The ‘Prison’ Population

Since the 1980s, the US prison and jail population has grown significantly.¹ The United States has the highest rates of incarceration in the world.² Currently more than 2 million people reside in U.S. prisons, jails, and juvenile facilities, and 7 million people, or one of every 32 adults, is either incarcerated, or on probation or parole.³ This incarcerated population is disproportionately poor, male, medically underserved, and from racial and ethnic minority groups.¹The female inmate population is increasing at a faster rate than the males however, and now comprise 7% of the total population. Because inmates generally have lacked health insurance before incarceration, their health problems have often not been addressed adequately or at all. The prevalence of infectious diseases in the correctional setting is four to 10 times that in the general U.S. population.¹

Each year, 10 million people enter and leave correctional facilities, and more than one half million offenders move back and forth between prison, their community, and back to prison.⁴ Correctional healthcare provides a window of opportunity to identify and treat communicable diseases, directly affecting the health of people in surrounding communities.¹ Nurses who are knowledgeable about the significant infectious diseases that occur in the correctional setting and who can collaborate with appropriate public health and community agencies can enhance the effectiveness of their interventions.

Initiated in 1989, The National Drug Control Strategy emphasizes mandatory minimum sentences for many drug crimes, resulting in more people being incarcerated for longer periods of time. Legal confinement, already associated with high-risk behaviors of substance abuse and prostitution, is also linked to greater risk of communicable diseases, such as HIV, viral hepatitis, and sexually transmitted diseases.⁵ The increase in the prison population is associated with the changing drug policies, with 74% of this increase being associated with drug-related offenses and longer prison terms.¹

As a result of this growing inmate population, there has also been an increase in the privatization of correctional healthcare to provide services to this rapidly growing population. One for-profit company alone provides healthcare to 10% of the nation’s inmates.⁶ Four states, all in the western U.S., hold at least 25% of their prisoners in private facilities.⁷ Participation and collaboration among all health service providers, public and private, and correctional staff is crucial for the successful control and prevention of communicable diseases in the correctional setting.

The Correctional Setting

While the term “prison” refers to any correctional facility, it is generally understood to refer to a state or federal facility that holds sentenced inmates for a year or more. Jails are county or local facilities that hold detained inmates or those sentenced to less than one year. With a median length of stay of one to three days, jails have very high turnover rates. Because of the high turnover, jails are more likely to present challenges with regard to infectious disease control and patient follow-up.

Communicable Disease Control

The control and management of infectious diseases in the correctional setting includes the diagnosis and treatment of individuals, and disease control and prevention strategies targeting this vulnerable population and its challenging environment.

A dynamic inmate population with frequent intra- and inter-facility transfers, discharges, and reincarcerations complicates disease surveillance and control; and because the setting is primarily correctional, not medical, conflicts can occur between custody and care. Correctional healthcare must be provided within the constraints of correction settings.⁸

Within that confine, the infection control program must ensure a clean, safe, and healthy environment to minimize the occurrence and transmission of communicable diseases by instituting systems and strategies for the effective ongoing screening and surveillance of those with or at risk of communicable diseases. A person knowledgeable in the control of infectious diseases should be responsible for the infection control program.⁸

A multidisciplinary infection control committee should meet regularly to define and evaluate policies and procedures, make recommendations for improvement, and address outbreaks or other urgent infection control situations. Recognizing the importance of effective control of infectious diseases, the American Public Health Association Task Force on Correctional Health Care Standards states that “Each prison or jail must have an infection control program that effectively monitors the incidence of infectious and communicable diseases among prisoners and staff…”⁹ The National Commission on Correctional Health Care, a voluntary national accreditation program for correctional healthcare services, has stipulated a correctional infection control program as an essential standard for accreditation.¹⁰ Infection control guidelines for the correctional setting are available from the Association for Professionals in Infection Control and Epidemiology.⁸

Admission Evaluation

Because as many as 50% of arrestees are released within 48 hours, screening programs are most effective at the time of intake or booking and before the return of high-risk individuals to their community. In a 2002 survey of jail inmates, about 80% of respondents reported that they were questioned about their health or medical history at the time of their admission to the correctional facility; 79% were asked if they ever felt suicidal; and 47% were asked if they were sick, injured or, intoxicated. Since admission, nearly 63% of inmates reported receiving a TST, and 22% reported receiving an HIV test.¹¹

