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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
The material in this report originated in the National Center for
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed),
Kevin Fenton, MD, PhD, Director, and the Division of Tuberculosis Elimination, Kenneth G. Castro, MD, Director.
Corresponding address: Division of Tuberculosis Elimination, National Center for
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
(proposed), CDC, 1600 Clifton Road, NE, MS E-10, Atlanta, GA 30333. Telephone: 404-639-8120; Fax: 404-639-8604.
Summary
Tuberculosis (TB) control can be particularly problematic in correctional and detention facilities, in which persons
from diverse backgrounds and communities are housed in close proximity for varying periods. This report provides a framework
and general guidelines for effective prevention and control of TB in jails, prisons, and other correctional and detention
facilities. Recommendations were developed on the basis of published guidelines and a review of the scientific literature. Effective
TB-prevention and -control measures in correctional facilities include early identification of persons with TB disease through
entry and periodic follow-up screening; successful treatment of TB disease and latent TB infection; appropriate use of
airborne precautions (e.g., airborne infection isolation, environmental controls, and respiratory protection); comprehensive
discharge planning; and thorough and efficient contact investigation. These measures should be instituted in close collaboration
with local or state health department TB-control programs and other key partners. Continuing education of inmates, detainees,
and correctional facility staff is necessary to maximize cooperation and participation. To ensure TB-prevention and
-control measures are effective, periodic program evaluation should be conducted.
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.
Methods
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.
Summary of Changes from Previous Recommendations
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.
Background
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--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--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--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--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--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--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.
Screening
Early identification and successful treatment of persons with TB disease remains the most effective means of
preventing disease transmission (47). Therefore, inmates who are likely to have infectious TB should be identified and begin
treatment before they are integrated into the general correctional facility population (i.e., at the time of admission into the
correctional system). When possible, newly arrived inmates should not be housed with other inmates until they have been
appropriately screened for TB disease. Screening programs in the correctional setting also allow for the detection of substantial numbers
of persons with LTBI who are at high risk for progressing to TB disease and would likely benefit from a course of treatment.
This secondary benefit of screening programs is often limited by inability to initiate and ensure completion of LTBI
treatment, particularly in short-term correctional facilities. In addition to screening at intake, routine (i.e., at least annual) screening
of long-term inmates and correctional facility staff (e.g., custody and medical) should be incorporated into the
TB-control program (48,49).
How screening activities should be implemented depends on multiple factors, including 1) the type of facility, 2)
the prevalence of TB infection and disease in the facility, 3) the prevalence of TB in the inmates' communities, 4) the
prevalence of other risk factors for TB (e.g., HIV) in the inmate population, and 5) the average length of stay of inmates in the
facility. The type of screening recommended for a particular facility is determined by an assessment of the risk for TB
transmission within that facility. The risk assessment should be performed at least annually and should be made in collaboration with
the local or state health department. A facility's TB risk can be defined as being minimal or nonminimal.
A facility has minimal TB risk if
- no cases of infectious TB have occurred in the facility in the last year,
- the facility does not house substantial numbers of inmates with risk factors for TB (e.g., HIV infection and
injection-drug use),
- the facility does not house substantial numbers of new immigrants (i.e., persons arriving in the United States within
the previous 5 years) from areas of the world with high rates of TB, and
- employees of the facility are not otherwise at risk for TB.
Any facility that does not meet these criteria should be categorized as a nonminimal TB risk facility.
Screening Methods
Symptom Screening
Whenever possible, health-care professionals should perform the initial screening. However, correctional officers in
jails (particularly those housing minimal numbers of inmates) frequently administer health intake questionnaires. If custody
staff members conduct the intake screening, they should
receive adequate periodic training in taking a medical history,
making necessary observations, and determining the appropriate disposition of inmates with signs or symptoms of possible
medical problems. Staff conducting medical intake should receive appropriate counseling and education regarding
medical confidentiality.
During their initial medical screening, inmates should be asked if they have a history of TB disease or if they have
been treated for LTBI or TB disease previously. Documentation of any such history should be obtained from medical records,
if possible. Inmates should be observed for the presence of a cough or evidence of significant weight loss. All incoming
inmates in any size jail, prison, or other detention facility (e.g., immigration enforcement) should be immediately screened
for symptoms of pulmonary TB by being asked if they have had a prolonged cough (i.e., one lasting
>3 weeks), hemoptysis (i.e., bloody sputum), or chest pain. The index of suspicion should be high when pulmonary symptoms are accompanied
by general, systemic symptoms of TB (e.g., fever, chills, night sweats, easy fatigability, loss of appetite, and weight loss).
Inmates should be interviewed systematically (i.e.,
using a standardized questionnaire) to determine whether they have
experienced symptoms in recent weeks. Inmates who have symptoms suggestive of TB disease should immediately
receive a thorough medical evaluation, including a TST or QFT-G, a chest radiograph, and, if indicated, sputum examinations.
Persons with symptoms suggestive of TB disease or with a history of inadequate treatment for TB disease should
be immediately placed in an AII
room§ until they have undergone a thorough medical evaluation. If deemed infectious,
such persons should remain in isolation until treatment has rendered them noninfectious. Facilities without an on-site AII
room should have a written plan for referring patients with suspected or confirmed TB to a facility that is equipped to
isolate, evaluate, and treat TB patients.
Symptom screening alone is an unsatisfactory screening mechanism for TB, except in facilities with a minimal risk for
TB transmission. The use of symptom screening alone often will fail to detect pulmonary TB in inmates.
Chest-Radiograph Screening
Screening with chest radiographs can be an effective means of detecting new cases of unsuspected TB disease at intake to
a correctional facility. In addition, radiographic screening
requires fewer subsequent visits than a TST (i.e., only those
inmates with suspicious radiographs or TB symptoms require follow-up). However, such screening will not identify inmates
with LTBI. One study demonstrated that screening inmates with a chest radiograph doubled the TB case-finding rate and
reduced the time from intake into the correctional facility to isolation substantially compared with TST testing (2.3 days and 7.5
days, respectively), thereby reducing the risk for TB exposure for other inmates and staff
(50). Digital radiographs (miniature or full-size) provide
enhanced imaging and improved storage and readability.
A miniature radiograph can be performed in
<1 minute and exposes the patient to approximately
one tenth the radiation dose of a conventional radiograph. One
cost-effectiveness analysis of miniature chest radiography for TB screening on admission to jail indicated that more cases
were detected with this method than either TST or symptom screening, and the cost of radiograph screening was less per
case detected (51). The extent to which radiologic screening is used in a given institution should be dictated by multiple
factors, including 1) local epidemiologic characteristics of TB disease; 2) inmate length of stay; 3) the ability of the
health-care professionals within the facility to conduct careful histories, tuberculin skin or QFT-G testing, and cross-matches with
state TB registries; and 4) timeliness of the radiographic
study and its reading. Screening with chest radiographs
might be appropriate in certain jails and detention facilities that house substantial numbers of inmates for short periods and
serve populations at high risk for TB (e.g., those with high prevalence of HIV infection or history of
injection-drug use and foreign-born persons from countries in which TB prevalence is high).
Inmates who are infected with HIV might be anergic and consequently might have false-negative TST results.
However, routine anergy panel testing is not recommended because it has not been demonstrated to assist in diagnosing or
excluding LTBI (52). In facilities that do not perform routine radiographic screening for all inmates, a chest radiograph should be part
of the initial screening of HIV-infected patients and those who are at risk for HIV infection but whose status is unknown.
In facilities with on-site radiographic screening, the chest radiograph should be performed as part of intake screening
and read promptly by a physician, preferably within 24 hours. Persons who have radiographs suggestive of TB should be
isolated immediately and evaluated further. Sputum-smear and culture examinations should be performed for inmates whose
chest radiographs are consistent with TB disease and might be indicated for at least certain persons who are symptomatic,
regardless of their TST, QFT-G, or chest radiograph results because persons with HIV and TB disease might have "negative"
chest radiographs in addition to false-negative TST or QFT-G results.
Mantoux TST Screening
Tuberculin skin testing using 0.1 mL of 5 tuberculin units (TU) of purified protein derivative (PPD) is the most
common method of testing for TB infection. Multiple-puncture tests (e.g., the tine test) should not be used to determine whether
a person is infected. Persons who have a documented history of a positive TST result (with a millimeter [mm] reading),
a documented history of TB disease, or a reported history of a severe necrotic reaction to tuberculin should be exempt from
a routine TST. For persons with a history of severe necrotic reactions and without a documented positive result with
a millimeter reading, a QFT-G may be substituted for the TST. Otherwise, such persons should be screened for symptoms
of TB and receive a chest radiograph unless they have had one recently (i.e., within 6 months) and are not
symptomatic. Pregnancy, lactation, or previous vaccination with Bacillus Calmette-Guerin (BCG) vaccine are not contraindications
for tuberculin skin testing. The TST is not completely sensitive for TB disease; its sensitivity ranges from 75%--90%
(53,54). Despite this limitation, skin testing, along with use of a symptom review, frequently constitutes the most practical approach
to screening for TB disease.
