Tuberculosis prevention and control in large jails: a challenge to tuberculosis elimination

BACKGROUND: This study assessed the extent to which 20 large jail systems have implemented national recommendations for tuberculosis (TB) prevention and control in correctional facilities. METHODS: Data were collected through questionnaires to jail medical directors and TB control directors, observation at the jails, and abstraction of medical records of inmates with TB disease and latent TB infection. RESULTS: Twenty percent of jail systems (4/20) had conducted an assessment of risk for TB transmission in their facilities, and 55% (11/20) monitored tuberculin skin test conversions of inmates and staff. Sixty-five percent (13/20) of jails had an aggregate record-keeping system for tracking TB status and treatment, which was usually paper based. Forty-five percent of jails (9/20) had policies to offer HIV counseling and testing to tuberculin skin test-positive patients, and 75% (15/20) screen HIV-infected inmates with chest radiographs. Three quarters of jails (15/20) had policies to always isolate patients with suspected or confirmed pulmonary TB in an airborne infection isolation room. Half of jails with airborne infection isolation rooms (6/12) conformed to Centers for Disease Control and Prevention (CDC) guidelines for monitoring negative pressure. CONCLUSIONS: Improvements are needed in conducting TB risk assessments and evaluations to determine priorities and reduce risk of transmission. Inadequate medical information systems are impeding TB control and evaluation efforts. Although HIV infection is the greatest cofactor for development of TB disease, jails have inadequate information on patients' HIV status to make informed decisions in screening and management of TB and latent TB infection. Jails need to improve the use of environmental controls.     

Houston authorizes presentation of HIV videos in city jails

The Houston City Council voted to begin showing HIV prevention videos in city jails. The city's Health and Human Services Department determined that inmates need the information but the plan was challenged by critics within the City Council and some citizens of the Houston area. A study found six percent of inmates in the county jail tested positive for HIV, compared to less than one percent of the population as a whole.     

Partner counseling and referral services to identify persons with undiagnosed HIV--North Carolina, 2001

Approximately one fourth of the 850,000-950,000 persons living with human immunodeficiency virus (HIV) in the United States are not aware of their infection and their risk for transmitting HIV. Identifying HIV-infected persons promptly after infection and directing them to medical care and prevention services is a national priority. Voluntary partner counseling and referral services (PCRS) help HIV-infected persons notify sex and needle-sharing partners of their need for HIV testing, enabling partners to receive early care and prevention counseling. To evaluate the success of these services in North Carolina, CDC analyzed PCRS data collected in 2001 by the North Carolina Department of Health and Human Services (NCDHHS). This report summarizes the results of that analysis, which determined that 125 (20.5%) of 610 tested partners of HIV index patients had HIV infections that were undiagnosed previously. These findings suggest that local and state health departments should consider PCRS an essential component of any comprehensive HIV-prevention program.     