Tuberculosis

Overall incidence of new tuberculosis cases in the U.S. population has remained at less than 10 cases per 100,000. Case rates in correctional populations have been substantially higher. Inmates have high rates of latent TB infection (LTBI) and are at higher risk of progressing to active disease associated with their higher rates of poverty, substance use, and HIV infection. In the United States, TB is increasingly concentrated among disadvantaged individuals, especially immigrants. Social and legal barriers are associated with inadequate TB testing and treatment among undocumented immigrants, increasing their risk of disease. Undocumented immigrants in detention and correctional facilities have the opportunity to receive TB testing and treatment that may not otherwise be available to them.¹²

Effective prevention and control of TB in jails, prisons, and other correctional and detention facilities require four fundamental activities: screening for TB infection and disease; containment and prevention of disease transmission; treatment of active TB disease and LTBI; and ongoing evaluation of the screening and containment efforts in collaboration with public health departments, especially with regard to discharge planning and contact investigations.¹²

Correctional facilities contribute to disease transmission because of such factors as overcrowding and poor ventilation. Movement of inmates into these facilities and back to their communities complicates TB control efforts. TB transmission occurs in the correctional setting as a result of inmate and staff exposure to inmates with undiagnosed TB disease. Thus, the most effective way to prevent TB transmission is the early recognition of individuals with TB disease before they are housed with the general population of inmates. Screening inmates for LTBI and symptoms of active TB disease at intake, and routine screening at least annually should be a part of the TB control program. Specific screening activities depend upon the type of facility, the prevalence of TB in the facility and in the inmates’ communities, and other inmate risk factors, such as HIV and substance use.¹²

TB Screening: All newly admitted inmates should be screened for TB symptoms, including prolonged cough (> 3 weeks), hemoptosis, chest pain, fever, night sweats, fatigue, anorexia, and weight loss. All symptomatic inmates should immediately receive a medical evaluation including a TST or a Quantiferon-TB Gold Test, chest radiograph, and sputum exam, if indicated. All symptomatic inmates should be placed in airborne isolation until TB disease is ruled out or until treatment renders them no longer infectious.¹²

The Tuberculin Skin Test is the most common method of screening for TB infection. The TST should be planted by a trained healthcare worker and read within 48 to 72 hours by measuring the induration (not the redness) across the width of the forearm. A TST of >10 mm is considered positive in inmates and staff with some exceptions. A >5 mm induration is considered positive in the immunocompromised, recent contacts of a TB case, or those suspected of having TB disease, based on signs or symptoms, or radiographic evidence. Pregnancy, lactation, or previous BCG vaccination are not contraindications of the TST.¹²

Two-step testing can improve the identification of those previously infected but whose response to the TST may have waned over time. The second TST is planted one to three weeks after the first in those with a negative result. If the second TST is positive, individuals are classified as having a previous TB infection.¹²

The Quantiferon-TB Gold Test was FDA approved in 2005 as a diagnostic tool for LTBI and disease, and like the TST, cannot distinguish between latent infection and disease. The advantages of the QFT-G are that results are obtained after a single patient encounter, are not affected by prior BCG vaccination, and eliminate the risk of false positive TST. However, disadvantages include the need to process the blood within 12 hours of collection, and the fact that only a limited number of laboratories can perform the test. Available data indicate the QFT-G is as sensitive as the TST for detecting TB disease and more specific (i.e., fewer false negative test results) than the TST for detecting LTBI.¹²

Screening with chest radiographs may be appropriate in certain facilities at high risk of TB. One study of radiographic screening doubled the facility’s case-finding rate and reduced the risk of TB transmission. A disadvantage of radiographic screening is that it does not identify those with LTBI.

Collaboration and Discharge Planning: Jails and prisons are major reservoirs of TB, and should be an integral part of the community’s TB control program. Cooperation between correctional medical staff and public health workers is critical for following inmates on TB treatment or preventive therapy as they move to other facilities or return to their community. Effective discharge planning can improve community follow-up care. Nurse case managers can play an important role in TB control in prisons by monitoring medication adherence, providing education, and conducting discharge planning. Education during incarceration regarding tuberculosis and the importance of completing treatment can improve follow-up care and treatment completion after release.

The use of the local TB registry to identify individuals’ prior TB treatment, drug susceptibility, treatment, and compliance history can facilitate optimum diagnosis and treatment. Case-reporting to the appropriate health agency is mandatory for all correctional facilities.

Discharge planning for those with TB disease and LTBI should include collaboration with public health and community healthcare providers for continuity of case management. Discharge planning should begin as soon as possible after diagnosis, with notification of the department of public health and the planning of appropriate support and referrals needed after discharge. Case management includes housing and social supports, addressing any language barriers. Substance abuse and mental health services should be in place by the time of discharge. These are all factors that are associated with medication adherence, which is crucial for effective TB control.