A trained health-care professional should place the TST and interpret the reaction 48--72 hours after the injection
by measuring the area of induration (i.e., the palpable swelling) at the injection site. The diameter of the indurated area should
be measured across the width of the forearm. Erythema (i.e., the redness of the skin) should not be measured. All reactions,
even those classified as negative, should be recorded in millimeters of induration.
In the majority of cases, a TST reaction of
>10 mm induration is considered a positive result in inmates and
correctional facility employees. However, an induration of
>5 mm is considered a positive result in the following persons:
- persons infected with HIV,
- persons who are recent contacts of patients with TB
disease,
- persons with fibrotic changes on chest radiograph
consistent with previous TB disease,
- organ transplant recipients and patients with other immunocompromising conditions (e.g., persons receiving
>15 mg/day of prednisone for >1 month), and
- persons suspected of having TB disease.
Persons who have a positive TST result and no symptoms suggestive of TB disease should be evaluated with a
chest radiograph within 72 hours after the skin test is interpreted. Persons who have symptoms suggestive of TB disease should
be evaluated immediately and placed in an AII room until TB is ruled out (see Symptom Screening).
The use of two-step testing can reduce the number of positive TSTs that would otherwise be misclassified as recent
skin-test conversions during future periodic screenings. Certain persons who were infected with
M. tuberculosis years earlier exhibit waning delayed-type hypersensitivity to tuberculin. When they are skin tested years after infection, they might have a
false-negative TST result (even though they are truly infected). However, this first skin test years
after the infection might stimulate the ability to react to subsequent tests, resulting in a "booster" reaction. When the test is repeated, the reaction might
be misinterpreted as a new infection (recent conversion) rather than a boosted reaction. For two-step testing, persons
whose baseline TSTs yield a negative result are retested 1--3 weeks after the initial test. If the second test
result is negative, they are considered not infected. If the second test result is positive, they are classified as having had previous TB infection.
Two-step testing should be considered for the baseline testing of persons who report no history of a recent TST and who will
receive repeated TSTs as part of an institutional periodic skin-testing program. In the majority of cases, a two-step TST is
not practical in jails because of the short average length of stay of inmates.
In the past, a panel of other common antigens was often applied with the TST to obtain information regarding
the competence of the patient's cellular immune system and to identify anergy. More recently, however, anergy testing has
been demonstrated to be of limited usefulness because of problems with standardization and reproducibility, the low risk for
TB associated with a diagnosis of anergy, and the lack of apparent benefit of preventive therapy for groups of anergic
HIV-infected
persons. Therefore, the use of anergy testing in conjunction with a TST is no longer recommended routinely for
screening programs for M. tuberculosis infection in the United States
(52).
Intracutaneous inoculation with BCG is currently used
worldwide as a vaccine against TB. BCG is a live
attenuated Mycobacterium bovis strain that stimulates the immune system to protect against TB. No reliable method has been developed
to distinguish TST reactions caused by vaccination with BCG from those caused by natural mycobacterial infections,
although reactions of >20 mm of induration are not likely caused by BCG
(55). TST is not contraindicated for persons who have
been vaccinated with BCG, and the TST results of such persons are used to support or exclude the diagnosis of
M. tuberculosis infection. A diagnosis
of M. tuberculosis infection and treatment for LTBI should be considered for any
BCG-vaccinated person who has a positive TST reaction. The same criteria for interpretation of TST results are used for both BCG-vaccinated
and nonvaccinated persons (56).
QuantiFERON®-TB Gold Test
In May 2005, the U.S. Food and Drug Administration (FDA) licensed QFT-G. This in-vitro diagnostic test measures
the amount of interferon-gamma produced by cells in whole blood that have been stimulated by mycobacterial peptides.
The peptides used in the test mimic proteins known as
ESAT-6 and CFP-10, which are present in M.
tuberculosis but absent from all BCG strains and from the majority of commonly encountered non-TB mycobacteria. The test is intended for use as
a diagnostic tool for M. tuberculosis infection,
including both TB disease and LTBI. As with a TST, QFT-G cannot
distinguish between LTBI and TB disease and should be used in conjunction with risk assessment, radiography, and other
diagnostic evaluations. The advantages of QFT-G compared with TST are that 1) results can be obtained after a single patient visit,
2) the variability associated with skin-test reading can be reduced because "reading" is performed in a qualified laboratory, and
3) QFT-G is not affected by previous BCG vaccination and eliminates the unnecessary treatment of persons with
false-positive results. QFT-G does not affect the result of future QFT-G tests (i.e., no "boosting" occurs). Limitations of the test include
the need for phlebotomy, the need to process blood specimens within 12 hours of collection for the most recent version of
the test, the limited number of laboratories that process the test, and a lack of clinical experience in interpreting test results.
The elimination of the second visit for reading the TST, however, is likely to render the QFT-G competitive in
cost-benefit considerations.
Although the performance of QFT-G has not been evaluated sufficiently in select populations of interest (e.g.,
HIV-infected persons), available data indicate that QFT-G is as sensitive as TST for detection of TB disease and more specific than TST
for detection of LTBI (57,58). CDC guidelines for QFT-G recommend that QFT-G can be used in place of TST in
all circumstances in which TST is currently used
(58). This includes initial and periodic TB screening for
correctional facility inmates and employees and testing of exposed persons in contact investigations. Because data are insufficient
regarding performance of QFT-G in certain clinical situations, as with a negative TST result, a negative QFT-G result alone might
not be sufficient to exclude M.
tuberculosis infection in these situations. Examples of such clinical scenarios include those
involving patients with severe immunosuppression who have had recent exposure to a patient with TB and patients being treated
or about to undergo treatment with potent tumor necrosis factor alpha
(TNF-a) antagonists.
Use of Local Health Department TB Registry
Correctional facilities and local health departments should collaborate to ensure effective TB screening in the
correctional setting. Inmates might provide inaccurate information on admission for multiple reasons, ranging from forgetfulness
and confusion to deliberate misrepresentation. Health departments should perform cross-matches with the local TB registry
and search for matches on known aliases, birth dates, maiden names, and other personal information for inmates suspected
of having TB infection. A readily accessible record of previous TB history, drug-susceptibility patterns, treatment,
and compliance can be useful in determining the disposition of a given patient with suspected TB.
Initial Screening
The following procedures should be used for the initial screening of inmates and detainees (depending on their length
of stay in the facility and the type of facility) and for all correctional facility employees, regardless of the type of facility.
Inmates in Minimal TB Risk Facilities
Inmates in all minimal TB risk correctional and detention facilities should be evaluated on entry for symptoms of
TB. Persons with symptoms of TB should be evaluated immediately to rule out the presence of infectious disease and kept in
an AII room until they are evaluated. If the facility does not have an AII room, the inmate should be transported to a
facility that has one. In addition, all newly arrived inmates should be evaluated for clinical conditions and other factors that increase
the risk for infection or the risk for progressing to TB disease, including the following:
- HIV infection,
- recent immigration,
- history of TB,
- recent close contact with a person with TB disease,
- injection-drug use,
- diabetes mellitus,
- immunosuppressive therapy,
- hematologic malignancy or lymphoma,
- chronic renal failure,
- medical conditions associated with substantial weight loss or malnutrition, or
- history of gastrectomy or jejunoileal bypass.
Persons with any of these conditions require further screening with a TST, a QFT-G, or a chest radiograph within 7 days
of arrival. Regardless of the TST or QFT-G result, inmates known to have HIV infection or other severe
immunosuppression, and those who are at risk for HIV infection but whose HIV status is unknown, should have a chest radiograph taken as part
of the initial screening. Persons who have an abnormal chest radiograph should be further evaluated to rule out TB disease; if
TB disease is excluded as a diagnosis, LTBI therapy should be considered if the TST or QFT-G result is positive.
Inmates in Nonminimal TB Risk Prisons
Immediately on arrival, all new inmates should be screened for symptoms, and any inmate with symptoms suggestive of
TB should be placed in an AII room and evaluated promptly for TB disease. If the facility does not have an AII room, the
inmate should be transported to a facility that has one.
Inmates who have no symptoms require further screening with a TST, a
QFT-G, or a chest radiograph within 7 days of
arrival. Regardless of their TST or QFT-G status, inmates known to have
HIV infection or other severe immunosuppression, and those who are at risk for HIV infection but whose HIV status is
unknown, should have a chest radiograph taken as part of the initial screening. Persons who have an abnormal chest
radiograph should be further evaluated to rule out TB disease; if TB disease is excluded as a diagnosis, LTBI therapy should be considered if
the TST or QFT-G result is positive.
