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

Discharge Planning

Correctional facilities should plan for the discharge of inmates and other detainees who have confirmed or suspected TB disease and those with LTBI who are at high risk for TB disease. Such planning is crucial to effective local TB control efforts within the community to which released inmates return. Facilities should ensure that their discharge plan is comprehensive and effective; the process should include 1) collaborating with public health and other community health-care professionals, 2) ensuring continuity of case-management, and 3) evaluating discharge-planning procedures and modifying procedures as needed to improve outcomes.

Postconfinement follow-up is a necessary component of TB-control efforts.[35,124] Effective discharge planning requires collaboration between corrections and medical staff (both intra- and inter-facility), and with public health and community-based service organizations.[37] Correctional facilities and public health departments should overcome multiple obstacles associated with postdetention follow-up,[125] including

  • short length of stay in a facility;

  • unscheduled release or transfer;

  • poorly defined or implemented channels of communication between correctional and public health authorities;

  • limited resources (i.e., staff, equipment, and medications) available to provide recommended TB prevention, screening, treatment, and discharge-planning services;

  • limited resources of the patient to make or keep appointments;

  • high prevalence of mental illness and substance abuse among correctional patients;

  • mistrust among inmates, which might result in the provision of aliases or incorrect contact or locating information; and

  • reincarceration with disruption in treatment or termination of public benefits.

Collaboration is essential to ensure that TB-control efforts are undertaken in the most cost-effective manner. Coordination between the correctional facility and the public health department maximizes the effectiveness of any efforts begun in a correctional facility,[126] and linking released detainees to the public health-care system might improve post-release adherence[35] and reduce recidivism.[127,128] The types of relationships forged will depend on the assessment of the TB risk in the facility and the community.

Comprehensive discharge planning is an important component of case management and is essential for ensuring the continuity of TB management and therapy among persons with TB disease and LTBI. Following release, former inmates face housing, employment, and other crises concerning basic needs that often take priority over their health. Multiple reports from the United States and other countries support the use of comprehensive discharge planning in TB control efforts.[42,129,130] Comprehensive discharge planning should be implemented for inmates with confirmed TB disease, suspected TB disease, and LTBI who also are at high risk for TB disease.

Discharge planning for persons with LTBI who are considered at high risk for developing TB disease is critical if treatment is begun in the correctional facility. Starting all inmates at high risk on LTBI therapy might not be feasible while they are in the correctional facility, and the policy determining which risk groups to start on treatment should be made in collaboration with public health personnel. Collaboration ensures appropriate communication and adequate resources for treatment after transfer to another facility or after release to the community. At minimum, all inmates who have begun therapy for LTBI in a correctional facility should be given community contact information for follow-up and continuity of care. Ideally, all inmates demonstrated to be infected with TB should be considered for therapy, and discharge planning to facilitate therapy should be comprehensive.[124] Because of high recidivism rates, discharge-planning efforts should begin in the detention phase and continue in the post-detention phase to ensure continuity of care as inmates move among different facilities and between correctional facilities and the community.

Initiate Discharge Planning Early. To ensure uninterrupted treatment, discharge planning for inmates who receive a diagnosis of TB disease should begin as soon as possible after diagnosis.[131] Corrections or health services administrators (or their designees) should assign staff to notify the public health department of inmates receiving treatment for TB disease or LTBI. Inmates with TB disease should be interviewed while still incarcerated (ideally by public health staff) to enable facility administrators to assess and plan for the appropriate support and referrals that will be needed after discharge.[131] Such personnel also should communicate with other facilities in the event of transfers of inmates.

Provide Case Management. To ensure continuity of care, all correctional facilities should assign personnel (preferably health-care professionals) to serve as case managers. These managers should be responsible for conducting discharge planning in the facility, which entails coordinating follow-up and communicating treatment histories with public health department and other health-care counterparts within the community.[42] In addition, case managers should employ strategies (e.g., mental-illness triage and referral, substance-abuse assessment and treatment, and prerelease appointments for medical care) to help former inmates meet basic survival needs on release. The role of case manager should be assigned to a facility staff member who is capable of establishing good rapport with inmates; an effective case manager might be capable of persuading TB patients who are being released into the community to supply accurate information needed to ensure follow-up care.

