MENU TITLE: TB in Correct. Facilities 1994-95.
Series: NIJ Research in Brief
Published: July 1996
20 pages
43,356 bytes

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U.S. Department of Justice
Office of Justice Programs
National Institute of Justice

National Institute of Justice
Research in Brief

Jeremy Travis, Director
May 1996

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Issues and Findings

Discussed in this Brief: Results of a 1994 survey
cosponsored by NIJ and CDC to determine the
existing dimensions of the TB problem in
correctional facilities housing adults and the
prevention and control strategies being used to
address it. The survey followed up on a similar
survey in 1992-93 and sought information on
infection and disease occurrence (including skin
test conversions, coinfection with HIV, and
drug-resistant and multidrug-resistant (MDR) TB);
tuberculosis screening; isolation, treatment, and
preventive therapy; and discharge policies. The
study also examined legal issues. 

Key issues: Prison and jail officials confront the
need to curb the spread of tuberculosis infection
and disease in correctional facilities that house
high-risk inmates frequently under crowded, poorly
ventilated conditions. In addition, they face the
problem of preventing recently released inmates
with infectious TB disease from infecting members
of the communities to which they return. Detecting
all cases of TB infection or disease within a
facility is difficult because of such problems as:

o Coinfection with HIV resulting in false negative
TB skin tests. 

o High turnover and short lengths of stay in jails,
making it impossible to administer and read TB skin
tests for all inmates.

Key findings: The survey revealed the following
with regard to TB infection:

o In 31 State prison systems, 14 percent of inmates
had positive tuberculin skin test results at
intake. 

o In 51 Federal/State systems surveyed, 25 reported
a total of 5,609 TB skin test conversions in the 2
years prior to the survey.

o Coinfection with TB and HIV increased among male
inmates in some systems since the 1992-93 NIJ/CDC
survey, but data on female inmates generally were
not provided.

Findings on TB disease included the following:                    o The number of inmates with TB
disease under
treatment declined since 1992-93.

o The use of CDC-recommended negative-pressure
rooms to isolate infectious inmates from the rest
of the prison population increased.

o Directly observed therapy (DOT) for TB disease
became more widespread in correctional systems;
directly observed preventive therapy (DOPT) also
increased. 

o As part of discharge planning, most correctional
systems referred to local health department TB
programs those inmates who had not completed
treatment prior to release or parole. 

o However, validation survey results revealed that
some facilities were not following their systems' 
TB treatment and control policies. 

Target audience: Corrections officials, public
health officials, State and local policymakers. 

-------------------------------

Tuberculosis in Correctional Facilities 1994-95

by Karen Wilcock, Theodore M. Hammett, Rebecca
Widom, and Joel Epstein

Many prisons and jails present optimal conditions
for the spread of tuberculosis (TB), a disease that
was resurgent in the United States in the 1980's
and early 1990's.1 Correctional facilities house
men and women who often come from those segments of
the community with high rates and risk of TB
because of such factors as poverty, poor living
conditions, substance abuse, and HIV/AIDS.
Overcrowding in a correctional facility increases
the potential for close and repeated contact with
an active case of TB. The significant health
problem posed by TB is further exacerbated by two
factors. First, because of immunosuppression,
persons coinfected with TB and HIV may not be
reactive on a tuberculin skin test and thus elude
detection; persons with unidentified or
incompletely treated TB can remain infectious for a
long time, further spreading infection and the
disease. Second, recent prison outbreaks of
multidrug-resistant tuberculosis (MDR-TB) raise the
threat of an often untreatable disease spreading in
a closely confined population.

To determine the scope of the TB problem in prisons
and jails, the National Institute of Justice (NIJ)
and the Centers for Disease Control and Prevention
(CDC) have cosponsored national surveys of
tuberculosis and tuberculosis control in
correctional facilities in conjunction with surveys
of HIV/AIDS.2 This Research in Brief presents
results from the eighth survey of State/Federal
prison systems and city/county jail systems,
conducted in 1994.

A more complete discussion of basic clinical
information and the history of TB in correctional
facilities can be found in the previous report,3 as
well as in CDC's published guidelines (see "CDC
Recommendations"). Some comparisons between the
results of the 1994 survey with those of the 1992-
93 survey are possible, although the 1994 survey
was not an exact replication of the previous
effort.