As the rate of TB disease in the United States has decreased, identification and treatment of persons with LTBI who are
at high risk for TB disease have become essential components of the TB elimination strategy promoted by ACET
(59). Targeted testing using the TST or QFT-G identifies persons at high risk for TB disease who would benefit from treatment for
LTBI. Prisons offer an excellent public health opportunity for identifying persons at high risk for TB who can be screened for
TB infection and placed on LTBI therapy, if indicated. If the TST is used, a two-step testing procedure should be
strongly considered when obtaining a baseline reading. A single step QFT-G is an adequate baseline. Inmates with a positive
test should be evaluated for LTBI therapy after TB disease is excluded.
Inmates in Nonminimal TB Risk Jails and Other Short-Term Detention Facilities
As in prisons, all new detainees in nonminimal TB risk jails should be screened on entry for symptoms, and any
detainee who has symptoms suggestive of TB should be placed immediately in an AII room and evaluated promptly for TB disease.
If the facility does not have an AII room, the inmate should be transported promptly to a facility that does have one.
Detainees without symptoms require further screening with a TST, a QFT-G, or a chest radiograph within 7 days of arrival.
Regardless of the TST or QFT-G result, detainees known to have HIV infection, and those who are at risk for HIV infection but
whose HIV status is unknown, should have a chest radiograph taken as part of the initial screening. Persons who have a
positive result should be further evaluated to rule out TB disease.
The primary purpose of screening in correctional settings is to detect TB disease. TST or QFT-G screening in jails to
initiate LTBI therapy often is not practical because of the high rate of turnover and short lengths of stay. Although not all
jail detainees have short lengths of stay, determining which
detainees will be in the jail for a long term is difficult.
Nationwide, approximately half of persons detained in local jails are released within 48 hours of admission. Thus, even if all
detainees can be tested at intake, a large proportion will be unavailable to have their TSTs read or to be evaluated when QFT-G test
results are available. Of those still in custody, a substantial percentage will be released before the radiographic and medical
evaluation is completed. In a 1996 study, 43% of detainees at a county jail in Illinois who had a positive TST result were released
or transferred before their evaluation could be completed
(3).
A substantial proportion of detainees who are incarcerated long enough to begin LTBI therapy will be released
before completion of treatment. A San Francisco study indicated that approximately 62% of detainees who were started on
LTBI treatment were released before completion
(40). These data illustrate the challenges of implementing a testing and
treatment program for LTBI in jails with highly dynamic detainee populations. Certain jails have adopted a targeted approach
of performing TSTs only on new detainees who are at high risk for TB disease (e.g., detainees with known HIV
infection). Screening for TB and treating LTBI are most effective within the jail setting if resources dedicated to discharge planning
and reliable access to community-based treatment are available. Modest interventions (e.g., education and incentives
[see Glossary]) in the jail setting can lead to improvements in linking released detainees to postrelease medical care and increase
the likelihood that therapy will be completed
(60,61).
Persons in Holding or Booking Facilities
City, county, and other law enforcement authorities frequently have facilities that hold arrestees and detainees for short
periods of time, ranging from hours to multiple days. TB symptom screening is recommended for all persons at the time of entry
into these facilities. Any detainee who has symptoms suggestive of TB should be immediately isolated and transferred to a facility
or hospital in which the detainee can be placed in an AII room and evaluated promptly for TB disease.
Employees in All Correctional and Detention Facilities
A medical history relating to TB should be obtained from and recorded for all new employees at the time of hiring, and
a physical examination for TB disease should be required. The results of the screening and examination should be
kept confidential; access should be granted to public health and infection control medical professionals only when necessary.
In addition, a TST or QFT-G should be mandatory for all
employees who do not have a documented history of a positive
result. To improve the accuracy of the baseline result, a two-step TST or a single-step QFT-G should be used for the initial
screening of employees who have not been tested during the preceding 12 months. Persons who have a positive TST or QFT-G
result should have a chest radiograph taken and interpreted and should be required to have a thorough medical evaluation; if
TB disease is excluded as a diagnosis, such persons should be considered for LTBI therapy. All
employees should be informed that they should seek appropriate follow-up and testing for TB if they are immunosuppressed for any reason (e.g., have
HIV infection). Any employee who has symptoms suggestive of TB should not
return to the workplace until a clinician has excluded a diagnosis of infectious TB disease.
Other Persons Who Might Need to be Screened
Certain persons who are neither inmates nor employees but who visit high-risk facilities on a regular basis also should
be considered for screening. These persons might include contractors (e.g., food handlers and service workers), volunteers,
and those providing religious ministries. Screening of these persons should follow the same procedures as those outlined
for employees.
Periodic Screening
Long-term inmates and all employees who have a negative TST or QFT-G result should have follow-up testing at
least annually. Persons who have a history of a positive test result should be screened for symptoms of TB disease. Annual
chest radiographs are unnecessary for the follow-up evaluation of infected persons. Test results should be recorded in
medical records and in a retrievable aggregate database of all TST or QFT-G results. Personal identifying information should be
kept confidential.
Correctional facilities can use multiple strategies to ensure annual screening of long-term inmates for newly acquired
TB infection. Certain institutions schedule annual screening on the inmate's date of birth or on the anniversary of the
inmate's most recent test. Other institutions and systems suspend
inmate movement and screen the entire population on the same
day every year. Methods of screening a subset of the inmate population (e.g., on a monthly basis) are beneficial because
they provide an ongoing assessment of M.
tuberculosis transmission within the facility.
Results from TST or QFT-G testing should be analyzed periodically to estimate the risk for acquiring new infection in
a correctional facility; however, this analysis should be completed by using only the test results of facility employees and
inmates who have remained in the facility continually during the interval between testing. The conversion rate equals the number
of employees or inmates whose test results have converted from negative to positive (i.e., the numerator) during a specific
interval divided by the total number of previously negative employees or inmates who were tested during the same interval (i.e.,
the denominator). In certain facilities, conducting an analysis of test results for specific areas or groups within the facility might
be appropriate.
More frequent screening is needed when a conversion rate is substantially higher than previous rates or when other
evidence of ongoing transmission is detected. A cluster (i.e.,
either two or more patients with TB disease that are linked
by epidemiologic or genotyping data or two or more TST or
QFT-G conversions occurring in the correctional facility
among inmates who are epidemiologically linked) or other evidence of person-to-person transmission also
warrants additional epidemiologic investigation and possibly a revision of the facility's TB prevention and control protocol.
Facilities in which the risk for infection with
M. tuberculosis is minimal might not need to maintain a periodic
screening program. However, requiring baseline TST or QFT-G testing of employees would enable medical staff to
distinguish between a TST or QFT-G conversion and a positive TST or QFT-G result caused by a previous exposure to
M. tuberculosis. A decision to discontinue periodic employee screening should be made in consultation with the local or state health department.
HIV Counseling, Testing, and Referral
HIV counseling, testing, and referral (CTR) should be routinely recommended for all persons in settings in which
the population is at increased behavioral or clinical risk for
acquiring or transmitting HIV infection, regardless of
setting prevalence (62). Because correctional facilities are considered settings in which the population is at increased risk
for acquiring or transmitting HIV, routine HIV CTR is recommended for inmates. Furthermore, HIV infection is the
greatest risk factor for progression from LTBI to TB disease
(63,64). Therefore, HIV CTR should be routinely offered to
all inmates and correctional facility staff with LTBI or TB disease if their HIV infection status is unknown at the time of
their LTBI or TB disease diagnosis (64,65). Correctional
facilities should be particularly aware of the need for
preventing transmission of M. tuberculosis in settings in which persons infected with HIV might be housed or might work
(66).
Use of Data to Refine Policies and Procedures
Correctional and detention facilities are strongly encouraged to collect and analyze data on the effectiveness of their
TB screening policies and procedures. Working in conjunction with their state or local TB-control program, correctional
and detention facilities should refine their screening policies and procedures as indicated by such data. In the absence of local
data that justify revision, correctional and detention
facilities should adhere to the screening recommendations
detailed above.