Characterizing medical providers for jail inmates in New York State

Objectives. People who are incarcerated exhibit high rates of disease, but data evaluating the delivery of medical services to inmates are sparse, particularly for jail settings. We sought to characterize the primary medical care providers for county jail inmates in New York State.Methods. From 2007 through 2009, we collected data on types of medical care providers for jail inmates in all New York State counties. We obtained data from state monitoring programs and e-mail questionnaires sent to county departments of health.Results. In counties outside New York City (n = 57), jail medical care was delivered by local providers in 40 counties (70%), correctional medical corporations in 8 counties (14%), and public providers in 9 counties (16%). In New York City, 90% of inmates received medical care from a correctional medical corporation. Larger, urban jails, with a greater proportion of Black and Hispanic inmates, tended to use public hospitals or correctional medical corporations as health care vendors.Conclusions. Jail medical services in New York State were heterogeneous and decentralized, provided mostly by local physician practices and correctional medical corporations. There was limited state oversight and coordination of county jail medical care.In 1976, the US Supreme Court issued a landmark decision, Estelle v Gamble, granting prisoners a constitutional right to standard-of-care medical services.¹ In fact, prisoners are the only civilian subgroup in the United States with a constitutionally guaranteed right to health care. Delivering medical care to inmates and ensuring continuity of care after release are logistically complex and costly endeavors. A recent nationwide survey found high rates of medical and psychiatric conditions among US prisoners, with nearly 70% of inmates reporting at least 1 chronic illness.²The challenges of providing standard-of-care medical services to prisoners are manifold. In most states, the correctional system is 2-tiered, composed of prisons and jails. Prisons hold sentenced inmates for periods of a year or longer; jails confine pretrial detainees and inmates sentenced to periods of less than 1 year. Jails pose particular challenges to health care delivery because of the large volume and rapid turnover of inmates. These challenges include discontinuity of care,³ lack of timely access to medical records, lack of trust between patient and provider,⁴ withdrawal from addictive substances,⁵ poor discharge planning,⁶ and loss of medical insurance.⁷ Unfortunately, data evaluating the delivery of medical services to inmates are sparse, particularly in jail settings. In the neglected field of prison health research, jails constitute a doubly marginalized domain for evaluation and advocacy.Since the 1970s, US incarceration rates have increased dramatically, with 2.3 million people incarcerated in jails and prisons at the end of 2008.⁸ An estimated 9 million individual inmates are admitted to and released from jail annually.⁹ This volume represents an enormous population of medically and psychiatrically vulnerable individuals circulating through the nation''s jails.The delivery of health services within the correctional system ultimately depends on the availability of trained medical care providers. In general, correctional facilities do not constitute a broadly attractive practice setting for most physicians. Prisoners'' health needs are not routinely addressed in medical or nursing school curricula.¹⁰ After a careful review of publicly available information, we were unable to find any comprehensive information describing the sector (public vs private providers) or training level of medical care providers for any US state. Nor were we able to identify any comprehensive surveys of health care providers for county jail inmates in the medical, social science, or popular literature. The popular press has addressed the issue of correctional medical care through a focus on privatization of these services.^11,12 However, analyses characterizing medical service providers for inmates have not been published.We conducted a statewide survey of medical care providers for county jail inmates, using New York State (NYS) as our study setting. The aim of our study was to determine who provided primary medical care to county jail inmates in NYS. To our knowledge, this is the first statewide study attempting to characterize providers of medical care to county jail inmates.     

Differences in Sexual Identity,Risk Practices,and Sex Partners between Bisexual Men and Other Men among a Low-Income Drug-Using Sample

Hepatitis B vaccination and targeted testing for hepatitis C virus (HCV) are recommended for jails with medical services available. This study estimates hepatitis B virus (HBV) and HCV infection prevalence among jail inmates, since most previous studies have been conducted among prison inmates. Prison and jail populations differ: jails hold a wide spectrum of persons for an average of 10–20 days, including persons awaiting arraignment, trial, conviction, or sentencing, while prisons typically hold convicted criminals for at least 1 year. A stratified random sample of sera obtained during routine syphilis testing of inmates entering jails in Chicago (March–April 2000), Detroit (March–August 1999), and San Francisco (June 1999–December 2000) was tested for serologic markers of HBV and HCV infection. All sera had been previously tested for antibody to HIV (anti-HIV). A total of 1,292 serum samples (12% of new inmates) was tested. Antibody to HCV (anti-HCV) prevalence was 13%. Antibody to hepatitis B core antigen (anti-HBc) prevalence was 19%, and hepatitis B surface antigen (HBsAg) prevalence was 0.9%; 12% had serologic evidence of hepatitis B vaccination. Hispanics had high rates of chronic HBV infection (3.6% HBsAg positive) along with Asians (4.7% HBsAg positive). Among HIV-infected persons, 38% were anti-HCV positive and 8.2% were HBsAg positive. Anti-HBc positivity was associated with anti-HCV positivity (aOR = 4.58), anti-HIV positivity (aOR = 2.94), syphilis infection (aOR = 2.10), and previous incarceration (aOR = 1.78). Anti-HCV-positivity was associated with anti-HBc positivity (aOR = 4.44), anti-HIV-positivity (aOR = 2.51), and previous incarceration (aOR = 2.90). Jail entrants had high levels of HCV and HBV infection and HIV co-infection; HBV prevalence was comparable to previous prison studies, and HCV prevalence was lower than prison studies. Hispanics had an unexpectedly high rate of chronic hepatitis B infection and had the lowest rate of hepatitis B vaccination. The finding that hepatitis B vaccination coverage among jail entrants is lower than the general population, despite this population’s increased risk for infection, highlights the need to support vaccination in jail settings.     