Survey method

As in earlier NIJ/CDC surveys, questionnaires were
sent to 88 correctional systems, including the
Federal Bureau of Prisons, all 50 State
correctional systems, and 37 large city and county
jail systems. The State/Federal response rate was
100 percent; 78 percent of the large city and
county jail systems provided information, although
the data provided were sometimes incomplete.
Questionnaires were answered primarily by
correctional health services personnel, but in some
cases, certain sections were answered by other
correctional administrators. Respondents relied on
sources such as internal management information
system data and written policies and procedures to
complete the survey forms. To ensure a high
response rate, telephone followup was carried out
over a 6-month period; respondents were also
telephoned if key responses on a returned
questionnaire were left blank or required
clarification.  

In addition to the basic survey, a validation
survey (an abbreviated version of the main
questionnaire covering only key policy issues) was
sent to 50 larger facilities in 14 State systems
and the Federal Bureau of Prisons. An effort was
made to achieve representativeness on some broad
dimensions (e.g., men's and women's facilities,
maximum- and medium-security facilities).

TB infection among inmates

Survey results indicate that TB infection continues
to be a frequently observed phenomenon among
inmates in correctional facilities, but only a
small percentage of infected persons ever develop
active disease. The prevalence of infection serves
as an indicator of how much disease activity is in
a population and also identifies potential
candidates for preventive therapy. Correctional
systems were asked to report the number of inmates
who tested positive at intake during the 2 years
preceding the survey.

Standard purified protein derivative (PPD) skin
tests administered at intake produced positive
reactions in more than 68,000 State/Federal and
over 14,000 city/county inmates, according to
survey responses. Twelve State/Federal prison
systems reported that from 0 to 5 percent of
prisoners were TB-positive at intake, and four
State/Federal systems reported that more than 20
percent of incoming prisoners had positive tests.
Rates of positive skin tests at intake ranged from
0 to 27 percent (with a mean of 8.9 percent) among
males tested in State/Federal systems; for females,
positive rates at intake ranged from 0 to 25
percent (with a mean of 6.7 percent). The few
city/county jail systems reporting on PPD results
indicated that the percentage of inmates positive
at intake ranged from 0 to 16 percent (with a mean
of 6.1 percent) among men and from 0 to 17 percent
(with a mean of 4.3 percent) among women. The fact
that 39 percent of State/Federal systems and 69
percent of city/county systems reported no data on
PPD positivity is important from a policy
standpoint because an effective TB control strategy
depends fundamentally on the presence of a sound
data base.

Skin test conversions. A single positive PPD test
result indicates past TB exposure and an infection
of unknown duration. Sometimes a change in skin
test reaction, or conversion from negative to
positive, occurs between screening intervals.
Conversions, either among inmates or staff,
indicate the likely transmission of infection from
one or more active cases within the same facility.
Long-term inmates and all staff with negative skin
test reactions should be retested annually. For
short-term inmates, such as those in city/county
jails, it is less likely that two TB skin-tests can
be performed during incarceration.  

Conversions among inmates. Correctional systems
were asked how many inmates had skin test
conversions in the 2 years prior to the survey;
however, since data were not sought on the number
of inmates with initial negative test results who
were tested for TB infection twice in the past 2
years, conversion rates could not be calculated.

Six State/Federal prison systems reported no skin
test conversions among inmates during the 2 years
preceding the 1994 survey, while 19 systems
reported having documented evidence of skin test
conversions in which both negative and positive
test results were obtained during the inmate's
confinement in that system. Seven State/Federal
systems reported having over 100 such conversions.
Two city/county jail systems had documented
conversions among inmates. However, 51 percent of
State/Federal systems and 79 percent of city/county
systems provided no information on inmate skin-test
conversions.

Twenty-five State/Federal prison systems reported a
total of 5,609 PPD conversions for the 2 years
prior to the 1994 survey. Only six city/county jail
systems provided conversion information in 1994; of
the 18 documented conversions they reported, 17
occurred within a single system. This large number
of conversions in a single jail system may have
been discovered through a contact investigation,
although systems were not asked to elaborate on the
circumstances of PPD testing.

Conversions among staff. Twenty State/Federal
prison systems reported a total of 598 conversions,
and 13 city/county jail systems reported 62
conversions. Fourteen systems reported having no
staff with PPD conversions. Many systems failed to
report the number of documented skin test
conversions among staff during the 2 years
preceding the survey. This is because the usual
practice is for staff to be tested outside of the
prison or jail system, and the prison or jail
system does not always receive records of their
tests and results. It is important for the
designated TB control person in each correctional
system to collect this information, in order to
monitor and evaluate TB screening and containment.