Case Reporting
All states require designated health-care professionals to
report suspected and confirmed cases of TB to their local or
state health department; this reporting is mandatory for all correctional facilities, whether private, federal, state, or
local. Correctional facility medical staff should report any suspected or confirmed TB cases among inmates or employees to
the appropriate health agency in accordance with state and local laws and regulations, even if the inmate or detainee
has already been released or transferred from the facility. Reporting cases to health departments benefits the correctional facility
by allowing it to obtain health department resources for case management and contact investigation in both the facility and
the community. For each suspected case of TB, the diagnosis or the exclusion of a diagnosis of TB should be
entered immediately
into 1) the person's medical record, 2) the retrievable aggregate TB-control database at the facility, and 3) the database at
a centralized office if the system has multiple facilities. In addition, drug-susceptibility results should be sent to the state or
local health department for use in monitoring the rates of drug resistance in the health department's jurisdiction.
Drug-susceptibility reports also should be sent to all health departments managing the infectious person's contacts because the
choice of medication for LTBI treatment is based on these drug-susceptibility test
results (64). Reports to local or state
health departments should identify the agency that has custodial responsibility for the inmate (e.g., county corrections agency,
state corrections agency, ICE, Federal Bureau of Prisons [FBOP], and U.S. Marshals Service [USMS]) and the
corresponding identification number for that agency (e.g., U.S. alien number, FBOP number, or USMS number). Federal law
enforcement agencies frequently contract for bed space with local or private detention facilities. Therefore, custodial authority
and corresponding custody identification numbers should be verified with the facility's custody staff; detention facility
medical staff might not have this information available.
Isolation in an Airborne Infection Isolation Room
Initiation
TB airborne precautions should be initiated for any patient who has signs or symptoms of TB disease or who
has documented TB disease and has not completed treatment or not been determined previously to be noninfectious.
Discontinuation
For patients placed in an AII room because of suspected infectious TB disease of the lungs, airways, or larynx,
airborne precautions can be discontinued when infectious TB disease is considered unlikely and either 1) another diagnosis is made
that explains the clinical syndrome or 2) the patient has three negative acid-fast bacilli (AFB) sputum-smear results
(67,68). The three sputum specimens should be collected 8--24 hours apart
(69), and at least one should be an early morning
specimen (because respiratory secretions pool overnight). Typically, this will allow patients with negative sputum-smear results to be
released from an AII room in 2 days. Incarcerated patients for whom the suspicion of TB disease remains after the collection of three
negative AFB sputum-smear results should not be released from airborne precautions until they are on standard multidrug anti-TB
treatment and are clinically improving. Because patients with TB disease who have negative AFB sputum-smear results can still be
infectious (70), patients with suspected disease who meet the above criteria for release from airborne precautions should not be
released to an area in which other patients with
immunocompromising conditions are housed.
A patient who has drug-susceptible TB of the lung, airways, or larynx, is on standard multidrug anti-TB treatment, and
has had a significant clinical and bacteriologic response to therapy (i.e., reduction in cough, resolution of fever, and
progressively decreasing quantity of AFB on smear result) is probably no longer infectious. However, because culture and
drug-susceptibility results are not typically known when the decision to discontinue airborne precautions is made, all
patients with confirmed TB disease should remain in an AII room while incarcerated until they
- have had three consecutive negative AFB sputum-smear results collected 8--24 hours apart, with at least one being
an early morning specimen,
- have received standard multidrug anti-TB treatment, and
- have demonstrated clinical improvement.
Because the consequences of transmission of MDR TB (i.e., TB that is resistant to isoniazid and rifampin) are
severe, infection-control practitioners might choose to keep persons with suspected or confirmed MDR TB disease in an AII
room until negative sputum-culture results have been documented in addition to negative AFB sputum-smear results.
Environmental Controls
Overview
Guidelines for preventing transmission of M.
tuberculosis in health-care settings and for environmental infection control
in health-care facilities have been published previously
(71,72). These guidelines and this report can be used to
educate correctional facility staff regarding use of environmental controls in TB infection-control programs.
Environmental controls should be implemented when the risk for TB transmission persists despite efforts to screen and
treat infected inmates. Environmental controls are used to remove or inactivate
M. tuberculosis in areas in which the organism
could be transmitted. Primary environmental controls consist of controlling the source of infection by using local exhaust
ventilation (e.g., hoods, tents, or booths) and diluting and removing contaminated air by using general ventilation. These controls
help prevent the spread and reduce the concentration of airborne infectious droplet nuclei (see Glossary). Environmental
controls work in conjunction with administrative controls such as isolation of inmates with suspected TB disease detected
through screening (see Glossary). Secondary environmental controls consist of controlling the airflow to prevent contamination of
air in areas adjacent to the source (AII rooms) and cleaning the air (using a HEPA filter or ultraviolet germicidal
irradiation [UVGI]) to increase the number of equivalent
ACH.¶ The efficiency of different primary or secondary environmental
controls varies; details concerning the application of these controls to prevent transmission of
M. tuberculosis in health-care settings have been published previously
(71). To be effective, secondary environmental controls should be used and
maintained properly, and their strengths and limitations should be recognized. The
engineering design and operational efficacy
parameters for UVGI as a secondary control measure (i.e., portable UVGI units, upper-room air UVGI, and in-duct UVGI) continue
to evolve and require special attention in their design, selection, and maintenance.
Exposure to M. tuberculosis within correctional facilities can be reduced through the effective use of environmental
controls at the source of exposure (e.g., an infectious inmate) or in general areas. Source-control techniques can prevent or
reduce the spread of infectious droplet nuclei into the air in situations in which the source has been identified and the generation of
the contaminant is localized by collecting infectious particles as they are released. Use of these techniques is particularly
prudent during procedures that are likely to generate infectious aerosols (e.g., bronchoscopy and sputum
induction) and when inmates with infectious TB disease are coughing or sneezing.
Unsuspected and undiagnosed cases of infectious TB disease contribute substantially to disease transmission
within correctional facilities (73). When attempting to control this type of transmission, source control is not a feasible
option. Instead, general ventilation and air cleaning should be relied on for environmental control. General ventilation can be used
to dilute the air and remove air contaminants and to control airflow patterns in AII rooms or other correctional facility
settings. Air-cleaning technologies include mechanical air filtration to reduce the concentration of
M. tuberculosis droplet nuclei and UVGI to kill or inactivate microorganisms so they no longer pose a risk for infection.
Ventilation systems for correctional facility settings should be designed, and modified when necessary, by
ventilation engineers in collaboration with infection-control practitioners and occupational health staff. Recommendations for
designing and operating ventilation systems in correctional facilities have been published
(48,49,74--76). The multiple types of and conditions for use of ventilation systems in correctional-facility settings and the individual needs of these settings
preclude provision of extensive guidance in this report.
Incremental improvements in environmental controls (e.g., increasing the removal efficiency of an existing filtration
system in any area) are likely to lessen the potential for TB transmission from persons with unsuspected or undiagnosed TB.
This information should not be used in place of consultation with experts who can advise on ventilation system and air
handling design, selection, installation, and maintenance. Because environmental controls will fail if they are not properly operated
and maintained, routine training and education of infection-control and maintenance staff are key components to a successful
TB infection-control program.
Airborne Infection Isolation Rooms
Inmates known or suspected of having TB disease should be placed in an AII room or AII cell that meets the design
and operational criteria for airborne infection isolation described previously
(71). Inmates deemed infectious should remain
in isolation until treatment or further evaluation has ensured that they are noninfectious. Facilities without an on-site AII
room
should have a written plan for referring patients with suspected or confirmed TB to a facility that is equipped to
isolate, evaluate, and treat TB patients.
New or renovated facilities should ensure that a sufficient number of AII rooms are available consistent with the facility
risk assessment. Under rare circumstances, if an AII room is not available and the immediate transfer of the inmate with
suspected infectious TB is not possible, the inmate should be housed temporarily in a room that has been modified to prevent the
escape of infectious aerosols outside the TB holding area. The heating, ventilating, and air-conditioning (HVAC) system in
this temporary TB holding area might have to be manipulated or augmented with auxiliary exhaust fans to create an inward
flow of air that reduces the potential escape of infectious aerosols. If possible, air from these areas should be exhausted directly
to the outdoors. If this is not feasible, the highest filtration efficiency compatible with the installed HVAC system should
be used. Because TB droplet nuclei are approximately 1--5 micrometers in size, filtration efficiency should be evaluated
for particles in that size range. Filter selection based on the American Society of Heating, Refrigerating and
Air-Conditioning Engineers (ASHRAE) Standard 52.2 Minimum Efficiency Reporting Value (MERV)--rating efficiency tables can help in
this evaluation (77). Secondary air cleaning techniques (portable air cleaners and UVGI) also can be used in these areas to
increase effective air cleaning.
Local Exhaust Ventilation
Aerosol-producing procedures should be performed in an area with a type of local exhaust ventilation that captures
and removes airborne contaminants at or near their source without exposing persons in the area to infectious agents. Local
exhaust devices typically use hoods. Two types of hoods are used: enclosing devices, in which the hood either partially or fully
encloses the infectious source, and exterior devices, in which the infectious source is near but outside the hood. Fully enclosed
hoods, booths, or tents are always preferable to exterior devices because of their superior ability to prevent contaminants
from escaping.