The following factors should be considered when planning community discharge of an inmate receiving treatment for TB[132]:

  • Where will the ex-inmate reside after discharge (e.g., a permanent residence, a halfway house, or a shelter)?

  • Will family or other support be available?

  • Are cultural or language barriers present?

  • What kind of assistance will be needed (e.g., housing, social services, substance abuse services, mental health services, medical services, and HIV/AIDS services)?

  • Does the inmate understand the importance of follow-up and know how to access health-care services?

Obtain Detailed Contact Information. To facilitate the process of locating former inmates, detailed information should be collected from all inmates with TB disease or LTBI for whom release is anticipated, including 1) names, addresses, and telephone numbers of friends, relatives, and landlords; 2) anticipated place of residence; and 3) areas typically frequented (e.g., restaurants, gyms, parks, and community centers).[61,133] Inmates also should complete a release form authorizing health department personnel to contact worksites, family members, corrections staff (parole officers), and public and private treatment centers. Inmates might give aliases or incorrect contact information because of fear of incrimination or deportation. The use of an alias can be a barrier to continuity of care on reentry to a correctional facility.

Assess and Plan for Substance Abuse and Mental Health Treatment and for Other Social Services. Substance abuse and other comorbid mental health conditions should be considered when developing a comprehensive discharge plan. Addiction affects health care, medication adherence, housing opportunities, social relationships, and employment and might be the greatest barrier to continuity of care for TB.[134] Mental illness can be a barrier when community service providers have not been trained to interact with mentally ill patients. Persons who are mentally ill might have difficulties keeping medical appointments. Collaboration between corrections and health department personnel can facilitate the placement of former inmates in substance abuse or mental-health treatment programs to improve the likelihood of social stabilization and continuity of care.[134,135]

Other social issues present barriers to released inmates. Loss of health insurance benefits while incarcerated is common, and former inmates might be required to wait 30-365 days after release to become re-eligible for benefits.[136,137] Certain correctional facilities have agreements with local Social Security Administration field offices to facilitate swift reactivation of these benefits (138); creation of and training in the use of such agreements are encouraged. Ideally, on entry into the correctional system, public benefits would be suspended, rather than terminated, and reactivated on release to eliminate gaps in coverage. Application for public benefits and insurance should be incorporated into the discharge planning phase whenever possible. If the inmate is likely to have limited access to care because of inability to pay for services on release, documentation should be made and another treatment mechanism identified.[139]

Make Arrangements for Postrelease Follow-Up. Before release, the inmate should be introduced (preferably face to face) to the employee from the community treatment agency who is responsible for community-based treatment and care.[139] When release dates are known, setting post-release appointments has been demonstrated to improve compliance.[128,134,140] Patients with TB disease should be given a supply of medication at discharge adequate to last until their next medical appointment. Discharge planners can work with advocacy groups or private or government-funded programs to facilitate a safe, supported transition into the community.[61]

Make Provisions for Unplanned Release and Unplanned Transfers. Administrative procedures should be in place for unscheduled discharge of inmates who are being managed or treated for TB.[36,141] Reporting requirements for inmates with TB disease who are released or transferred to another facility vary among states and jurisdictions. Despite mandatory notification policies, notification of public health officials varies from 87%-92% for inmates with TB disease[37,126] to only 17% for inmates with LTBI.[36,37] Correctional facility staff responsible for health department notification should relay information about all scheduled and unscheduled releases as it becomes available. All TB information concerning persons who are being transferred to other correctional settings should be provided to the receiving facility. In addition, inmates should be given a written summary or discharge card outlining their treatment plan to ensure continuity of care in case of unplanned and unanticipated release.[131,142] Inmates with TB disease who are eligible for release or transfer to another medical or correctional facility but continue to be infectious should remain in airborne precautions during and after transfer until noninfectious.[132]

Provide Education and Counseling. Patient education and documentation of education in the correctional facility is critical; multiple misconceptions persist among inmates and facility staff regarding means of transmission, differences between infection and disease, and methods of prevention and treatment for TB.[143] Persons receiving treatment should be counseled about the importance of adhering to the treatment plan[131] as a measure to improve postrelease follow-up.[61] Education should be delivered in the inmate's first preferred language and should be culturally sensitive with respect to ethnicity, sex, and age.[135,144,145,146,147] The inmate should be actively involved in all education sessions to encourage communication regarding previous transition experiences (e.g., the inmate's treatment motivations and any positive or negative experiences with specific providers).[141] Inmates with LTBI who have not been started on therapy should be counseled on their risk factors, encouraged to visit the public health department, and provided with information about access to care after release.