Coinfection with HIV 

Systems were asked to report the number of
PPD-positive inmates for the 2 years preceding the
survey who were also HIV-positive. This question
was posed as the last in a hierarchical series in
1994:

o How many inmates had been skin-tested at intake
during the previous 2 years?

o How many of those tested were PPD-positive?

o How many of the PPD-positive inmates were also
HIV-positive?

Among prisoners in State/Federal systems with both
TB and HIV test results, approximately 11 percent
were TB-positive. Of these PPD-positive prisoners,
9 percent were coinfected. In city/county jail
systems, 0.3 percent of PPD-positive prisoners were
also HIV-positive. 

Many systems were unable to provide data on TB and
HIV coinfection, particularly for women inmates.
Reports were available for male inmates from 19
State/Federal prison systems and from 14 such
systems for women. Three city/county jail systems
provided this information for men, and two provided
it for women. Seven State/Federal systems reported
no instances of coinfection among male PPD-positive
inmates. In five State/Federal systems, fewer than
1 percent of PPD-positive men were also
HIV-positive; in five other systems, from 1 to 10
percent of male inmates were coinfected, and over
10 percent of PPD-positive men were also positive
for HIV in two systems. Eight State/Federal systems
reported no cases of coinfection among females with
positive PPD tests; two systems reported that
between 1 and 10 percent of PPD-positive women were
also positive for HIV, and four systems reported
that more than 10 percent of women were both PPD-
and HIV-positive. 

The 1992-93 survey had also asked systems to report
on coinfection, but not in a hierarchical
framework--as used in 1994; in addition, systems
were not asked in 1992-1993 to provide information
on intake. As a result, the 1992-1993 and 1994
surveys are not directly comparable in this
respect. Sixteen State/Federal systems responded to
this question in both surveys; three reported a
decrease in coinfections, seven reported the same
number for both surveys, and six reported an
increase. A total of 87 coinfections in
State/Federal systems were reported in 1992-93; in
1994, the number of coinfected at intake was 1,581.
New York reported the largest number of coinfected
inmates in both surveys, with 34 in 1992-93 and
1,512 in 1994.

One city/county jail system reported 0.2 percent
coinfection for men; the other two responding jail
systems reported that 8 and 42 percent,
respectively, of male TB-positives were also
HIV-positive. For females, both reporting
city/county jail systems indicated that no cases of
coinfection had been found.   

TB disease among inmates 

The survey asked correctional systems whether any
prisoners currently in the system were under
treatment for TB disease (excluding Mycobacterium
avium, a tuberculous infection causing neurologic
complications that is often associated with AIDS).
The majority of systems reported having between 0
and 10 cases of TB under treatment. The total numbers 
for the various systems were reported as of May 1, 
1994 (they can, therefore, be used as a midyear 
total population estimate), while information on 
the number of prisoners under treatment was often 
drawn from records having various dates. For the 51
State/Federal systems, reporting dates ranged from
December 1993 (one system) to mid-December 1994.
Dates for city/county systems ranged from the end
of January 1994 to late September 1994. Some data
are missing, particularly for women. For example, a
system may have reported cases of TB disease for
men and not for women, meaning either that there
were no cases for women or that the count was
simply unavailable. Many systems indicated they had
no cases for men or women. As a result, the data do
not provide a solid basis for calculating formal TB
case rates.

State/Federal systems reported 663 cases under
treatment in the 1994 survey, compared to 805 in
1992-93. Four State/Federal systems did not provide
this information in 1994; two of these had reported
no cases in 1992-93, and the others had reported 4
and 12 cases, respectively. In 1992-93, 372 cases
were under treatment in city/county systems, while
the 1994 survey indicated 256 such cases. The fact
that seven systems provided no case numbers in
1994, compared to four in the earlier survey, may
account for part of the discrepancy in figures for
city/county jails. At least one of this round's
nonresponding systems indicated in the earlier
survey that it had a large number of cases under
treatment.  

Drug-resistant TB among inmates. Tuberculosis
disease that is resistant to the leading
medications poses very serious problems for
correctional facilities. Resistant strains of TB
can be transmitted to others. If a TB strain is
resistant to only one drug, others from the list of
the most effective treatments can be selected;
however, if a strain is resistant to both isoniazid
(INH) and rifampin (RMP), the two most widely used
and effective anti-TB drugs, then treatment options
are seriously reduced. In both surveys, a similar
number of systems reported about the same numbers
of drug-resistant TB cases; however, systems were
not asked to provide information on cumulative
inmate cases of drug-resistant TB disease in 1994,
as they had been in 1992-93. 