Enclosing devices should have sufficient airflow to remove
>99% of airborne particles during the interval between
the departure of one patient and the arrival of the next. The time required to remove a given percentage of airborne particles
from an enclosed space depends on 1) the ACH number,
2) the location of the ventilation inlet and outlet, and 3) the
physical configuration of the room or booth. The time interval required to ensure the proper level of airborne contaminant
removal from enclosing devices varies according to ACH
(Table 1). For example, if an enclosing device operates at six ACH, and the
air inlet and exhaust locations allow for good air mixing, approximately 46 minutes would be required to remove 99% of
the contaminated air after the aerosol-producing procedure has ended. Similarly, an additional
23 minutes (total time: 69 minutes) would be required to
increase the removal efficiency to 99.9%. Doubling the ventilation rate decreases the
waiting time by half.
General Ventilation
General ventilation is used to 1) dilute and remove contaminated air, 2) control the direction of airflow in a
correctional facility setting, and 3) control airflow patterns in rooms. Recommended ventilation rates for correctional facility settings
are typically expressed in ACH. Ventilation recommendations for selected areas in new or renovated correctional
facility settings should be followed (Table 2). The feasibility of achieving a specific ventilation rate depends on the construction
and operational requirements of the ventilation system and might differ for retrofitted and newly constructed facilities.
The expense and effort of achieving a high ventilation rate might be reasonable for new construction but not be as feasible
when retrofitting an existing setting.
Ventilation design guidance for correctional facilities and related areas has been published
(78). This design guidance includes specific ventilation recommendations regarding
total ventilation, filtration efficiency, and
environmental design parameters. For minimum outdoor air supply recommendations, the guidance refers to ASHRAE Standard
62, Ventilation for Acceptable Indoor Air Quality. In 2004, ASHRAE revised and renumbered this standard to
ANSI/ASHRAE Standard 62.1 (74). For areas within correctional facilities that are not intended to contain persons with infectious TB,
the recommended minimum outdoor air supply rates should meet or exceed those recommended in ANSI/ASHRAE
Standard 62.1-2004 (74). When risk analysis
reveals an enhanced potential for undiagnosed cases of infectious TB, facility
designers and owners may consider using higher supply rates of outdoor air (e.g., those recommended for areas within
health-care
facilities anticipated to contain infectious patients). Minimum outdoor air supply recommendations for health-care
facilities have been published (71,79). Because correctional areas frequently will not have an exact equivalent area within the
health-care environment, the designer or owner should identify an analogous health-care area from which to choose the outdoor
air supply recommendation. This selection should be made on the basis of occupant risk factors for TB, occupant activities,
and occupant density within the area. For example, the intake, holding, and processing area of a higher risk correctional
facility might be considered analogous to the emergency waiting room area in a health-care facility. In that case, the
recommended outdoor air supply would be at least two ACH.
The direction of air movement relative to adjacent areas is necessary for the containment of contaminated air. Air within
a correctional facility should flow to minimize exposure of others within the building (Table 2). For example, air inside an
AII room or cell should flow from the corridor and air-supply grille across the worker, then across that patient, and finally out of
the room. To ensure that air is flowing from the corridor into an AII room or cell, smoke testing should be performed daily, even
if the AII room or cell is equipped with a pressure-sensing device. Air flow (supply air and exhaust air) should be measured at
least annually and compared with the designed air flow rates to ensure that optimal directional air flow and air exchange rates are
being maintained (Table 2).
Air Cleaning Methods
Detailed information has been published regarding the selection, design, maintenance, and safety considerations
associated with air cleaning methods (i.e., filtration and UVGI)
(71). Designers and end users should consult this information.
Air removed from areas likely to contain infectious aerosols (e.g., AII cells, sputum collection and other procedure rooms,
and intake areas) should be exhausted directly to the outdoors to ensure that it cannot immediately reenter the building or pose
a hazard to persons outside, in accordance with applicable federal, state, and local regulations. If discharging air to the outside
is not feasible, HEPA filters should be used to clean the air before returning to the general ventilation system. Such
recirculation is acceptable only if the air is recirculated back into the same general area from which it originated.
For general population areas in which infectious aerosols are not anticipated but might be present (from persons
with undiagnosed TB disease), total exhaust ventilation should be considered where and when the outdoor
environmental conditions (temperature and humidity) are compatible with a single-pass system without undue energy or equipment
costs. When recirculating air from these areas, the minimum ASHRAE-recommended level of filtration is a MERV-8 filter
(78). However, CDC encourages selection and use of filters with higher MERV ratings to provide an incremental improvement
in the protection afforded by this mechanism. The filtration system should be designed to prevent filter by-pass and to
allow filter leakage testing and safe filter changes. A combination of air cleaning methods (e.g., MERV-rated filters and
supplemental UVGI) may be used to increase effective air cleaning.
When used, UVGI should be applied in-duct (i.e., inside the ductwork of existing HVAC systems) or in the upper room
of the area to be treated to ensure that organisms are inactivated. Upper-air systems should be designed, installed, and
monitored to ensure both sufficient irradiation in the upper room to inactivate
M. tuberculosis and safe levels of UVGI in the
occupied space.
Environmental Control Maintenance
To be most effective, environmental controls should be
installed, operated, and maintained correctly. Ongoing
maintenance should be part of any written TB infection-control plan. The plan should outline the responsibility and authority
for maintenance and address staff training needs.
Failure to maintain environmental control systems properly has adversely impacted TB control and prevention efforts
at facilities throughout the United States. At one hospital,
improperly functioning ventilation controls were believed to be
a factor in the transmission of MDR TB disease to four persons (three patients and a correctional officer), three of whom
died (80). In three other multihospital studies evaluating the performance of AII rooms, failure to routinely monitor
air-pressure differentials (whether manually or through use of continuous monitoring devices) resulted in a substantial percentage of
the rooms being under positive pressure
(81--84).
Correctional facilities should schedule routine preventive maintenance that covers all components of the ventilation
systems (e.g., fans, filters, ducts, supply diffusers, and exhaust grilles) and any air-cleaning devices in use. Performance
monitoring
should be conducted to verify that environmental controls are operating as designed. Performance monitoring should
include 1) directional airflow assessments using smoke tubes and use of pressure monitoring devices sensitive to pressures at
0.001 inch of water gauge and 2) measurement of supply and exhaust airflows to compare with recommended air change rates
for the respective areas of the facility. Records should be kept to document all preventive maintenance and repairs.
Standard procedures should be established to ensure that
1) maintenance staff notify infection-control
personnel before performing maintenance on ventilation systems servicing
inmate-care areas and 2) infection-control staff
request assistance from maintenance personnel in checking the
operational status of AII cells and local exhaust devices (e.g.,
booths, hoods, and tents) before use. A protocol that is well written and followed will help to prevent unnecessary exposures
of correctional facility staff and inmates to infectious aerosols. Proper labeling of ventilation system components (e.g.,
ducts, fans, and filters) will help identify air-flow paths. Clearly labeling which fan services a given area will help prevent
accidental shutdowns (85). In addition, provisions should be made for emergency power to avoid interruptions in the performance
of essential environmental controls during a power failure.
Respiratory Protection
Considerations for Selection of Respirators
Respiratory protection is used when administrative (i.e., identification and isolation of infectious TB patients)
and environmental controls alone have not reduced the risk for infection with
M. tuberculosis to an acceptable level. The use
of respiratory protection is most appropriate in specific settings and situations within correctional facilities. For
example, protection is warranted for inmates and facility staff when they enter AII rooms, transport infectious inmates, and
participate in cough-inducing procedures.
Respirators should be selected from those approved by CDC/National Institute for Occupational Safety and
Health (NIOSH) under the provisions of Title 42, Part 84 of the Code of Federal Regulations
(86). Decisions regarding which respirator is appropriate for a particular situation and setting should be made on the basis of a risk assessment of the
likelihood for TB transmission.** For correctional facilities, a CDC/NIOSH-approved N95 air-purifying respirator will provide
adequate respiratory protection in the majority of situations that require the use of respirators. If a higher level of respiratory
protection is warranted, additional information on other classes of air-purifying respirators and powered air-purifying respirators
(PAPRs) is available (71). The overall effectiveness of respiratory protection is affected by 1) the level of respiratory protection
selected (i.e., the assigned protection factor), 2) the fitting characteristics of the respirator model, 3) the care taken in donning
the respirator, and 4) the effectiveness of the respiratory protection program, including fit testing and worker training.