Bloodborne Diseases

Persons incarcerated in correctional systems have a disproportionate burden of bloodborne diseases. The AIDS rate is more than three times that in the general U.S. population; and between 12% and 39% of all cases of chronic hepatitis B and C infections were incarcerated in the past year. Inmates have a high prevalence of illicit drug use. Despite laws prohibiting sex in prison, between 2% and 30% of inmates have sex while incarcerated; outbreaks of hepatitis B among inmates are thought to reflect this sexual activity.¹³

Tattoos and other percutaneous exposures do occur in prison and have the potential to expose inmates and staff to hepatitis B. While the risk of transmission of bloodborne disease via tattoos is unknown, a Canadian survey reports that 45% of inmates receive tattoos, often using dirty needles. A study in the U.S. suggested an increased risk of infection with the hepatitis B virus (HBV) and hepatitis C virus (HCV) among those tattooed in prison.^13,14

HIV: At year’s-end 2004, 1.9% of state prison inmates and 1.1% of federal inmates were HIV infected. Among female inmates, 2.6% were HIV infected as compared to 1.8% HIV infection rate in male inmates. Three states — New York, Florida, and Texas — house nearly half of all HIV-infected inmates in the country. The number of HIV-infected inmates has been stable in recent years in all states except New York, where the number has decreased. New York still has the highest HIV prevalence rate (7%) in the United States. One in every 18 prison deaths is AIDS-related.¹⁵ Twenty states test all inmates, either on admission or while in prison. In a 2002 prison survey, more than two in 10 inmates reported being tested for HIV since admission.¹¹

An estimated 17% of HIV-infected people pass through the correctional system every year, providing an important opportunity for prisons and jails to impact public health and HIV care.¹⁶ The provision of HIV care in the correctional setting requires the collaboration of the medical and custodial staff. The National Commission on Correctional Health Care (NCCHC) recommends early diagnosis and treatment of HIV-infected inmates through voluntary testing with informed consent, and the voluntary testing of all pregnant women to allow for early prenatal intervention if the woman so chooses. The NCCHC recommends quality medical treatment for inmates with HIV and systems in place to assure continuity of therapy with automatic medication renewal systems to prevent interruptions in care.¹⁶

Hepatitis B: The prevalence of chronic HBV in the U.S. general population is 0.4% to 0.5%; its prevalence in the correctional setting ranges from 13% to 47%, varying by region. The majority of HBV in inmates is community-acquired. HBV transmission occurs within the correctional setting, with incidence rates estimated to range from 0.82% to 3.8% per year. Sex is the predominant mode of transmission of hepatitis B. Control and prevention of hepatitis B is most effectively achieved with the hepatitis B vaccine.¹³

The CDC has recently recommended hepatitis B vaccination of all detained adolescents and all adults who receive a medical evaluation in a correctional facility who lack documentation of prior immunization or immunity. A major barrier to hepatitis B vaccination of inmates has been the transient nature and high turnover of inmates. While the goal of a vaccination program is to administer the complete series of three doses of hepatitis B vaccine, high levels of hepatitis B antibody develop after one or two doses. Protective antibody levels of 30% to 50% are obtained after one dose and up to 75% after two doses of HBV vaccine in healthy young adults. Vaccinating inmates in prisons has been shown to be feasible and cost-saving.¹³

There are 750,000 employees, two-thirds of whom are security staff at risk of occupational exposure to body fluids. All staff with potential exposure to blood and other potentially infectious body fluids are recommended to be vaccinated against hepatitis B. Immunization within 24 to 48 hours after HBV exposure is 70% to 90% effective in preventing HBV transmission.¹³

The CDC recommends that inmates identified with chronic HBV infection be evaluated to determine the extent of liver disease and the appropriateness of antiviral therapy. The NCCHC in a position statement supports screening all inmates for HBV, and referring inmates with hepatitis for diagnostic studies, and when indicated, treatment with appropriate agents.¹⁷

Hepatitis C: HCV is more prevalent in the general population than HIV and TB in the United States. There are 3.9 million cases of hepatitis C in the U.S., 1.8% of the general population. Seventy percent to 90% of cases are due to long-term percutaneous exposure to blood. This includes injection drug users, hemophiliacs, and blood transfusion recipients. Prevalence is 10% among hemodialysis patients, and 5% among those with high-risk sexual practices. Prevalence is between 1% to 2% among healthcare workers, similar to the prevalence among the general U.S. population. Prevalence of chronic HCV infection is 12% to 35% among prison inmates.¹³

