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TB Prevention and Control In Prisons and Jails: New CDC Guidelines

by John E. Dannenberg

The National Center for Disease Control (CDC) updated its 1996 standard guidelines for effective prevention and control of tuberculosis (TB) in detention facilities by issuing fifteen new recommendations in 2006.
These were necessary because TB is still spreading in the United States, often multiplying in jails and prisons as well as in detention facilities housing recent immigrants from indigenously infected Mexico, Vietnam and the Philippines. In 2003, .07 % of the total U.S. population was incarcerated, but 3.2 % of the total TB cases occurred therein.
Often, the rate of TB infection in jails and prisons has run ten times that in the average state population. Thus, interdiction of this disease in detention facilities, jails and prisons is imperative.

Principal factors contributing to high infection rates in incarceration settings include risky behavior leading to disease spread such as the use of injected drugs. Low socioeconomic status is also a common factor, often because of the corresponding lack of TB education and access to public health treatment. TB appears both in active disease form as well as in latent infection. Many persons who once had TB but still carry the bacterium can become actively infectious again simply because they failed to properly complete the available standard treatment regimen initially.
This, in turn, leads to mutation of the TB organism into multi-drug-resistant forms that are increasingly harder to treat. Since it only takes one highly infectious person to infect a whole building, early detection and isolation is paramount.

Prisoners are on average more susceptible to getting TB because they carry a high rate of immune-compromising HIV infection. Indeed, most AIDS victims die of opportunistic infections that simply overwhelm their weakened immune systems. Considering the HIV factor, detention facilities are faced with an urgent need for initial intake screening to catch any phase of TB disease. Screening is done with skin tests, chest X-rays and sputum cultures. A new skin test (QFT-G) approved in 2005 is able to distinguish between actually diseased patients and those who were once immunized for TB with a weakened TB strain. This test is also important because HIV-compromised people, whose immune deficiency desensitizes them, often do not respond (?false negatives?) to the normal TB allergic-reaction skin test.

The new CDC guidelines now include jails, where only prisons were previously listed. All prisoners must be screened at entry and before being housed in the general population. Ventilation requirements in detention facilities have been greatly expanded to include exhaust, air cleaning, and environmental control. For example, new standards recommend six air changes per hour in cells and dormitories, versus less than two before. When prisoners who are being treated for TB infection are released, they must be followed in the community to ensure that their treatment continues uninterrupted until complete.

The recent record here was that half of releasees visited a medical clinic only once after discharge.) Thus, it was decreed that corrections staff must work closely with public health staff to coordinate TB training and treatment for this highly susceptible population. Additionally, prison and jail staff must work with U.S. Immigrations and Customs Enforcement to follow high-risk detainees as they transfer among various county and state lockups around the country.

One simple factor seems overriding, yet is most often neglected. TB is an airborne disease, but ventilation in detention facilities is notably poor. This is the perfect storm for widespread infection. While aerobic isolation of highly infectious victims (once identified) for treatment is legally required, the protection of normal populations (and their correctional and medical staff) depends upon minimal exposure via good ventilation techniques. Detention cells and dorms today should comply with the national air-handler standard ANSI/ASHRAE Standard 68.1-8004.
Air recirculation is circumscribed as well. Moreover, air handler maintenance is crucial and must be part of any TB infection control plan. Filters, ducts, fans, diffusers and grilles must be cleaned regularly. (Of course, in most detention facilities, little or no preventive maintenance occurs, thus only exacerbating the spread of TB and other airborne diseases.) Even where adequate ventilation may exist on paper, overcrowding quickly overwhelms ventilation systems.

The new guidelines have been endorsed by the Advisory Council for the Elimination of Tuberculosis, the National Commission on Correctional Health Care and the American Correctional Association. This 80 page report should be followed by all detention entities to stem TB disease where it festers most: in prisons and jails. See: Prevention and Control of Tuberculosis in Correctional and Detention Facilities, Recommendations from CDC, 2006; CDC, 1600 Clifton Road NE, MS-E-10, Atlanta, GA, 30333. The report is also available on the PLN website.

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