Of the 35 cases with any drug resistance reported
to the 1994 survey, 24 (69 percent) were cited as
being resistant to both INH and RMP. Although based
on relatively small numbers, this proportion is
much higher than that found in a nationwide survey
conducted by the CDC, where 24 percent (114/472) of
cases with any drug resistance were resistant to
both INH and RMP.4

TB control policies

TB is an airborne disease, transmitted via droplet
nuclei (e.g., the dried residue of droplets from
sneezes or coughs) from patients who have pulmonary
or laryngeal TB and who cough, laugh, spit, or
otherwise emit sputum containing the TB bacteria
(called Mycobacterium tuberculosis). TB can be
transmitted through repeated exposure in crowded,
poorly ventilated environments; it does not require
intimate contact. Priority TB control activities,
as identified by CDC 5 are:

o Rapidly identifying, reporting, isolating, and
initiating appropriate therapy for active and
potentially infectious cases of TB. 

o Ensuring the continuity and completion of therapy
through direct observation and other
adherence-enhancing strategies.

o Rapidly identifying and evaluating contacts of
infectious TB cases and initiating preventive
therapy for infected persons. 

o Identifying persons with TB infection at high
risk for developing active TB and ensuring that
they complete a full course of preventive therapy.

CDC's specific guidelines for TB control in
correctional facilities are designed to help these
facilities avoid the spread of TB and diminish the
numbers of cases that are exported to the community
as prisoners are released. The CDC guidelines have
recently been updated and include recommendations
for both long- and short-term facilities, thus
providing more specific guidance for jails as well
as for prisons.6

Screening policies and practices

CDC guidelines for TB screening. Several types of
screening for TB are used in correctional
facilities. Symptom screening involves checking for
signs and symptoms of TB through a systematic
interview that inquires about persistent,
productive cough; chest pain; coughing up blood;
fever, chills, and night sweats; loss of appetite
and weight loss; and tiring easily, especially
during the preceding 6 weeks. Symptom screening
should be performed as soon as possible. During the
regular medical evaluation, inmates should be asked
whether they have had TB disease, been treated, or
received preventive therapy for TB.

A second screening procedure involves the PPD
(purified protein derivative) or Mantoux tuberculin
skin test. The PPD is injected under the skin and,
after 48 to 72 hours, interpreted by an experienced
reader, who measures the diameter of the swollen
area that can be felt around the injection site and
records the result in millimeters. Chest
radiographs are also used in screening for TB
disease when the incidence or prevalence of TB is
high and the time required for skin testing makes
that method impractical or may delay the isolation
of infectious persons. Generally, a
posterior-anterior view of the chest is taken. 

For all facility types, CDC recommends TB symptom
screening of incoming inmates. Inmates who are
found to have symptoms of TB should be isolated and
further evaluated. For short-term facilities
serving populations at low risk for TB, this is the
only recommended screening. To fall in this
category, facilities would have no existing cases
and draw inmates from communities that have had no
TB cases within the previous year. Some small
facilities in rural areas may meet this definition. 

CDC recommends more than symptom screening in
short-term facilities with high-risk populations.
Prisoners who stay long enough should be tuberculin
skin-tested within 14 days of arrival if their
medical records do not include a documented
positive skin test result. Those with TB symptoms
or with positive tuberculin skin tests should be
given radiographs and medical evaluations. Any
inmates known to be HIV-positive or to be at high
risk for HIV should be given a radiograph as part
of the initial screening process. CDC suggests that
large jails may want to consider using onsite
radiography for all prisoners.

CDC recommends that while long-term facilities also
begin with symptom screening, they should give a
skin test to each asymptomatic inmate without a
documented prior positive result. An inmate with
positive PPD results should be given a radiograph
and evaluated; an inmate who tests PPD-negative but
is HIV-positive or at high risk for HIV also should
be given a radiograph and evaluated. Annual PPD
tests are recommended for inmates who have negative
tests.

Screening recommendations for staff include an
evaluation of medical history during the physical
exam performed at hiring and mandatory tuberculin
skin-testing for those without a documented
positive skin-test result. Staff members who have
not been tested for 12 months or more should be
retested. Any staff member with symptoms suggestive
of TB should be sent home until infectious TB has
been ruled out. A staff member who has positive
test results should be given a radiograph and a
medical evaluation. Further, staff members should
be told that if they are immunosuppressed for any
reason, they should consult their personal
physicians for additional followup.