Nearly one-third of prison inmates aren't gettng proper care

A study by Stadtlanders Pharmacy and the University of Pittsburgh shows that 36 percent of HIV-positive inmates do not receive adequate care based on government standards. These inmates, in both prisons and jails, are on regimens either "generally not recommended" or "not recommended" by Department of Health and Human Services guidelines. Of the 36 percent, 28 percent were placed on regimens that have some clinical benefit, but usually not enough to sustain initial viral suppression. The study was limited by the rapid turnover in high-volume jails and the fact that Stadtlanders can only track what medications are supplied to the facilities, not medications that are actually taken. Stadtlanders is the nation's largest supplier of medications to private firms furnishing health care services in correctional facilities.     

Deaths in New York City Jails, 2001–2009

Approximately 90 000 inmates are admitted annually to the New York City jail system, many of whom require a high level of medical or mental health services. According to our analysis of deaths in custody from 2001 to 2009, crude death rates have dropped significantly despite the increasing age of the population. Falling HIV-related mortality appears to contribute to this change. Other observations include low rates of suicide across all 9 years and increasing age of the population in recent years.Although relatively little has been published concerning deaths of inmates in jail, available information from the Department of Justice indicates declining numbers of deaths in jails starting in 2008, with comparable declines in deaths specifically related to HIV.1 These data also show that suicide and cardiovascular disease are leading causes of death. Medical care in the New York City jail system is provided by the Correctional Health Services (CHS) bureau of the New York City Department of Health and Mental Hygiene, whereas all custody and security is provided by the New York City Department of Correction (DOC). Extensive health care screening occurs during the jail admission process, and necessary care is afforded to all patients.2The prevalence of medical and mental health problems in jails is high.3 Although the CHS performs rigorous reviews of every death, we undertook an analysis of deaths in the aggregate as part of quality improvement efforts. We present data on the deaths of CHS patients who died while incarcerated from 2001 to 2009.     

Telemedicine services to a county jail

Local and county jails rarely offer telepsychiatry services to their inmates. We have established a telepsychiatry pilot project between the Kansas University Medical Center and the Lyon County Jail in Emporia, Kansas. A total of 264 telepsychiatry consultations were conducted with jail inmates. Of these, 70 were initial evaluations and 194 were follow-up visits; only one inmate refused to be seen. Approximately one-third of all inmates were seen for psychiatric consultation within one week of their incarceration and 68% were seen within one month of incarceration. Among lessons learned during the first year of service were: the monthly demand for consultations was five times greater than projected; moderately to severely ill inmates with a broad range of psychiatric illness can be seen and treated effectively using videoconferencing; and the technology was accepted by the jail personnel and the inmates alike and integrated into the jail's routine in terms of the delivery of psychiatric care.     

Mentally disordered women in jail: who receives services?

OBJECTIVES: Many jail inmates have severe psychiatric disorders (e.g., schizophrenia, major affective disorders). The courts have mandated that detainees have a constitutional right to treatment. We investigated what proportion of female jail detainees needed mental health services, what proportion received services, and what variables predicted who received services. METHODS: Trained interviewers administered a psychiatric evaluation (the NIMH Diagnostic Interview Schedule) to 1272 randomly selected female jail detainees during jail intake in a large Midwestern city. Project staff then documented whether women subsequently received services, using records and case files. RESULTS: Of the women who needed services, 23.5% received them while they were in jail. Type of disorder, treatment history, and socio-demographic variables all affected the odds of a mentally ill woman's receiving services. CONCLUSIONS: Correctional health care is a growing national public health problem. The magnitude of mental health service needs far exceeds current resources.     

