility Zero TB cases in last year Not a “high-risk” population (HIV, IDU) Not large numbers of foreign born Employees not otherwise at risk for TB All other facilities are non-minimal risk

Individual Risk Assessment Minimum Risk Facility Inmates with TB symptoms require immediate isolation in an AII room Individuals in minimum-risk facilities require further evaluation if clinical condition or risk factor for TB HIV require CXR

Non-Minimum Risk Facility Review symptoms at entry immediately place symptomatic in a AII room TB test (TST, QFT-G, CXR) within 7 days CXR for HIV infected or immunosuppressed Consider therapy for positive test results

TB Screening: > Minimal Risk Facility Entry Screen for symptoms TB Symptoms Present? Obtain medical History Yes No Isolate and evaluate If treatment not completed, CXR and evaluate Previous TST + documented? Yes

TB Screening: > Minimal Risk Facility Retest periodically In long-term facilities Yes No CXR and evaluate HIV+ or at risk for HIV but status unknown? No previous TST+ documented TST* or QFT-G TST+ or QFT-G? Yes CXR and evaluate *2-step testing recommended for Initial testing in facilities that perform periodic TST testing

Recommendations Report suspect cases by all entities including federal facilities to local or state HD Screen all incoming inmates at entry with at least a TB symptom review Perform risk assessment Isolate TB suspects immediately Plan for discharge early Provides a special section on ICE detainees

New and Renewed Emphasis Summarizes treatment for TB and latent TB infection Expands on collaboration between health departments and medical staff Emphasizes contact investigations Provides details for evaluation of TB control activities Offers guidance on training and education

Airborne Infection Isolation (AII) Initiate TB AII precautions for any patient who Has signs and symptoms of TB disease Has not completed treatment Has not previously been determined non- infectious

When to Discontinue AII Discontinue AII when infectious TB is unlikely Another diagnosis is made Patient has 3 negative AFB sputum smears If patient has 3 negative AFB smear results Release after starting 4 anti-TB drugs Patient improving clinically

LTBI - Treatment Prioritize patients Preferred treatment 9 months INH Daily or biweekly (DOT) Other regimens 4 months rifampin NOT 2 months of pyrazidamide and rifampin Drug resistance

Collaboration Requires formal mechanisms Designated liaisons Regular meetings Written agreements Case management Discharge planning Contact investigations

Case Management Care should be individualized Management should be coordinated with health department Most inmates released before treatment is completed Evaluate outcomes

Detention Center- Jail Hospital Clinic Shelter Homeless Clinic Soup Kitchen Jails – A Community Institution

Discharge Planning Requires coordination between corrections and public health Begin as soon as possible Interview by health department should occur before release

Contact Investigations Goal is to interrupt TB transmission Collaboration with public health essential Scope of investigation depends on Site of TB disease (pulmonary, laryngeal) AFB smear status (smear positive) “Index of suspicion”