Screening practices. Prison and jail systems were
asked to report on screening practices for TB
infection and disease. Of the 51 State and Federal
prison systems, 44 (86 percent) reported screening
all incoming inmates for TB disease. Of the 29
responding city and county jail systems, 24 (83
percent) reported screening all inmates at intake. 

Thirty-three facilities in 13 systems responded to
the validation study on this issue and revealed
that not all facilities followed system policy with
respect to screening for TB disease. Ten of the
systems that participated in the validation study
reported screening all incoming inmates for TB
disease, but only 85 percent of the 26 facilities
in these 10 systems reported carrying out this
policy.

Screening inmates for TB infection is more common
than screening for TB disease in State/Federal
correctional systems. Of the 51 State/Federal
prison systems, 50 reported screening all incoming
inmates for TB infection, and 44 stated that this
policy was mandatory. Of the 29 city/county jail
systems, 19 (66 percent) reported testing all
incoming inmates, and 14 indicated that this was
mandatory. All systems in the validation study
reported testing all incoming inmates for TB
infection, and all of the facilities in these
systems reported carrying out this policy. For 11
of the systems in the validation study, testing of
all incoming inmates was mandatory, and 82 percent
of the facilities in these systems complied. In
1992-93, systems were asked if inmates were
routinely tested for TB infection at least
annually, while in 1994, they were asked if they
were tested at intake and at regular intervals
thereafter. Forty State/Federal systems reported
annual testing in 1992-93, and 46 systems reported
testing at intake and regular intervals thereafter
in 1994.  

Housing policies and practices

A primary TB control measure is the isolation of
infectious cases to prevent spreading the disease
to other inmates. The most common and recommended
isolation measure in prisons and jails is use of
negative-pressure isolation rooms (i.e., isolation
rooms with ventilation that does not flow into the
general ventilation system) either in the infirmary
or in a community hospital. Sixty-one percent of
State/Federal systems reported using
negative-pressure isolation rooms in the prison
infirmary, and 59 percent of these systems reported
using negative-pressure rooms in community
hospitals. When the two categories are combined, 65
percent of State/Federal systems reported using
negative-pressure rooms in the infirmary, community
hospitals, or both. Of city/county jail systems, 48
percent reported using negative-pressure rooms in
jail infirmaries, and 52 percent reported using
negative-pressure rooms in community hospitals.
When the categories are combined, 66 percent of
city/county jail systems reported using
negative-pressure rooms in one or the other
location, or in both.
 
These 1994 NIJ/CDC survey results show some
important changes since 1992-93. Where just under
one-third of prison and jail systems reported using
negative-pressure rooms for all inmates with
potentially infectious TB in the earlier survey, in
1994 the proportion reporting the exclusive use of
negative-pressure rooms had more than doubled.

In 1994, 76 percent of prison systems and 72
percent of jail systems reported isolating inmates
until three negative sputums had been collected on
consecutive days. (The current CDC recommendation
is that three consecutive sputums be collected on
different days and, additionally, that the patient
must be on effective therapy and improving
clinically.) Fourteen of the 39 prison systems
reporting this practice also mentioned using other
indicators to determine duration of isolation, as
did 6 of 21 jail systems. In 1992-93, 82 percent of
prison systems and 64 percent of jail systems had
reported isolating inmates until they could produce
three successive daily negative sputum smears.    

The validation study showed that approximately
two-thirds of the facilities in systems that
reported policies for isolating TB cases in
negative-pressure rooms agreed that this was their
practice. Ten of the 13 systems in the validation
study indicated that inmates were isolated until
three negative sputum smears were collected, and 68
percent of the facilities in these systems followed
this practice. These results suggest that
significant minorities of facilities are admittedly
not following recommended TB control procedures--
despite their systems' policies calling for such
measures.   

Treatment policies and practices

Current CDC guidelines7 recommend that the initial
course of treatment for TB disease for most
patients should include four drugs: INH, RMP,
pyrazinamide (PZA), and either ethambutol (EMB) or
streptomycin (SM). PZA and SM should not be used in
pregnant women. If there is little possibility of
drug resistance (i.e., the primary INH resistance
rate in the community is less than 4 percent, and
the patient has had no previous treatment for TB,
is not from a country with a high prevalence of
drug-resistant TB, and has had no known exposure to
a patient with drug-resistant TB), then the first
three of the drugs listed can be used. In persons
with positive smears or cultures at the beginning
of therapy, response to treatment should be
monitored by smear and culture at least monthly
until the results are negative. Directly observed
therapy (DOT) is recommended for all inmates. 

