Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC

Endorsed by the Advisory Council for the Elimination of Tuberculosis, the National Commission on Correctional Health Care, and the American Correctional Association

Disclosures

Morbidity and Mortality Weekly Report. 2006;55(27):1-44. 

In This Article

Introduction

Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis that adversely affects public health around the world.[1] In the United States, TB control remains a substantial public health challenge in multiple settings. TB can be particularly problematic in correctional and detention facilities,[2] in which persons from diverse backgrounds and communities are housed in close proximity for varying periods. Effective TB prevention and control measures in correctional facilities are needed to reduce TB rates among inmates and the general U.S. population.

The recommendations provided in this report for the control of TB in correctional facilities expand on, update, and supersede recommendations issued by the Advisory Council for the Elimination of TB (ACET) in 1996.[3] This report provides a framework and general guidelines for effective prevention and control of TB in jails, prisons, and other correctional and detention facilities. In addition, on the basis of existing scientific knowledge and applied experience of correctional and public health officials, this report defines the essential activities necessary for preventing transmission of M. tuberculosis in correctional facilities. These fundamental activities can be categorized as 1) screening (finding persons with TB disease and latent TB infection [LTBI]); 2) containment (preventing transmission of TB and treating patients with TB disease and LTBI); 3) assessment (monitoring and evaluating screening and containment efforts); and 4) collaboration between correctional facilities and public health departments in TB control. These overarching activities are best achieved when correctional facility and public health department staff are provided with clear roles of shared responsibility.

The recommendations in this report can assist officials of federal, state, and local correctional facilities in preventing transmission of TB and controlling TB among inmates and facility employees. The target audience for this report includes public health department personnel, correctional medical directors and administrators, private correctional health vendors, staff in federal and state agencies, staff in professional organizations, and health-care professionals. The report is intended to assist policymakers in reaching informed decisions regarding the prevention and control of TB in correctional facilities.

To update the existing guidelines, with assistance from ACET, CDC organized and convened the Tuberculosis in Corrections Working Group, an ad hoc group of persons with expertise in public health and health care in correctional facilities. Organizations represented in the Working Group included ACET, the National Commission on Correctional Health Care, the American Correctional Association, the American Jail Association, and the Society of Correctional Physicians. The Working Group reviewed published guidelines and recommendations, published and unpublished policies and protocols, and peer-reviewed studies discussing overall TB prevention and control and aspects of TB prevention and control specific to correctional and detention facilities. These guidelines, recommendations, policies, protocols, and studies form the basis for the Working Group's recommendations. Because controlled trials are lacking for TB prevention and control activities and interventions specific to correctional and detention facilities, the recommendations have not been rated on the quality and quantity of the evidence. The recommendations reflect the expert opinion of the Working Group members with regard to best practices, based on their experience and their review of the literature.

These guidelines are intended for short- and long-term confinement facilities (e.g., prisons, jails, and juvenile detention centers), which are typically referred to as correctional facilities throughout this report. These recommendations differ as follows from those made in 1996:

  • The target audience has been broadened to include persons working in jails and other detention facilities.

  • The need for correctional and detention facilities to base screening procedures for inmates and detainees on assessment of their risk for TB is emphasized. A description of how TB risk should be assessed is included.

  • The need for institutions to conduct a review of symptoms of TB for all inmates and detainees at entry is discussed.

  • The need for all inmates and detainees with suspected TB to be placed in airborne infection isolation (AII) immediately is emphasized.

  • Testing recommendations have been updated to reflect the development of the QuantiFERON®-TB Gold test (QFT-G), a new version of the QuantiFERON®-TB (QFT) diagnostic test for M. tuberculosis infection.

  • The section on environmental controls has been expanded to cover local exhaust ventilation, general ventilation, air cleaning, and implementation of an environmental control program. Ventilation recommendations for selected areas in new or renovated correctional facilities have been included.

  • A section on respiratory protection has been added, including information on implementing respiratory protection programs.