Recidivism in HIV-Infected Incarcerated Adults: Influence of the Lack of a High School Education

Recidivism is a pervasive problem facing the incarcerated. Incarcerated persons who are human immunodeficiency virus (HIV)-infected often have multiple risk factors associated with initial incarceration and recidivism, in particular, injection drug use. Yet, some jails provide case management for HIV-infected inmates to provide continuity of health care, which might have positive effects on reentry into the community. We sought to measure recidivism and factors related to recidivism in an HIV-infected cohort in an urban county jail with an active case management program. Fifty-two inmates surveyed in 1999 at the San Francisco County Jail were followed for rearrests through 2006. In follow-up, 73% were re-incarcerated on an average of 6.8 times for 552 days. Risk factors included nonwhite ethnicity, history of homelessness and crack use, common risk factors for incarceration. Less than high school education was associated with recidivism, shorter time to reincarceration, and more incarcerations. HIV-infected inmates spend a high proportion of time in multiple incarcerations, a reflection of the cyclical nature of incarceration despite comprehensive case management. Well-known risk factors for incarceration were associated with recidivism; in addition, lack of high school education played a prominent role. Education should be explored as a way to make further progress on breaking the cycle of incarceration.     

HIV screening of male inmates during prison intake medical evaluation--Washington, 2006-2010

Since 2006, CDC has recommended routine, opt-out human immunodeficiency virus (HIV) screening for patients in health-care settings with a prevalence of undiagnosed HIV infection of ≥0.1%. Before September 2007, the Washington State Department of Corrections (WADOC) only provided HIV testing to inmates on request. In September 2007, WADOC began routine HIV opt-in screening in which inmates were notified that HIV screening would be performed during the prison intake medical evaluation if they consented. In March 2010, WADOC switched to a routine opt-out HIV screening model in which inmates are notified that HIV screening will be performed unless they decline. To assess the proportion of inmates screened and the number of infections diagnosed during the use of the three HIV testing policies, WADOC reviewed HIV testing data for male inmates undergoing intake medical evaluation during January 2006--December 2010. From January 1, 2006, to August 31, 2007, 5% of 12,202 incoming inmates were tested for HIV at their request during the intake medical evaluation, and three (0.50%) of those tested had newly diagnosed HIV infection. From September 1, 2007, to March 15, 2010, 72% of 16,908 inmates agreed to opt-in HIV screening, and 13 (0.11%) tested positive for HIV. From March 16, 2010, to December 31, 2010, 90% of 5,168 inmates agreed to opt-out HIV screening, and six (0.13%) tested positive for HIV. Compared with routine opt-in HIV screening, opt-out HIV screening was associated with a greater proportion of inmates tested, without decreasing the rate of case detection.     

Sexually Transmitted Infections Among Incarcerated Women: Findings From a Decade of Screening in a Los Angeles County Jail, 2002–2012