Ninety-four percent of State/Federal prison systems
reported employing DOT for all inmates receiving
treatment for TB disease, as did 90 percent of
city/county jail systems. In 1992-93 only 77
percent of prison systems and 84 percent of jail
systems reported using DOT for all inmates under
treatment for TB disease. Validation study results
showed a 90-percent agreement between facilities
and systems with respect to DOT for inmates under
treatment.

The majority of HIV-negative inmates were treated
for at least 6 months for TB (the CDC-recommended
treatment duration) in 1994 (78 percent for
State/Federal systems and 66 percent for
city/county systems). In 1992-93, 77 percent of
both prison and jail systems reported treating
HIV-negative inmates for at least 6 months.
Forty-nine percent of State/Federal systems and 48
percent of city/county systems reported treating
coinfected inmates for 9 or more months in 1994,
while more than 60 percent of both prison and jail
systems had reported this policy in 1992-93. It
should be noted that in 1994, the CDC recommended
that treatment duration be changed to 6 months for
drug-susceptible, coinfected persons responding
adequately to therapy.8  

INH preventive therapy 

Most asymptomatic but infected inmates should be
given preventive therapy with INH to reduce their
likelihood of developing active disease.9 CDC
recommends that, once active disease has been ruled
out, all PPD-positive persons who are
non-HIV-infected be considered for at least 6
months of INH (300 mg daily or 900 mg twice weekly)
and dually infected persons be considered for 12
months of prophylaxis.10

CDC also recommends that all preventive therapy be
directly observed.11 This is particularly important
since people on preventive therapy are asymptomatic
and may never have experienced TB symptoms, a
circumstance that offers little incentive for them
to adhere to a lengthy course of medication.

As was the case for TB disease treatment, an
increased percentage of prison systems reported in
the 1994 survey that directly observed prevention
therapy (DOPT) was provided for all inmates with TB
infection (76 percent vs. 67 percent in 1992-93).
Nine of the 51 State/Federal systems that reported
not using DOPT in the earlier survey reported its
use in 1994. However, four prison systems that did
not use DOPT in 1994 had reported employing it in
1992-93. The percentage of jail systems using DOPT
for all infected inmates was approximately the
same. 

According to the validation study, reports from
systems and facilities as to who received
preventive therapy were somewhat inconsistent. Ten
of 13 systems in the validation study stated they
practiced DOPT, while 88 percent of the reporting
facilities in those 10 systems claimed to
administer DOPT to all inmates. Most (12 of the 13
in the validation study) systems reported that all
inmates under 35 years of age with positive skin
tests received preventive therapy, and 72 percent
of facilities in those systems agreed. Nine of the
13 systems in the validation study reported that
they gave preventive therapy to recent converters,
to all inmates with positive reactions--whatever
their age, and to all coinfected inmates. The
concurrence rates for facilities in these systems
were 83 percent, 55 percent, and 78 percent. Eight
systems in the validation study stated that they
administered preventive therapy to all HIV-positive
inmates who demonstrated anergy (i.e., no response
to the skin test); only 45 percent of the
facilities in these systems reported doing this.
Four systems in the validation study said they
administered therapy to all close contacts of a TB
case; the agreement rate from facilities in these
systems was 58 percent.

Discharge policies

Systems were asked about discharge planning for
inmates with TB disease or infection who had not
finished their course of therapy prior to discharge
or parole. Most systems (94 percent of
State/Federal systems and 100 percent of
city/county systems) reported that they referred
inmates to local health department TB programs on
release. Many systems also informed health
departments about inmates and provided locating
information (86 percent of State/Federal and 97
percent of city/county systems). Relatively few
systems went as far as scheduling appointments for
inmates (32 percent of State/Federal and 38 percent
of city/county systems). Validation study results
showed that all 13 systems said they referred
inmates to health departments, and 88 percent of
facilities in those systems agreed; 12 systems
reported that they informed health departments
about inmates, and 81 percent of facilities agreed.
However, five systems reported that they scheduled
appointments for inmates, but only 30 of the
facilities in those systems confirmed this
practice.

The 1994 survey did not include specific questions
on environmental controls, nor were questions posed
concerning education and training. Systems were
asked to indicate whether they would like to
receive assistance from the public health
department on a number of different aspects of TB
control. Over 30 systems expressed an interest in
receiving help with educational programs/materials
and with discharge planning. Other types of
assistance were of interest as well, but to a
smaller number of systems. 