Implementing a Respiratory Protection Program
All facilities should develop, implement, and maintain a respiratory-protection program for health-care workers or
other staff who use respiratory protection. Respiratory-protection programs are required for facilities covered by the
U.S. Occupational Safety and Health Administration (OSHA)
(71,87--89). The key elements of a respiratory protection
program include 1) assignment of responsibility, 2) training, and 3) fit testing
(71,87,90,91). All correctional facility staff who
use respirators for protection against infection with
M. tuberculosis must participate in the facility's respiratory protection
program (e.g., understand their responsibilities, receive training, receive medical clearance, and engage in fit testing)
(71). In addition to staff members, visitors to inmates with TB disease should be offered respirators to wear while in AII rooms and instructed
on proper use. Certain regular visitors (e.g., law enforcement officials, social workers, ministers and other religious
representatives, and attorneys and other legal staff) might be there in an occupational capacity. Each facility, regardless of TB risk
classification (i.e., minimal or nonminimal), should develop a policy on the use of respirators by visitors of
patients.
Precautions for Transporting Patients Between Correctional or Detention Facilities
Recommended precautions to take when transporting
patients between facilities have been published
(71). Patients with suspected or confirmed infectious TB disease should be transported in an ambulance whenever possible. The
ambulance ventilation system should be operated in the nonrecirculating mode and the maximum amount of outdoor air be provided
to
facilitate dilution. If the vehicle has a rear exhaust fan, it should be used during transport. If the vehicle is equipped with
a supplemental recirculating ventilation unit that passes air through HEPA filters before returning it to the vehicle, this
unit should be used to increase the number of ACH. Airflow should be from the cab (i.e., front of vehicle) over the patient and
out the rear exhaust fan. If an ambulance is not used, the ventilation system for the vehicle should bring in as much outdoor air
as possible, and the system should be set to nonrecirculating. If possible, the cab should be physically isolated from the rest of
the vehicle, and the patient should be placed in the rear seat. Drivers or other persons who are transporting patients
with suspected or confirmed infectious TB disease in an enclosed vehicle should wear at least an N95 disposable respirator. If
the patient has signs or symptoms of infectious TB disease (i.e., positive AFB sputum-smear
result), consideration might be given to having the patient wear a surgical or procedure mask, if possible, during transport, in waiting areas, or when others
are present.
Diagnosis and Treatment of Latent Tuberculosis Infection and
Tuberculosis Disease
The principles of diagnosis and treatment of LTBI and TB disease discussed in this section are guidelines and not meant
to substitute for clinical experience and judgment. Medical providers not familiar with the management of LTBI and TB
disease should consult a person with expertise. All facilities' local operations procedures should include plans for consultation
with and referral to persons with expertise in TB and should include criteria delineating when consultation and
referral are indicated.
Although the index of suspicion for TB disease varies by individual risk factors and prevalence of TB in the
population served by the correctional facility, correctional facilities typically are considered higher-risk settings (see
Screening). A diagnosis of TB disease should be considered for any
patient who has a persistent cough (i.e., one lasting
>3 weeks) or other signs or symptoms compatible with TB disease (e.g., hemoptysis, night sweats, weight loss, anorexia, and fever).
Diagnostic tests for TB include the TST, QFT-G, chest radiography, and laboratory examination of sputum samples or other body
tissues and fluids.
Persons exposed to inmates with TB disease might become latently infected with
M. tuberculosis depending on host immunity and the degree and duration of exposure. Therefore, the treatment of persons with TB disease plays a key role in
TB control by stopping transmission and preventing
potentially infectious cases from occurring
(92). LTBI is an asymptomatic condition that can be diagnosed by the TST or QFT-G.
Interpreting TST Results
A baseline screening TST result of >10 mm induration is considered positive for the majority of correctional facility
staff and inmates, and these persons should be referred for medical and diagnostic evaluation. However, for correctional
facility staff and inmates who have had a known exposure in a correctional facility (i.e., close contact with an inmate or staff
member with infectious TB disease) after having a previous (baseline) TST value of 0 mm, TST results of
>5 mm should be considered positive and interpreted as a new infection. Correctional facility staff and inmates with a screening baseline TST result of
>1 mm, but <10 mm, who are subsequently exposed to TB disease, should be considered newly infected if they have TST
values increase by >10 mm on retest
(Table 3). For example, a baseline TST result with 8 mm induration and a repeat TST result
1 year later with 18 mm induration would indicate a new infection. However, a repeat TST result with 12 mm
induration would not indicate a new infection.
When decisions are made for the diagnosis and treatment of LTBI and choosing the cut-off value for a positive
reaction, certain risk factors (e.g., immunocompromising conditions and known contact with a TB patient) should be
assessed. Correctional facility staff and inmates who have TST indurations of 5--9 mm should be advised that their results might be
an indication for treatment under certain conditions.
Special Considerations in Interpreting the TST
Interpretation of the TST might be complicated by previous vaccination with BCG, anergy, and the "boosting"
effect. Detailed recommendations describing how the TST should be interpreted in relation to these possible confounders have
been published (64,93).
Correctional Staff and Inmates who Refuse Testing for
M. tuberculosis Infection
A correctional facility staff member or inmate who refuses testing for
M. tuberculosis infection should first be
educated regarding the importance of routine screening of correctional facility staff and inmates. If the person continues to refuse
to have a TST, the option may be offered for the person to be tested using the QFT-G test (and vice versa). The decision to
offer an alternative test depends on the reason for refusal and should be consistent with the patient's underlying wishes
(e.g., offering QFT-G in place of TST is acceptable if the patient objects to having injection of a substance but agrees to
having blood drawn).
Interpreting the QuantiFERON®-TB Gold Test Data
Interpretation of QFT-G data is initially performed electronically; an approved interpretation method is
automatically performed by the software supplied by the manufacturer
(Table 4) (58). A complete description of the test's interpretation
is included in the product insert.
Persons who have a positive QFT-G result should be
referred for a medical and diagnostic evaluation. On serial testing,
a person with QFT-G results changing from negative to positive should be referred for medical and diagnostic evaluation
and considered to be a QFT-G converter. Risk factors (e.g., the facility's prevalence of TB disease and personal risk factors)
should be assessed when making decisions about the diagnosis and treatment of LTBI.
Interpreting Chest Radiographs
Persons with Suspected Pulmonary TB
Multiple types of abnormalities demonstrated on chest
radiographs are strongly suggestive of pulmonary TB
disease, including upper-lobe infiltration, cavitation, and pleural
effusion. Infiltrates can be patchy or nodular and observed in
the apical or subapical posterior upper lobes or superior segment of the lower lobes. If radiographic or clinical findings
are consistent with TB disease, further studies (e.g., medical evaluation, mycobacteriologic examinations of sputa or tissue,
and comparison of current and prior chest radiographs) should be performed
(65). Persons with TB pleural effusions might
have concurrent unsuspected pulmonary or laryngeal TB disease
(94). These patients should be considered infectious
until pulmonary and laryngeal TB disease is excluded. Patients with suspected extrapulmonary TB disease also should be
suspected of having pulmonary TB until concomitant pulmonary disease is excluded.
The radiographic presentation of pulmonary TB in HIV-infected persons might be atypical. Apical cavitary disease is
less common among such patients than HIV-negative patients. More common findings among HIV-infected persons
are infiltrates in any lung zone, mediastinal or hilar adenopathy, or, in rare cases, a normal chest radiograph
(65,95--97).
Persons with LTBI
To exclude pulmonary TB disease, a chest radiograph is
indicated for all persons in whom LTBI is diagnosed. If
chest radiographs do not indicate pulmonary TB, and no symptoms consistent with TB disease are present, persons with
positive test results for TB infection should be considered for treatment for LTBI. Persons with LTBI typically have normal
chest radiographs, although they might have abnormalities suggestive of previous TB disease or other pulmonary conditions.
In certain patients with TB symptoms, pulmonary infiltrates might be apparent on chest computed tomography scan
or magnetic resonance imaging study but not on chest radiograph. Previous, healed TB disease typically produces
radiographic findings that differ from those associated with current TB disease. These findings include nodules, fibrotic scars,
calcified granulomas, and apical pleural thickening. Nevertheless, a chest radiograph by itself cannot be used to distinguish
between current and healed TB. Nodules and fibrotic
scars might contain slowly multiplying tubercle bacilli and pose substantial risk
for
progression to TB disease. Calcified nodular lesions (i.e., calcified granulomas) and apical pleural thickening indicate lower
risk for progression to TB disease (65).
Pregnant Women
Because TB disease is dangerous to both the mother and the fetus, a pregnant woman who has a positive TST
or QFT-G result or who is suspected of having TB disease should receive a chest radiograph (with shielding consistent with
safety guidelines) as soon as feasible. If symptoms or other high-risk conditions (e.g., HIV infection) are identified, a
chest radiograph might have to be performed during the first trimester of pregnancy
(64,65,98).