  • Treatment recommendations for TB and LTBI have been updated on the basis of the most recent treatment statements published by CDC, the American Thoracic Society (ATS), and the Infectious Diseases Society of America.

  • Emphasis is placed on case management of inmates with TB disease and LTBI.

  • The need for early discharge planning coordinated with local public health staff is emphasized.

  • A section has been included on U.S. Immigration and Customs Enforcement detainees.

  • The importance of collaboration between correctional facility and public health staff is emphasized, particularly with respect to discharge planning and contact investigation.

  • The need for corrections staff to work closely with public health staff to tailor an appropriately comprehensive training program to achieve and sustain TB control in a correctional facility is emphasized.

  • The need for public health workers to receive education regarding the correctional environment is emphasized.

  • Program evaluation is emphasized. Recommended areas of evaluation include assessment of TB risk in the facility, performance measurement for quality improvement, collaboration, information infrastructure, and using evaluation information to improve the TB-control program.

During 1980--2003, the number of incarcerated persons in the United States increased fourfold, from approximately 500,000 in 1980 to approximately 2 million in 2003.[4,5] A disproportionately high percentage of TB cases occur among persons incarcerated in U.S. correctional facilities. In 2003 at midyear, although 0.7% of the total US population was confined in prisons and jails, 3.2% of all TB cases nationwide occurred among residents of correctional facilities.[6] Although overall incidence of new TB cases among the U.S. population has remained at <10 cases per 100,000 persons since 1993,[6] substantially higher case rates have been reported in correctional populations.[2] For example, the incidence of TB among inmates in New Jersey during 1994 was 91.2 cases per 100,000 inmates, compared with 11.0 cases per 100,000 persons among all New Jersey residents.[3] In 1991, a TB case rate for inmates of a California prison was 184 cases per 100,000 persons, which was 10 times greater than the statewide rate.[7] In addition, in 1993, the TB rate for inmates in the New York State correctional system was 139.3 cases per 100,000 persons, an increase from the rate of 15.4 during 1976--1978.[3,8] In California, the TB case rate reported from an urban jail in a high-prevalence area was 72.1 cases per 100,000 inmates in 1998, representing 10% of the county's cases in that year.[9] Studies have demonstrated the prevalence of LTBI among inmates to be as high as 25%.[10,11,12,13,14] Other studies have demonstrated a correlation between length of incarceration and positive tuberculin skin test (TST) response, indicating that transmission might have occurred in these facilities.[15,16]

At least three factors contribute to the high rate of TB in correctional and detention facilities. First, disparate numbers of incarcerated persons are at high risk for TB (e.g., users of illicit substances [e.g., injection drugs], persons of low socioeconomic status, and persons with human immunodeficiency virus [HIV] infection). These persons often have not received standard public health interventions or nonemergency medical care before incarceration. Second, the physical structure of the facilities contributes to disease transmission, as facilities often provide close living quarters, might have inadequate ventilation, and can be overcrowded.[9,17,18,19] Third, movement of inmates into and out of overcrowded and inadequately ventilated facilities, coupled with existing TB-related risk factors of the inmates, combine to make correctional and detention facilities a high-risk environment for the transmission of M. tuberculosis and make implementation of TB-control measures particularly difficult.[19] Despite recent efforts to improve TB-control measures in correctional and detention facilities, outbreaks of TB continue to occur in these settings, and TB disease has been transmitted to persons living in nearby communities.[20,21,22] Consequently, correctional and detention facilities are critical settings in which to provide interventions for detecting and treating TB among a vulnerable population.

Addressing the Challenges of TB Control in Correctional Facilities. Published recommendations for elimination of TB in the United States include testing and treating inmates in correctional facilities for LTBI to prevent the development and transmission of TB.[23] The basis for this recommendation is that LTBI and coinfection with HIV are more common in these underserved populations than in the general population.[24,25,26] However, treating correctional inmates for LTBI can be challenging.