Legal issues

Correctional officials may be concerned about
liability with respect to the transmission and
treatment of TB in their facilities. Additional
discussion on this topic can be found in the report
on the 1992-93 survey.12 Recently adjudicated cases
have centered on two issues:

o Failure to protect inmates from acquiring TB or
provide adequate treatment or care.

o Failure to respect individuals' constitutional
rights by instituting a mandatory TB testing
program. 

Six instances alleging the first type of failure
have been reported. In a case in a Federal District
Court in Wyoming, Blumhagen v. Sabes13, a prisoner
claimed that following the discovery of an active
case of TB, prison officials had the entire prison
population screened for the disease but failed to
quarantine or isolate the sick inmate. Followup
tests or proper procedures to control the spread of
the disease were not performed, and the prison
population was not monitored.

The District Court found that the prisoner's
allegations amounted to differences of opinion
about proper medical treatment and not "the type of
subjective indifference to the medical needs of the
prisoners that the controlling cases require." The
court's decision in Blumhagen acknowledged the
decision in DiGidio v. Pung14 (holding that "a
consistent pattern of reckless or negligent conduct
is sufficient to establish deliberate
indifference") but distinguished the ruling and
held that it need not be followed. The Blumhagen
decision also noted that the court had found no
decisions holding that "speculative harm in future
is sufficient to meet" the "serious medical need"
requirement. Finally, the court noted that the
plaintiffs may have a claim for malpractice and
that Wyoming had waived its sovereign immunity.

Three cases in Texas also revolved around issues of
adequate protection of inmates from TB. Two of
these are pending against the Harris County
Sheriff, while a third case was dismissed. James H.
King v. Johnny Klevenhager [sic], Sheriff, et
al.,15 involves a plaintiff's "civil suit for
medical negligence." The plaintiff alleges that,
while housed in the Harris County Jail during 1992,
he received inadequate medical attention, was
subjected to intolerable living conditions due to
overcrowding, and was exposed to tuberculosis.
Preston Briggs v. Jerry Eversole et al.,16 another
pro se case, involves a plaintiff's "complaint for
violation of civil rights pursuant to 42 USC
1983." In his pleadings the plaintiff claims that,
since his incarceration in the Harris County Jail
in January 1993, his civil rights have been
violated. Among his claims are assertions that he
was unreasonably exposed to tuberculosis from other
inmates, that he was injured on an ongoing basis
because of the inadequate flow of air in the jail,
and that he received inadequate medical attention.
In a case that was dismissed, John Friedel and
Dorcas Friedel v. Sheriff Johnny Klevenhagen et
al.,17 the plaintiff alleged that he contracted
tuberculosis while in prison, that the disease was
never properly diagnosed, and that he was never
treated for his TB.

Two cases in Massachusetts dealt with the issue of
violating inmates' civil rights through mandatory
testing programs. The primary issue in Langton v.
Commissioner of Correction,18 was whether prison
officials are authorized to compel inmates to
submit to TB testing under State law. The inmates
argued that the defendants had no authority to
force them to submit to the TB test. In
Massachusetts, the State Legislature had mandated
specifically that, during each prisoner's physical
exam, special attention be given to determining the
presence of communicable diseases, particularly
pulmonary tuberculosis. The Appeals Court ruled
that the Commissioner of Correction has the
responsibility to maintain security, safety, and
order at all State correctional facilities. The
court further ruled that, although an inmate's
incarceration does not divest him of the right of
privacy and interest in preserving his bodily
integrity, it does limit those constitutional
rights when the State's interests in prison
security and inmate health are at issue.
Furthermore, the court said that disciplinary
procedures implemented to deal with inmate refusals
to take the TB test were lawful.

On the other hand, a Federal District Court judge
in New York recently ruled that the State
correctional department must return to the general
population a person who had been held in "medical
keeplock" (solitary confinement) for 3-1/2 years
because he refused a PPD test. Skin testing is
mandatory for New York State inmates, but this
prisoner refused the test on the grounds that it
violated the tenets of his Rastafarian religion. In
an affidavit, the inmate stated that "accepting
artificial substances into the body constitutes a
sin and shows profound disrespect to our creator."
The court held that the inmate, "in choosing to
undergo the conditions of medical keeplock for a
period of over 3-1/2 years, had shown remarkable
conviction for what he stated are his religious
beliefs."19

Implications for policy and practice

These recent legal cases, as well as concerns about
the spread of TB within correctional facilities--
and, ultimately, beyond, as released inmates return
to their communities-indicate the need for
continuing attention to prison health policies and
practices. The study found that although policies
for the prevention, treatment, and control of
tuberculosis have been mandated by legislatures or
stipulated as corrections systems policies, some
facilities did not comply.