Evaluation of Sputum Samples
Sputum examination is a key diagnostic procedure for pulmonary TB disease
(93) and is indicated for the following
inmates and correctional facility staff:
- persons suspected of having pulmonary TB disease
because of a chest radiograph consistent with TB disease,
particularly those with any respiratory symptoms suggestive of TB disease;
- persons with chest radiographic findings suggestive of previous, healed TB disease;
- HIV-infected persons with any pulmonary symptoms
(regardless of chest radiograph findings); or
- persons suspected of having pulmonary TB disease for which bronchoscopy is planned (all sputum specimens should
be collected and final results of staining for AFB should have been reviewed before proceeding with bronchoscopy
[67]).
Specimen Collection
Persons requiring smear- and culture-sputum examination should submit at least three sputum specimens
(collected 8--24 hours apart, with at least one specimen collected in the early morning)
(71,99). Specimens should be collected in a sputum induction booth or in an AII room. In
resource-limited settings without environmental containment, collection
is safer when performed outdoors. Patients should be instructed how to produce an adequate sputum specimen, and a
health-care professional should supervise and observe the collection of sputum, if possible
(93). For patients who are unable to produce an adequate sputum specimen, expectoration might be induced by inhalation of an aerosol of warm,
hypertonic saline (71).
Laboratory Examination
Detection of AFB in stained smears by microscopy can provide the first mycobacteriologic indication of TB disease.
A positive result for AFB in a sputum smear is predictive of
increased infectiousness; however, negative AFB
sputum-smear results do not exclude a diagnosis of TB disease if clinical suspicion is high. In 2002, only 63% of U.S. patients
with reported positive sputum cultures had positive AFB sputum smears
(100).
Although smears allow for the detection of mycobacteria, definitive identification, strain typing, and
drug-susceptibility testing of M.
tuberculosis can be performed only via culture
(93). A culture of sputum or other clinical specimen that contains
M. tuberculosis provides a definitive diagnosis of TB disease. In the majority of cases, identification of
M. tuberculosis and drug-susceptibility results are available within 28 days using recommended rapid methods (e.g., liquid culture and DNA probes).
A negative culture result is obtained in approximately 14% of patients with confirmed pulmonary TB disease
(100) . Testing sputum with certain techniques (e.g., nucleic acid amplification [NAA]) facilitates the rapid detection and identification of
M. tuberculosis, but should not replace culture and drug-susceptibility testing in patients with suspected TB disease
(88,101,102). Recommendations for use and interpretation of NAA tests in the diagnosis of TB disease have been published
previously (101,102).
Laboratories should report positive smear results within
24 hours of collection and positive cultures within 24 hours of
the notation of the positive culture. Drug-susceptibility tests should be performed on initial isolates from all patients to assist
in the identification of an effective anti-TB regimen. Drug-susceptibility tests should be repeated if 1) sputum
specimens continue to be culture-positive 3 months after initiation of treatment or if 2) persons whose cultures had converted to
negative subsequently revert to positive
(65,93).
Treatment for LTBI
Treatment for LTBI is essential to controlling and eliminating TB disease in the United States because it
substantially reduces the risk that TB infection will progress to TB disease
(23). Certain persons are at high risk for developing TB
disease once infected, and every effort should be made to begin these persons on a standard LTBI treatment regimen and to
ensure that they complete the entire course of treatment for LTBI . Before treatment for LTBI is started, TB disease should be
ruled out by history, medical examination, chest radiography, and when indicated, mycobacteriologic studies.
Candidates for Treatment of LTBI
Correctional facility staff and inmates in the following high-risk groups should be given treatment for LTBI if their
reaction to the TST is >5 mm, regardless of age
(64,65):
- HIV-infected persons,
- recent contacts of a TB patient,
- persons with fibrotic changes on chest radiograph consistent with previous TB disease, and
- patients with organ transplants and other immunocompromising conditions who receive the equivalent of
>15 mg/day of prednisone for >1 month.
All other correctional facility staff and inmates should be considered for treatment of LTBI if their TST results
are >10 mm induration. If QFT-G is used, any correctional facility staff member or inmate with a positive QFT-G result
should be considered for LTBI treatment. Decisions regarding initiation of LTBI treatment should include consideration of
the likelihood of the patient continuing and completing LTBI treatment under supervision if released from the facility
before the treatment regimen is completed.
Persons with previously positive TST results who have previously completed treatment for LTBI (i.e.,
>6 months of isoniazid, 4 months of rifampin, or another regimen) do not need to be treated again unless concern exists that reinfection
has occurred. Other persons who might be poor candidates for treatment of LTBI include those with a previous history of
liver injury or a history of excessive alcohol consumption;
active hepatitis and end-stage liver disease are relative
contraindications to the use of isoniazid or pyrazinamide for treatment of LTBI
(64,103). If the decision is made to treat such patients,
baseline and follow-up monitoring of serum aminotransaminases are recommended.
Treatment Regimens for LTBI
Standard regimens have been developed for the treatment of LTBI
(Table 5). The preferred treatment for LTBI is 9 months
of daily isoniazid or biweekly dosing administered by DOT. Although regimens are broadly
applicable, modifications should be considered for certain populations (e.g.,
patients with HIV infection) and when drug resistance
is suspected.
Reports of severe liver injury and death associated with the combination of rifampin and pyrazinamide for treatment
of LTBI prompted ATS and CDC to revise previous recommendations. These recommendations now state that this
regimen typically should not be offered for the treatment of LTBI
(64,103--107). If the potential benefits substantially outweigh
the demonstrated risk for severe liver injury and death associated with this regimen and the patient has no contraindications
this regimen may be considered; a physician with experience treating LTBI and TB disease should be consulted before use of
this regimen (103). Clinicians should continue the appropriate use of rifampin and pyrazinamide in standard multidrug
anti-TB regimens for the treatment of TB disease
(65).
For all LTBI treatment regimens, nonadherence to intermittent dosing results in a larger proportion of total doses
missed than daily dosing; therefore, all patients on intermittent treatment should receive DOT. In addition, DOT should be
used with daily dosing of LTBI treatment whenever feasible. Patients with the highest priority for DOT are those at the highest
risk for progression from LTBI to TB disease, including
persons with HIV infection and persons who are recent contacts
of infectious patients with pulmonary TB.
Contacts of Patients with Drug-Susceptible TB Disease
Contacts of patients with drug-susceptible TB disease who once tested negative but subsequently have a positive TST
result (i.e., >5 mm) should be evaluated for treatment of LTBI. The majority of persons who are infected will have a positive
TST result within 6 weeks of exposure; therefore, contacts of patients with drug-susceptible TB disease who have initial
negative TSTs should be retested 8--10 weeks after the end of exposure to a patient with suspected or confirmed TB disease
(108). Persons with TB infection should be advised that they can be re-infected with
M. tuberculosis if re-exposed
(109--111). If they have not been treated previously, HIV-infected persons (regardless of TST result or previous LTBI treatment history),
persons receiving immunosuppressive therapy (regardless of TST result or previous LTBI treatment history), and persons with
a known previous (to current exposure) positive TST also should be considered for LTBI treatment.
Treatment of LTBI should not be started until a diagnosis of TB disease has been excluded. If the presence of TB disease
is uncertain because of an equivocal chest radiograph, a standard multidrug anti-TB therapy might be started and adjusted
as necessary, depending on the results of sputum cultures, drug-susceptibility tests, and clinical response
(65). If cultures are obtained without initiating therapy for TB disease, treatment for LTBI should not be initiated until all cultures are reported
as negative, which might take 6--8 weeks.
Contacts of Patients with Drug-Resistant TB Disease
Treatment for LTBI caused by drug-resistant M.
tuberculosis organisms is complex and should be conducted in
consultation with the local health department's TB control program and persons with expertise in the medical management of
drug-resistant TB. Often this will require waiting for results of susceptibility testing of the isolate from the presumed source
patient. Treatment should be guided by in vitro susceptibility test results from the isolate to which the patient was
exposed (65,112,113).
Pretreatment Evaluation and Monitoring of Treatment
Routine laboratory monitoring during treatment of LTBI is indicated only for patients with abnormal baseline tests and
for persons at risk for hepatic disease. Baseline laboratory testing is indicated only for persons infected with HIV,
pregnant women, women in the immediate postpartum period (typically within 3 months of delivery), persons with a history of
liver disease, persons who use alcohol regularly, and persons who have or who are at risk for chronic liver disease
(64).