Objectives. We describe and report findings from a screening program to identify sexually transmitted infections (STIs) and HIV among female inmates in Los Angeles County Jail.Methods. Chlamydia and gonorrhea screening was offered to entering female inmates. Women were eligible if they were (1) aged 30 years or younger, or (2) pregnant or possibly pregnant, or (3) booked on prostitution or sex-related charges. Voluntary syphilis and HIV testing was offered to all women between 2006 and 2009. This analysis reports on data collected from 2002 through 2012.Results. A total of 76 207 women participated in the program. Chlamydia prevalence was 11.4% and gonorrhea was 3.1%. Early syphilis was identified in 1.4% (141 of 9733) and the overall prevalence of HIV was 1.1% (83 of 7448). Treatment levels for early syphilis and HIV were high (99% and 100%, respectively), but only 56% of chlamydia and 58% of gonorrhea cases were treated.Conclusions. Screening incarcerated women in Los Angeles County revealed a high prevalence of STIs and HIV. These inmates represent a unique opportunity for the identification of STIs and HIV, although strategies to improve chlamydia and gonorrhea treatment rates are needed.The ability of correctional facilities to provide access to medically underserved and otherwise marginalized populations makes them an ideal location for health screening and prevention measures, representing an important public health opportunity.1–3 Populations passing through correctional facilities represent a group that is at increased risk for sexually transmitted infections (STIs), including HIV, as the prevalence of risk factors such as substance use, transactional sex, previous history of an STI, and inconsistent condom use with multiple partners is high.3–6 Furthermore, in some instances correctional facilities have noted higher prevalence of STIs and HIV than other institutions (e.g., sexual health clinics) serving high-risk clients. Studies of STI prevalence conducted in jails have revealed relatively high prevalence of chlamydia among inmates ranging from 7% to 22%, with gonorrhea prevalence ranging from less than 1% to 9%.7–10 Likewise, the prevalence of HIV among jail inmates is relatively high with an estimated 1.2% to 1.8% infected, compared with 0.3% in the US general population.11,12 In fact, modeling data suggests that approximately 14% of persons living with HIV pass through a correctional facility in their lifetime, with the proportion being as high as 20% among African Americans and Hispanics.13Beyond reducing the disease burden in correctional facilities, the potential community-level benefits from programs aimed at STI and HIV prevention, screening, and treatment are substantial.8,11,12,14–16 An examination of community-level chlamydia prevalence following the establishment of a jail screening program in San Francisco, California, revealed a significant decline in chlamydia positivity among young women testing at community clinics serving a population with high incarceration rates.8 Specifically, the authors noted that chlamydia positivity among female attendees at a clinic located in a neighborhood in which the prevalence of jail testing was high declined from 16% in 1997 to 8% in 2004, while no changes occurred in a clinic located in a neighborhood with low jail testing (5% in 1997 and 5% in 2004).8 The potential community-level impact of STI screening services has been noted in other jail settings.14,15 In New York City, implementation of universal screening for men aged 35 years and younger entering jail resulted in a 59% increase in citywide reported male chlamydia case rate and the adult jails identified and reported 40% more cases than all 10 New York City public STI clinics.15 The population-level impact of jail screening is also supported by modeling data, which suggest that the community prevalence of chlamydia can be reduced by up to 54% by using jail-based chlamydia screen-and-treat programs.16Despite the fact that correctional facilities serve populations that are at increased risk for STIs, screening services in jails are limited.17,18 Potential reasons for this are manifold, and include the competing agendas of security and control versus health and welfare, as well as other logistical concerns including staffing, space, and rapid turnover of inmates in jail settings.1,17 However, jail-based STI and HIV interventions could potentially have a significant public health impact. Jails, which are most often run by sheriff departments or local governments, are designed to hold individuals awaiting trial or serving short sentences. As such, a much larger number of people cycle through jails than through prisons with more than 12 million admissions in the United States in 2012 compared with nearly 700 000 for prisons.19,20 Recognizing an important public health opportunity, the Los Angeles County Sheriff’s Department (LASD) in California developed a partnership with the Los Angeles County Department of Public Health (DPH) to offer STI screening for female inmates in the Los Angeles County Jail—the largest jail system in the United States.21 The objective of this report is to describe our experience and report findings from this screening program among women incarcerated in the Los Angeles County Jail from 2002 to 2012.     

HIV Issues for Rural Hospitals in U.S. Frontier Areas

A Survey of 108 hospital administrators in the eight states of the Mountain Census Region was conducted to identify frontier rural hospitals' experiences (fewer than 50 beds) in the provision of care and services to patients with HIV infection; to assess the availability of HIV care and services in these small, remote rural hospitals; and to assess the status of education and policy development related to HIV infection. Of the 62 hospitals that responded, 16 (26%) had provided care and services to HIV-infected patients. Acute inpatient and emergency room care were the services most commonly utilized. An additional 11 hospitals reported the presence of HIV-positive individuals in their medical service areas. Thus, nearly 44 percent of the hospitals were aware of the importance of addressing HIV infection as a local concern. Employees in the hospitals that had experienced caring for HIV-positive persons expressed more concern about acquiring HIV infection than those in hospitals that had not. Four nursing assistants, two registered nurses, and one dietary worker had refused to provide care. HIV education consisted primarily of video programs, presentations by in-house staff, and sending employees away to workshops. Despite this HIV education, most staff remain fearful of caring for HIV infected patients. Major concerns expressed by the hospital administrators were related to enforcing universal precautions, confidentiality, staff response, community acceptance, and cost of care. Only 30 hospitals (48%) had AIDS policies in effect, and these focused primarily on infection control and universal precautions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Highly active antiretroviral therapy use and HIV transmission risk behaviors among individuals who are HIV infected and were recently released from jail