Incarceration may also represent a unique public
health opportunity to provide long-term, directly
observed therapy to persons with TB disease and
directly observed preventive therapy to those who
might otherwise go untreated. Following CDC
guidelines, strong TB prevention, treatment, and
control programs in correctional facilities can
help contain the spread of TB within the greater
community. 

--------------------------

Notes

1. Hammett, T. and L. Harrold, Tuberculosis in
Correctional Facilities, Issues and Practices,
National Institute of Justice and Centers for
Disease Control and Prevention, 1994.

2. Ibid.

3. Ibid.

4. Alan Bloch et al., "Nationwide Survey of
Drug-Resistant Tuberculosis in the United States,"
Journal of the American Medical Association, March
2, 1994, 271:665-671.

5. CDC, Screening for tuberculosis and tuberculous
infection in high risk populations: recommendations
of the Advisory Council for the Elimination of
Tuberculosis," Morbidity and Mortality Weekly
Report, 44(No. RR-11):19-34, 1994. 

6. CDC, Controlling Tuberculosis in Correctional
Facilities, Atlanta 1995.

7. Ibid.

8. ATS/CDC, "Treatment of Tuberculosis and
Tuberculosis Infection in Adults and Children," Am
J Respir Crit Care Med, 149:1359-74, 1994.

9. ATS/CDC, "Control of Tuberculosis in the United
States," Am Rev Respir Dis, 146:1623-1633, 1992.

10. ATS/CDC, "Treatment of Tuberculosis and
Tuberculosis Infection in Adults and Children."

11. CDC, "Prevention and Control of Tuberculosis in
Correctional Facilities: Recommendations of the
Advisory Council for the Elimination of
Tuberculosis."

12. Hammett and Harrold, Tuberculosis in
Correctional Facilities, chapter 10.

13. Blumhagen v. Sabes, 834 F. Supp. 1347, 1353 (D.
Wyo. 1993).

14. DiGidio v. Pung, 920 F. 2nd 525 (8th Cir.
1990).

15. James H. King v. Johnny Klevenhager [sic],
Sheriff, et al., No. 93-52770. 

16. Preston Briggs v. Jerry Eversole et al., No. H-
93-1485. 

17. John Friedel and Dorcas Friedel v. Sheriff
Johnny Klevenhagen et al., No. 93-58890. 

18. Langton v. Commissioner of Corrections, 614
N.E. 2d 1002 (Mass. App. Ct. 1993).

19. McKinley, James C. Jr., "Isolation Ends for
Prisoner Who Refused Testing for TB," New York
Times, August 22, 1995, p. B5.

--------------------------

CDC Recommendations

Controlling TB in Correctional Facilities (1995), a
new CDC publication, is based on the latest
recommendations of the Advisory Council for the
Elimination of Tuberculosis (ACET) for the
prevention and control of TB in correctional
facilities. Designed for use by correctional
medical staff, correctional facility
administrators, health department staffs, and
anyone responsible for providing training and
guidance in implementing TB control policies, the
ACET recommendations cover needs of both short- and
long-term correctional facilities. This resource is
intended to encourage collaboration between health
departments and their jurisdictions' correctional
facilities. Specific assistance is provided through
case studies, screening algorithms, treatment
tables, and sample forms for information
management.

Copies may be ordered by calling 404-639-1819,
faxing 404-639-8628, or writing:

Information & Technology Services
National Center for HIV, STD, and TB Prevention
Mailstop E-06
Centers for Disease Control and Prevention
1600 Clifton Road, N.E.
Atlanta, GA 30333

Please provide name, organization, address with a
ZIP code, and a daytime phone.

--------------------------

This research was conducted by Abt Associates Inc.
The study team consisted of: Karen Wilcock,
associate; Theodore M. Hammett, vice president;
Rebecca Widom, research assistant; and Joel
Epstein, analyst.

---------------------------

Prepared under contract OJP-89-C-009 to Abt
Associates Inc. from the National Institute of
Justice, Office of Justice Programs, U.S.
Department of Justice. Findings and conclusions of
the research reported here are those of the authors
and do not necessarily reflect the official
position or policies of the U.S. Department of
Justice.

--------------------------

The National Institute of Justice is a component of
the Office of Justice Programs, which also includes
the Bureau of Justice Assistance, Bureau of Justice
Statistics, Office of Juvenile Justice and
Delinquency Prevention, and the Office for Victims
of Crime.

NCJ 157809