1. TB Prevention and Control in Correctional and Detention Facilities, 2006
Mark Lobato, MD
Division of TB Elimination
Centers for Disease Control and Prevention
Northeast TB Controllers Meeting
October 24, 2006
This is an old story, with some new recommendations for one of the residual pockets of TB in the US.

2. What’s New? (1) Bases guidelines on existing evidence
Broadens definition of corrections to include detention facilities
Uses a risk assessment approach
Testing by TST or QFT-Gold
The recommendations now include detention centers where detainees and inmates may be held prior to trial or
sentencing.

3. 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.
Collaboration, education, and evaluation are given high visibility as important TB control activities.
For the first time ICE facilities are specifically signaled out as an important venue for screening high-risk foreign born persons.

4. Symptom Screening Specifies which questions to ask
Train staff on screening interview techniques
Starting with the specific questions that should be asked of inmates for symptom screening to who should ask the questions and how the interviewers should be trained.

5. TB Testing TST should be done within 7 days
Offer a menu of options (TST, QFT, CXR)
HIV-infected persons require a CXR
Although there was no consensus of how best to test for TB and LTBI, the participants felt that waiting 14 days before testing.
A menu of options should be offered so that local and state officials who best know the populations and resources that are available could decide whether a TST or a CXR was the screening tool of choice.
The role of QFT is unknown at this time, but is an acceptable option for testing.

6. 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
The guidelines divide facilities into minimum risk and non-minimum risk based on the number of TB cases seen in the past year and the risk profile of the inmate population.

7. TB Screening: Minimal Risk Facility
Entry
Screen for
symptoms TB
Symptoms
Present?
Yes
Isolate and
evaluate
The guidelines emphasize the need for CFs to develop a risk assessment of the facility. Minimal risk facilities, i.e. no cases
diagnosed, perform symptom screening. This does not mean that no testing is required. Routine testing is not called for unless the individual has a risk and that individual should be tested. No
Yes
TST or
QFT – G
CXR (HIV+)
Inmate has
TB risk? No
No further
test

8. Non-Minimum Risk Facility
Symptom review 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

9. TB Screening: > Minimal Risk Facility
Entry
Screen for
symptoms TB
Symptoms
Present?
Isolate and
evaluate
In non-minimum risk facilities, the screening and testing algorithm remains unchanged with the exception of adding QF
as an option for testing. Renewed emphasis is placed on CXR for HIV-infected regardless of their TST result. No
Obtain medical History
If treatment not
completed, CXR
and evaluate
Yes
Previous TST +
documented? No

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

11. Recommendations
Report suspect cases by all entities including federal facilities to local or state HD
Screen all incoming inmates at entry with a symptom review
Perform risk assessment
Screen high risk inmates with a tuberculin skin test (or QuantiFeron-TB) within 7 days of entry
Isolate TB suspects immediately
Plan for discharge early
Special section on ICE detainees
Although some of the recommendations are not new, the prioritization and the framing of the issues are new.
Reporting of TB cases to the local health entity is the responsibility of the facility including federal facilities.
Screen all inmates at minimum and non-minimum risk facilities using symptoms questionnaires.
Testing for TB and LTBI should be completed within 7 days of entry.
Isolate immediately and plan for discharge early.
And, a special section is devoted to ICE detainees.

12. New and Renewed Emphasis
Summarizes changes in treatment for TB and latent TB infection
Expands collaboration between health departments and medical staff
Emphasizes contact tracing and outbreak investigations
Provides details for evaluation of TB control activities
Offers guidance on training and education
The section on treatment of TB and LTBI is a summary from the recent 2000 and 2003 guidelines.
Emphasizes contact tracing and outbreak investigations
Provides details on evaluation of TB control activities at the level of the facility.
Discusses role of information systems
Offers guidance on training and education of correctional staff as well as patients, contacts, and inmates with LTBI.

13. Jails – A Community Institution
Shelter
Soup
Homeless
Clinic
Kitchen
Hospital Clinic
Detention and correctional facilities are part of a larger community that needs to be taken into account. To control TB in the facility and reduce transmission in the community collaboration among these institutions is paramount.
Jail
Detention Center -

14. Discharge Planning
Requires coordination between corrections and public health
Begin soon after diagnosis
Interview by health department ideally should occur before release
Because most inmate-patients with TB do not complete treatment while incarcerated, case management and discharge planning becomes an important adjunct for adequate treatment.

15. Collaboration Requires formal mechanisms
Designated liaisons
Regular meetings
Written agreements
Conduct contact investigations with input from health departments
Address referral of soon-to-be released inmates
TB programs are the leaders in promoting collaboration and should be actively involved in correctional contact investigations
and discharge planning.

16. Evaluation Assess level of TB risk Collect and organize data
Analyze data and present conclusions
Make improvements based on findings
Correctional administrators, health care professionals including contracted companies and health departments should collaborate to develop a TB and infection control training program. Quality and timely data are key to evaluation.

17. Public health must go to jail.