There is no vaccine for HCV prevention; prevention practices in the correctional setting must focus on risk reduction, such as counseling regarding harm-reduction practices related to sexual activity and illicit drug use. Secondary and tertiary prevention includes identifying and testing those at high risk of HCV, and evaluation of those who test HCV positive for chronic infection, liver disease, and the need for further medical management.¹³

The NCCHC recommends in its 2002 position statement that prison health staff consider a diagnosis of hepatitis C in patients with risk factors for HCV and recommends that long-term prison facilities offer standard HCV therapy to appropriate candidates for treatment. Education on HCV should be incorporated into jail and prison health education programs and should include culturally sensitive and accurate information for both staff and inmates about practices that reduce risk of transmission.¹⁸

Control and Prevention of Bloodborne diseases: All staff — healthcare workers, correctional staff, and inmate workers who are at risk of exposure to body fluids, such as housekeeping and laundry staff in clinics or infirmaries — need comprehensive periodic training in standard precautions. Ongoing education for medical and correctional staff and inmates should be an integral part of the infection control program. Body fluid exposures are not infrequent occurrences in the correctional setting and are very stressful to all involved. Clearly written policies and procedures regarding handling of body fluid exposures should be readily available to all shifts, because altercations can result in potentially significant exposure. Knowledge of the risks of various body fluid exposures and appropriate preventive, prophylactic, and treatment measures will minimize the risk of bloodborne disease transmission.¹³

Sexually Transmitted Diseases

All correctional facilities need to offer STD screening and treatment services, as well as educational programs on prevention and risk reduction information. Jails and prisons must institute screening and treatment protocols for all newly admitted inmates to reduce the risk of transmission to other inmates. Jail screening programs are particularly important because they provide an opportunity to identify individuals at high risk of STD who might otherwise not receive care. Approximately 78% of newly incarcerated females had abnormal Pap smears, and more than 50% had vaginal infections or STDs. Rapid urine screening tests are available for gonorrhea and chlamydia. STD screening and treatment should also include syphilis, herpes, and genital warts.

Because it is known that an estimated 2% to 30% of inmates have sex while incarcerated, condom distribution would limit STD transmission; however, sexual intercourse is forbidden in this setting. Condoms are available in only five city and county systems and two state systems, and no condoms are available in any adolescent facility.¹³

Enteric Disease

Hepatitis A virus is transmitted mainly via the fecal-oral route. Twelve percent to 25% of cases report exposure to a patient with HAV via household or other close personal contact or through sexual contact; 45% to 50% report no known source of exposure. No reported outbreak of HAV is reported to have occurred in the correctional setting. Prevalence of HAV is 22% to 39%, similar to that of the general U.S. population. No increased risk of HAV is associated with working in the correctional setting. Currently, six of 17 states that routinely immunize children and adolescents for HAV have vaccination programs in their juvenile detention facilities. A limited number of adult facilities offer HAV vaccine only to those with HCV or to other adults also at risk, including men who have sex with men and injection drug users.¹³

Inmate workers with oversight by correctional or contract staff usually prepare meals for staff and inmates. Medical clearance and education of inmate food handlers may be the responsibility of medical staff. A foodborne outbreak can be recognized by increased complaints of nausea, vomiting, and/or diarrhea in a group a short period of time after eating. Prompt evaluation of stool and suspected foods is essential. Local or state health departments can provide guidance in conducting foodborne outbreak investigations.⁸

Education

Prisons and jails are unique cultural institutions that group together individuals largely from marginalized populations. Providing culturally competent educational programs that are sensitive and appropriate to patients of diverse ethnic and religious backgrounds is challenging. Barriers are many, and in addition to the correctional environment itself, include illiteracy and mental illness, distrust of all correctional service providers, and just as importantly, one’s own personal biases and moral and ethical beliefs.

Discharge Planning

An estimated 95% of all current inmates will be released to their community. Approximately 12% of inmates were homeless before arrest, but 30% to 50% are homeless after release. Discharge planning should include case management and collaboration with public health and community healthcare providers. Problems after release include the shame and stigma of being a felon, which can limit housing and employment opportunities. Case management includes housing, social supports, substance abuse, and mental health and medical services as needed.¹

JB’s TST result was 12 mm. His chest radiograph was negative and he was asymptomatic. Prior to the initiation of isoniazid, a liver function test was obtained and found to be elevated. He was tested for hepatitis B and C and was found to be HCV positive. He was offered the hepatitis A and B vaccines, and upon discharge two months after, was referred to the local community health center for follow-up care, which included directly observed therapy for his LTBI, and further evaluation of his hepatitis C.