We evaluated highly active anti-retroviral therapy (HAART) use and risk behaviors among 177 inmates who were HIV infected and were released and reincarcerated in San Francisco, Calif, jails over a 12-month period. During the month preceding reincarceration, HIV transmission risk behaviors were common among respondents, and 59% of those with a history of antiretroviral use were not taking HAART. HAART discontinuation was independently associated with homelessness, marijuana use, injection drug use, and not receiving community medical care. Postrelease interventions for inmates who are HIV infected are needed.     

Jail contractor, ex-inmate settle denial-of-care suit

Prison Health Services Inc., a health-care provider for a county jail in Maine, settled a lawsuit alleging that it deprived an HIV-positive inmate of antiretroviral medications in an attempt to save money. David McNally brought the suit after he was confined to the Cumberland County Jail, where his HIV treatment was withheld for 3 days. McNally and his doctor both reported his medical condition and the need for continuing treatment for HIV. The lawsuit alleged that McNally's rights, under the Americans with Disabilities Act, were violated because of a different quality of care given to inmates based on HIV status.     

Health Behind Bars: Utilization and Evaluation of Medical Care among Jail Inmates

Jail and prison inmates experience disproportionately high levels of chronic and acute physical health problems, resulting in increased utilization of health services in correctional institutions. Variations in both health status and health care utilization are likely, although several important factors have been under-researched. Gender, in particular, is presumed to influence health outcomes and use of medical care in correctional facilities. The current study explores the physical health status of a systematic sample of 198 male and female inmates incarcerated in a large county jail located in a medium-sized Southern city. Using multiple regression analysis, predictors of physical health status, utilization of medical care, and inmates' evaluations of the accessibility and quality of health care are identified. The results indicate that gender and age are the most consistent demographic predictors of health status and medical care utilization, with females and older inmates reporting higher morbidity and concomitantly higher numbers of medical encounters. The experience of incarceration also appears to influence the physical health of inmates, as self-reported health problems increase with inmates' duration of incarceration. Evaluations of jail medical care differ significantly by gender, with female inmates reporting more difficulty accessing health services, yet higher satisfaction with the quality of services received. The results suggest a need for medical care in correctional settings to adapt to the medical needs of older inmates and women, in addition to improving treatment for chronic conditions and preventive services.     

Injury Surveillance in New York City Jails

To characterize injuries occurring in jails, we analyzed injury report forms from the New York City jail system. We abstracted data from 4695 injury report forms representing 3863 patients. Of the injuries reported, 66% were classified as intentional. The 2 leading causes of injuries were inmate-on-inmate aggression (40%) and slips and falls (27%). Injuries place a considerable burden on jail health care systems, and there is a need for more studies on this problem and development of injury prevention programs.Although inmate injuries place a considerable burden on both individuals and the jail health care system, there is little published research on the topic.1–4 These injuries also have an impact on the communities to which inmates return and have been found to compound existing barriers to employment, education, housing, and substance abuse treatment, which can affect reintegration into the community and increase the likelihood of recidivism.5–10New York City has one of the largest jail systems in the United States, with more than 90 000 admissions annually and a daily inmate population of approximately 13 000. Inmates are in the custody of the New York City Department of Correction (DOC), and the New York City Department of Health and Mental Hygiene (DOHMH) is responsible for their health care. According to protocols developed by the 2 agencies, all inmates who are injured or suspected of being injured are taken to the jail clinic by the DOC for medical evaluation even if their injuries appear minor or if they intend to refuse treatment. We analyzed New York City jail system injury report data in an effort to gain a better understanding of the extent and nature of injuries occurring in jails.