All patients should undergo clinical monitoring at least monthly. This monitoring should include 1) a brief
clinical assessment regarding the signs of hepatitis (i.e., nausea, vomiting, abdominal pain, jaundice, and yellow or brown urine)
and 2) education about the adverse effects of the drug(s) and the need for prompt cessation of treatment and clinical
evaluation should adverse effects occur. All aspects of the clinical encounter should be conducted in private and in the patient's
primary language.
Severe adverse events associated with the administration of tuberculin antigen or treatment of LTBI or TB disease
(e.g., those resulting in hospitalization or death) should be reported to MedWatch, FDA's Safety Information and Adverse
Event Reporting Program at telephone 800-FDA-1088, by facsimile at 800-FDA-0178, or via the Internet by sending Report
Form 3500 (available at http://www.fda.gov/medwatch/safety/3500.pdf). Instructions regarding the types of adverse events
that should be reported are included on MedWatch report forms. In addition, severe adverse effects associated with LTBI
treatment should be reported to CDC's Division of Tuberculosis Elimination at telephone 404-639-8118.
Treatment for TB Disease
A decision to initiate treatment (i.e., combination anti-TB chemotherapy) should be made on the basis of
epidemiologic information; clinical, pathological, and radiographic findings; and the results of microscopic examination of
AFB-stained sputum smears and cultures for mycobacteria. A positive AFB-smear result provides strong inferential evidence for
the diagnosis of TB, and combination chemotherapy should be initiated promptly unless other strong evidence against
the diagnosis of TB disease is present (e.g., a negative NAA test). If the diagnosis is confirmed by isolation of
M. tuberculosis or a positive NAA test, treatment should be continued until a standard course of therapy is completed. Because as few as 50%
of patients with positive sputum culture results for
M. tuberculosis will have negative sputum AFB-smear results
(93), when initial
AFB-smear results are negative, empiric therapy for TB is indicated if the clinical suspicion for TB disease is high.
Regardless of the decision to begin anti-TB treatment, diagnoses other than TB should be considered and appropriate
evaluations undertaken in patients with negative AFB-smear results. A diagnosis of culture-negative pulmonary TB can be made if
sputum cultures are negative, the TST result is positive (in this circumstance, a reaction of
>5 mm induration is considered positive),
a clinical or radiographic response is observed 2 months after the initiation of therapy, and no other diagnosis has
been established. An adequate regimen for culture-negative pulmonary TB includes an additional 2 months of isoniazid
and rifampin to complete 4 months of treatment
(65). If no clinical or radiographic response is
observed by 2 months, treatment can be stopped, and other diagnoses (including inactive TB) should be considered. If AFB-smear results are negative,
and suspicion for TB disease is low, treatment can be deferred until the results of mycobacterial cultures are known and
a comparison chest radiograph is available (typically at 2 months). Among persons who have not begun treatment and in
whom suspicion of TB is low, treatment of LTBI should be considered if 1) cultures are negative, 2) the TST result is positive
(>5 mm induration), and 3) the chest radiograph is unchanged after 2 months. A person with TB expertise should be
consulted for unusual or complex situations.
Individualized case management should be provided for all patients with TB disease
(114--116). In addition, patient management should be coordinated with officials of the local or state health department; suspected or confirmed TB
cases should be reported to the local or state health department in accordance with laws and regulations. Regimens for treating
TB disease should contain multiple drugs to which the
organisms are susceptible. For persons with TB disease, treatment with
a single drug can lead to the development of mycobacterial resistance to that drug. Similarly, adding a single drug to a
failing anti-TB regimen is not recommended because it can lead to resistance to the added drug
(65).
For the majority of patients, the preferred regimen for treating TB disease consists of an initial 2-month phase of
isoniazid, rifampin, pyrazinamide, and ethambutol, followed by a continuation phase of isoniazid and rifampin lasting
>4 months, for a minimum total treatment period of 6 months
(Tables 6 and 7). The decision to stop therapy should be made on the basis of
the number of doses taken within a maximum period (not simply a 6-month period)
(65). Persons with cavitary pulmonary TB disease and positive cultures of sputum specimens at the completion of 2 months of therapy should receive a longer,
7-month continuation phase of therapy (total duration:
9 months) because of the substantially higher rate of relapse among persons
with this type of TB disease (65).
If interruptions in TB therapy occur, the decision should be made whether to restart a complete course of treatment
or continue the regimen as originally intended. In the majority of instances, the earlier the break in therapy and the longer
its duration, the more serious the effect and the greater the need to restart the treatment from the beginning.
Continuous treatment is more important in the initial phase of therapy, when the bacillary burden is highest and the chance of
developing drug resistance is greatest. Although no evidence on which to base detailed recommendations exists, examples of
practical algorithms for managing interruptions in therapy have been described previously
(65).
For HIV-infected persons who are receiving antiretroviral therapy, TB treatment regimens might need to be
altered. Whenever possible, the care of persons with concomitant TB and HIV should be provided by or in consultation with
persons with expertise in the management of both TB and HIV-related disease
(65). To prevent the emergence of rifampin
resistance, persons with TB, HIV, and CD4+ T-lymphocyte cell counts <100
cells/mm3 should not be treated with highly
intermittent (i.e., once- or twice-weekly) regimens. These
patients should instead receive daily therapy during the
intensive phase (i.e., first 2 months) and receive daily dosing or 3 doses per week by DOT during the continuation phase
(117). Antiretroviral therapy should not be withheld because the patient is being treated for TB if it is otherwise indicated. Nevertheless, beginning
both antiretroviral therapy and combination chemotherapy for TB at nearly the same time is not advisable. Although data on
which to base recommendations are limited, experience in the fields of HIV and TB suggests that treatment for TB should
be initiated first. Delaying the initiation of antiretroviral therapy until 4--8 weeks after starting anti-TB therapy is
advantageous because it 1) better enables providers to ascribe a specific cause to a drug side effect, 2) decreases the severity of
paradoxical reactions, and 3) decreases adherence challenges for the patient. Until controlled studies have been conducted that evaluate
the optimal time for starting antiretroviral therapy in patients with HIV infection and TB, this decision should be
individualized on the basis of 1) the patient's initial response to treatment for TB, 2) the occurrence of side effects, and 3) the availability
of multidrug antiretroviral therapy. Because drug-drug interactions might be less frequent with use of rifabutin, substitution
of rifabutin for rifampin might be indicated with certain antiretroviral medications. Detailed information on TB treatment
in HIV-infected persons has been published
(65,107). Updates are posted on the Internet as new findings become available
(at
http://www.dhfs.state.wi.us/aids-hiv/resources/overviews/aids_hiv.htm,
http://www.hiv-druginteractions.org, and
http://www.cdc.gov/nchstp/tb/tb_hiv_drugs/toc.htm).
Drug-susceptibility testing should be performed on all initial isolates from patients with TB disease. When results
from drug-susceptibility tests become available, the treatment regimen should be adjusted accordingly
(65,113,114,118,119) (Tables 6 and
7). Medical providers treating patients with drug-resistant TB disease should seek expert consultation
and collaborate with the local health department for treatment decisions
(65).
The primary determinant of treatment outcome is patient adherence to the drug regimen. Thus, careful attention should
be paid to measures designed to enable and foster adherence
(65,119,120). DOT is the preferred treatment strategy for
all persons with TB disease and high-risk (e.g., HIV infected) persons with LTBI. DOT should be used throughout
the entire course of therapy whenever feasible. Practitioners providing treatment to inmates should coordinate DOT with the
local health department on an inmate's release. The local health department also may be involved in monitoring therapy
for correctional facility staff (65).
Challenges to Treatment Completion
Achieving completion of treatment for LTBI or TB disease often is difficult, particularly in correctional facilities. Movement
of inmates both within and outside of correctional systems interferes with continuity of care and might lead to treatment default
(121). Comprehensive case management that includes discharge planning and coordination with other correctional facilities and
health departments is needed to ensure completion of therapy for patients with TB disease and LTBI
(42).
Multiple studies have demonstrated that inmates have relatively low LTBI treatment completion rates, particularly those
in jails who are likely to be released before their therapy has been completed
(14,28,40,122). For a substantial proportion
of inmates, referrals for follow-up after release are not made; of inmates whose appointments are scheduled, 40%--60% will
not attend their first clinic visit (36,40). Multiple interventions have been attempted to improve LTBI treatment completion
in this population, including patient education while in jail, use of incentives, and use of DOT
(61,122,123). None of these strategies has had substantial success, although
patient education and use of DOT have increased completion rates modestly
in certain situations (61,122). Active case management, as recommended for TB disease, should be considered as a next step
in improving the completion rates for LTBI treatment
(14,42).
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.
Collaboration Between Correction Facilities and Public Health Officials
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
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.
Components of Discharge Planning
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--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 |