DOT for TB disease or LTBI in the correctional setting provides an opportunity for educating and counseling inmates and for establishing a routine of medication administration. The effect, if any, of DOT on postrelease behavior has not been evaluated formally, but this practice might enhance adherence.[122]

Case-management strategies begun in the correctional facility should be continued after release for former inmates with confirmed or suspected TB disease and those with LTBI who are at high risk for progression to TB disease. Incentives and enablers (see Glossary) have improved adherence in incarcerated[35,60,61] and nonincarcerated[148,149] populations, and incentives combined with education and counseling optimize both short- and long-term adherence.[40,60,61,150] Case management that takes into account cultural differences and addresses not only TB-control matters but patient-defined needs (particularly among foreign-born persons) results in improved completion rates for LTBI therapy.[145] Case management by health department personnel after release is critical for continuity of care in the event of reincarceration. The provision of follow-up information from local health departments and community-based organizations back to corrections staff is helpful in determining whether discharge planning is effective.

Background. Persons with TB disease detained by ICE officers are a potential public health threat because they typically are highly mobile, likely to leave and reenter the United States before completion of TB therapy, and at high risk for interrupting treatment.[151] Therefore, ensuring treatment of such detainees is important to the national strategy to eliminate TB in the United States.[32,152]

In March 2003, the detention and removal functions of the former Immigration and Naturalization Service (INS) were transferred from the U.S. Department of Justice (DOJ) to the U.S. Department of Homeland Security (DHS). ICE is a division of DHS and detains approximately 200,000 persons annually while enforcing immigration law. ICE detainees are screened for TB disease at service processing centers, staging facilities, contract detention facilities, and local jails. Frequent transfers of ICE detainees between detention facilities are common.

ICE detention provides an opportunity to identify persons with confirmed and suspected TB disease and initiate treatment, if appropriate. ICE detainees with confirmed or suspected TB disease receive treatment while they are in custody. Presently, ICE does not deport detainees with known infectious TB, but such persons might be deported when noncontagious, even if treatment has not been completed or the final culture and susceptibility results are pending.

Discharge Planning for ICE Detainees. In May 2004, ICE approved a policy to implement a short-term medical hold of persons with suspected or confirmed TB disease until continuity of care is arranged, which affords the ICE health services program the time needed to facilitate continuity of TB therapy arrangements before the patient's release or removal. The ICE health services program seeks to enroll all persons with confirmed or suspected TB disease in programs that facilitate the continuity of TB therapy between countries. These programs (e.g., CureTB, TB Net, and the U.S.-Mexico Binational Tuberculosis Referral and Case Management Project) facilitate TB referrals and follow-up for patients who move between the United States and other countries.

ICE field office directors may consider a stay of removal for persons with MDR TB or other complicated cases, so they can receive and complete treatment in the United States before removal. In detention settings in which ICE detainees are held, facility staff who are responsible for TB communication should notify the ICE health services program of persons with confirmed or suspected TB disease. Collaboration with detention facilities and local and state health departments will facilitate enrollment in the appropriate continuity of care program before transfer, release, or repatriation. Correctional facility staff should identify these patients as ICE detainees when reporting TB cases to local and state health departments.

Evaluation of a discharge planning program is critical and should begin with an assessment of existing programs and activities. Program evaluation should be incorporated into the overall correctional quality improvement/assurance program.[153] Data from program evaluation studies should be documented and published to ensure that correctional facility and public health department staff are informed regarding effective measures and the effective translation of research findings into practice.[123] Evaluation of discharge planning should include measurements of

  • adherence to therapy,

  • cost savings (from unduplicated testing for persons with LTBI and completion of care without re-starts and extensions),

  • recidivism, and

  • the effectiveness of the collaboration between medical and corrections staff (both within and among facilities) and between correctional facilities and the public health department and other community agencies.

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