TB in Corrections Phoenix, Arizona

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1 TB in Corrections Phoenix, Arizona March 24, 2011 Contact Investigation in the Correctional Setting Jessica Quintero, BAAS March 24, 2011 Jessica Quintero, BAAS has the following disclosures to make: No conflict of interests No relevant financial relationships with No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Contact Investigation in Correctional Settings Jessica Quintero, BAAS Heartland National TB Center March 24, 2011 Goal of Contact Investigation The overall goal is to interrupt transmission of M.tuberculosis Identifying, isolating, and treating persons with TB disease. Identifying infected contacts of the source patient and providing them with a complete course of treatment for latent TB infection. 2

3 Framework with general guidelines for effective prevention and control of TB in jails, prisons, and other correctional and detention facilities. These measures should be instituted in close collaboration with local or state health department TB control programs and other key partners. CDC Guidelines Data Collection and Management is an Essential Component of a Successful Investigation Two correctional information systems are critical to the efficient conduct of a contact investigation: 1. An inmate medical record system containing TST results and other relevant information 2. An inmate tracking system. 3

4 TB Transmission is Determined By Source patient AFB smear positive Cavitary disease Delayed diagnosis Contact Immunosuppression Exposure Air volume Ventilation Duration Characteristics High Likelihood of Transmission Source Patient Contacts Exposure AFB smear positive Cavitary disease Delayed diagnosis Immunosuppression HIV infected Diabetes Other medical conditions Air volume Low air volume Confined space Ventilation Confined air with little or no ventilation Recirculated air without HEPA filtration Duration of exposure Longer and frequent exposure 4

5 Contact Investigations Should be Conducted in the Following Circumstances Suspected or confirmed pulmonary, laryngeal, l or pleural TB with cavity disease on chest radiograph or positive AFB smears. Suspected or confirmed pulmonary (non-cavitary) or pleural TB with negative AFB smears and a decision has been made to initiate TB treatment. MMWR Guidelines for the Infection of Contacts of Persons with Infectious Tuberculosis December 16,

6 Stepwise Procedures Notify correctional management officials Interview the source patient t Define the infectious period Convene the contact investigation team Update correctional management officials Obtain source case inmate traffic history Tour exposure sites Develop contact list Prioritize contacts Stepwise Procedures Conduct a medical record review on high priority contacts. Place and read initial TST or perform IGRA Place and read initial TST or perform IGRA Evaluate HIV- infected contacts or TB disease and LTBI promptly Make referrals for contact evaluation Calculate the infection rate and determine the need to expand the investigation Place and read follow up TST s or perform follow up IGRA s Determine the infection/transmission rate Write summary report 6

7 Stepwise Procedures Notify correctional management officials i The administrator should be notified thru appropriate chain of command. Conduct a source patient chart review The following data should be collected History of previous exposure to TB History of TB symptoms Weight history Chest radiograph Previous TST or IGRA result Mycobacteriology reports NAA test results HIV status Other medical risk factors 7

8 Interview the source patient Chart review and case interview Done within 1 working day for AFB smear positive respiratory specimens or cavitations on CXR. Done with in 3 working days for all other persons 2 nd interview should be conducted 7-14 days after the first. What to ask: onset of symptoms, potential community contacts, location of contact, etc Define the infectious period The infectious period is typically 12 weeks before TB diagnosis or onset of cough (which ever is longer, may need to expand beyond 12 weeks). If the patient has no TB symptoms, is AFB smear negative, and has a non-cavitary CXR the infectious period can be reduced to 4 weeks. 8

9 Convene the contact investigation team A TB team should be convened and tasked with planning an investigation. A leader, roles and responsibilities, and schedules should be identified. Your team should consist of Infection control Medical Nursing Custody Local public health personnel Update correctional management officials 9

10 Obtain source case inmate traffic history Dates and locations of the patients housing during the infectious period. Tour exposure sites Information should be obtained regarding any correctional facility that has housed the patient during the infectious period. Number of inmates housed together at one time Housing arrangement (cells vs. dorms) General size of the air space Basic ventilation system (facility engineer) Pattern of daily inmate movement (eating, working, recreation) *Don t forget to include work, home, school, etc if the infectious period started prior to incarceration. 10

11 Develop contact list & Prioritize List of exposed contacts should be generated and grouped according to current location (still incarcerated, released, or transferred) Persons with the most exposure and HIV infected or other immunosuppressed contacts (regardless of duration of exposure) are considered highest priority Conduct a medical record review on high priority contacts. TST or IGRA status CXR history History of treatment for LTBI Other high risk medical conditions Weight history HIV status t Evaluate HIV- infected contacts for TB disease and LTBI promptly. 11

12 Place and read initial TST or perform IGRA Make referrals for contact evaluation Referrals should be made for Released or transferred inmates Family members Frequent visitors 12

13 Calculate the infection rate and determine the need to expand the investigation To calculate the infection rate the total number of inmates whose TST or IGRA has converted from negative to positive should be divided by the total number with a TST placed and read or performed. Persons with a previous positive should NOT be included into your calculations The rate is relative to the population. Place and read follow up TST s or perform follow up IGRA s 13

14 Write summary report The report should briefly describe the circumstances of the investigation to include. How it was conducted d Results Number of secondary cases if any infection rates Any special interventions include follow up What worked well, lessons learned The report should be distributed to corrections administrators and the local health department. Medical Evaluation of Contacts HIV- Infected Inmates HIV- infected contacts should Be interviewed for symptoms Have a TST or IGRA Have a chest radiograph Complete a course of treatment for LTBI (once TB disease has been ruled out) regardless of the TST or IGRA result Treatment should be initiated even for persons with a history of previous treatment of LTBI or TB disease because of possibility of re-infection. 14

15 Medical Evaluation of Contacts HIV- Negative Inmates with Previous Negative TST or IGRA Conduct mandatory TST or IGRA testing of all previously negative (HIV and TST or IGRA) inmate contact at baseline (unless previously tested within 1-3 months of exposure Repeat testing 8-10 weeks from the most recent contact with the source patient. Medical Evaluation of Contacts TST and IGRA Converters Offer treatment for LTBI (unless medically contraindicated) to Persons whose TST or IGRA result converts to positive OR Persons with newly documented positive TST or IGRA results Inmate contacts who refuse medically indicated treatment for LTBI should be monitored regularly for symptoms 15

16 Responsibilities for TB Exposure in Correctional Facility The facility where the exposure occurred has the primary responsibility for identifying i and evaluation the contacts inside the facility Local Health Department should provide consultation to the facility Local Health Department is responsible for the contacts outside of the facility Responsibilities for TB Exposure in Correctional Facility THE FACILITY WHERE THE EXPOSURE OCCURRED HAS THE PRIMARY RESPONSIBILITY FOR IDENTIFYING AND EVALUATING THE CONTACTS INSIDE THE FACILITY. LHA SHOULD PROVIDE CONSULTATION TO THE FACILITY LHA IS RESPONSIBLE FOR THE CONTACTS OUTSIDE OF THE FACILITY 16

17 Control Measures for Cases A case or suspect is considered Infectious until: At least 3 successive sputum smears, collected at least 8 hours apart, at least one of which is taken first thing in the morning, are negative for acid fast bacilli Anti-tuberculosis tuberculosis treatment is initiated Clinical signs and symptoms of active tuberculosis are improved Avoid Wide Scale Testing Wide scale investigations divert attention ti away from the high h priority it activities necessary to interrupt transmission in the facility, mass screening of all persons who had any contact with the source patient should be avoided. 17

18 Any Questions 18

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