Before being incarcerated, inmates might have faced barriers to accessing community health services necessary for the detection and treatment of TB disease and LTBI.[27] In addition, inmates released from correctional facilities often do not attend clinic visits or adhere to treatment regimens. One study of inmates released before completion of TB therapy indicated that only 43% made at least one visit to the clinic after release.[28] In another jail setting, using an educational intervention increased the rate of clinic visits after release from 3% to only 23%.[29]

In the United States, TB is concentrated increasingly among the most disadvantaged populations, particularly immigrants.[30] Detained immigrants are arriving largely from countries with a high prevalence of TB (e.g., Mexico, the Philippines, and Vietnam) and therefore present unique challenges in the elimination of TB in the United States*.[31] Social and legal barriers often make standard testing and treatment interventions inadequate among undocumented immigrants.[31] In certain instances, these patients have become resistant to first-line anti-TB drugs because of the interrupted treatment received in their countries of origin.[32] However, undocumented immigrants placed in detention and correctional facilities have an opportunity to receive TB screening and begin treatment for TB disease.[33]

Rationale for Updating and Strengthening TB Control and Prevention Guidelines. Transmission of M. tuberculosis continues to be documented within correctional facilities, primarily as a result of undiagnosed TB. Inmates with undiagnosed TB disease place other inmates and correctional staff at risk for TB, and when released, these persons also can infect persons living in surrounding communities.[16,17,20,21,22,34,35]

Despite the continued transmission of TB in correctional settings, few comprehensive evaluations of the implementation of TB-detection and -control procedures in correctional facilities have been performed.[36,37,38] Nevertheless, correctional facilities are increasingly basing their TB prevention and control procedures on studies and data that support judicious interventions, including screening, case finding, case management, outbreak and contact investigations, and treatment for LTBI.[7,9,14,21,28,33,34,39,40,41,42,43,44,45,46] Improving TB prevention and control practices within these settings is necessary to reduce rates of disease and eventually eliminate TB. TB prevention and control practices within correctional facilities should be strengthened for multiple reasons:

  • M. tuberculosis is spread through the air. One highly infectious person can infect inmates, correctional staff, and visitors who share the same air space.

  • Immediate isolation of infectious patients can interrupt transmission of M. tuberculosis in the facility.

  • Prompt initiation of an adequate regimen of directly observed therapy (DOT)† helps ensure adherence to treatment because a health-care professional, a specially trained correctional officer, or a health department employee observes the patient swallowing each dose of medication. This method of treatment can diminish infectiousness, reduce the risk for relapse, and help prevent the development of drug-resistant strains of M. tuberculosis.

  • Inmates of correctional facilities have been reported to have relatively high rates of HIV infection; persons who are coinfected with HIV and M. tuberculosis are at high risk for progressing from LTBI to TB disease.

  • A completed regimen of treatment for LTBI can prevent the development of TB disease in persons who are infected with M. tuberculosis.

  • Correctional facility officials have an opportunity to treat inmates who have TB disease or LTBI before such inmates are released into the community.

  • Because a substantial proportion of inmates do not have any other access to the health-care system, the correctional setting can be a primary source of health information, intervention, and maintenance.

* The epidemiology of TB in the United States has changed dramatically since the early 1990s. Immigration from countries with a high prevalence of TB contributes substantially to the continued high rates of disease and transmission among foreign-born persons. In 2003, the rate of TB among foreign-born persons in the Untied States was 8.7 times higher than the rate for persons born in the United States. More than half of new TB cases in 2003 occurred in foreign-born persons, particularly those from Mexico, the Philippines, and Vietnam. Of 114 patients in whom multi-drug resistant TB (MDR TB) were diagnosed, foreign-born persons accounted for 95 (83%) cases.[6] Detention facilities and local jails frequently contract with U.S. Immigration and Customs Enforcement (ICE) to house detainees, a practice that should be accounted for in assessing a facility's risk status.

† Therapy that involves providing the anti-TB drugs directly to the patient and watching as the patient swallows the medications. DOT is the preferred core management strategy for all patients with TB. DOT for LTBI is referred to sometimes as directly observed preventive therapy.

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