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No. 2, 2006

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS 

An Outbreak Response in a Rural, Southwest Missouri County Jail

Introduction: The Missouri TB control program has a long-standing history of collaborating with the University of Missouri’s Sinclair School of Nursing. One benefit of this collaboration is the opportunity for TB staff to serve as preceptors to senior-level nursing students pursuing a bachelor of science degree in nursing (BSN), thus promoting public health in our next generation of nurses. During this past fall-winter semester, we had the good fortune to work with Ms. Caitlin Tremblay, RN, BSN. She joined us when our limited resources were spread particularly thin owing to an outbreak response. This particular response involved a rural jail in southwest Missouri epidemiologically linked to a previous outbreak in a Kansas prison. The following is Caitlin’s summary of the outbreak response and the activities to which she was able to contribute. Since her graduation, Caitlin has joined us at the Missouri Department of Health and Senior Services (MDHSS) as a Project Specialist and continues to assist the TB program. If your state or local TB program has not already entered into a partnership with area BSN or other academic programs, I hope that after reading this you will be encouraged to do so!

—Lynelle Phillips, RN, MPH
CDC Public Health Advisor
Missouri Department of Health and Senior Services

Background

Jasper County, population 108,000, is located in southern Missouri. This county’s poverty rate is approximately 14.5%, compared to the statewide rate of 11.7%. The annual per capita income is approximately $3000 less than in the rest of the state. Missouri leads the country in methamphetamine lab incidents; in 2004, Jasper County was the second highest county in methamphetamine lab seizures and dumpsites. The county’s largest city is Joplin and its county seat is Carthage. Jasper County formerly depended upon the lead and granite mining industry that began in the 1850s. As a result of this booming mining industry, at the turn of the 20^th century, Carthage had the most millionaires per capita in the country. Remnants of this wealth can still be seen on some streets in the town, with large, ornate houses, a stark contradiction to nearby impoverished neighborhoods.

Many of the poorest areas of Carthage are inhabited by immigrants, mostly from Latin American countries, with an unknown percentage having legal status issues. They live in this area for the work, and provide labor to the food processing plants located within the county. Multiple people often live in run-down, substandard housing units.

Jasper County Jail

Jasper County Jail is located in the center of Carthage, next to the downtown square. It has a circular design consisting of six pods, with cells within the pods where the inmates sleep at night. Its capacity is 167 inmates, although the census was typically 230 inmates during the course of this investigation. Some cells containing four bunks were holding up to eight inmates at a time (cots are added for the additional cell mates). At night, the inmates are locked in their cells, but they are released to common areas each day, where they remain for about 10 hours. The residents of each pod go to the gym area as a group, separate from the other groups, for 1 hour daily. Pod A holds sex offenders and rapists, B holds females, C and D hold petty crime offenders (many drug-related crimes), E holds county offenders, and F holds maximum-security offenders. Among these inmates, those in pod E have the longest average stay in the jail, approximately 108 days, according to jail staff.

One full-time licensed practical nurse serves the entire inmate population. A generalized medical questionnaire is given to all new inmates to fill out. No testing or other medical check is done on inmates unless a medical problem is identified on the questionnaire or the inmate is clearly sick.

According to maintenance staff, two air-filtration systems filter the air within the jail; the first system handles pods A, B, and C, and the other system filters pods D, E, F, and the gym. On the day of the site tour, the jail appeared to have poor lighting, and the air seemed dank, stale, and heavy.

Timeline

Mid-July 2005: An undocumented immigrant from Guatemala, aged 45, who was incarcerated on drug charges and housed in pod C of Jasper County Jail from May 6 to July 16, 2005, was transferred to Western Reception of the Diagnostic and Correctional Center in St. Joseph, Missouri. During his intake exam, he was diagnosed with early pulmonary tuberculosis (TB) disease, subsequently confirmed by tuberculin skin test (TST), chest radiograph (CXR), sputum smear, and culture. He is referred to as Case A.

Early August 2005: A contact investigation was initiated and initial TSTs were placed on all inmates in Jasper County Jail who had been present during Case A’s incarceration.

Mid-August 2005: CXRs were taken of all inmates with positive TSTs found at the time of initial testing. A person with highly infectious pulmonary TB disease (Case B) was discovered in pod E of Jasper County Jail. Case B is a 40-year-old African-American male with a history of untreated diabetes. Upon diagnosis with TB, he was immediately transferred to a local hospital and later to the Missouri Department of Corrections. The contact list was then expanded to include all inmates present for the entirety of Case A’s and Case B’s incarcerations. 

Mid-October 2005: Spoligotype results were returned and revealed that Case A and Case B were not infected with the same strain of TB.

Mid-October 2005: A 66-year-old homeless man (Case C), a cellmate of Case B for 10 days in May, was discovered at a halfway house with symptoms consistent with pulmonary TB. Although his TST result was negative, the public health nurse obtained a sputum specimen owing to his symptoms. He was diagnosed later in the month as having culture-confirmed M. tuberculosis. Case C was not believed to have been infectious at the time of diagnosis, but to ensure compliance with treatment, was immediately admitted to the Missouri Rehabilitation Center inpatient TB ward for treatment.

Early November 2005: Case C’s spoligotype and MIRU were returned and matched Case B’s, results consistent with transmission involving Case B and Case C. The findings that Case B was highly infectious, based on a positive sputum spear and cavitary lung disease, and that Case C was not highly infectious, based on a negative sputum smear for acid-fast bacilli and a negative chest x-ray, suggests that Case B was the source of Case C’s tuberculosis.

Prioritizing, Locating, and Testing Contacts

Lists were developed of all inmates present in the jail from late March to mid August 2005, corresponding to the incarceration of Case A and Case B. Case C was not believed to have been infectious at the time of his incarceration, so his contacts were not included. Priorities were then assigned to all contacts to the cases, using 2x2 tables and statistical analysis. Initially, analysis showed increased risk for cellmates of each case and for pod mates of Case B. With a contact database of 455 people, it was necessary to prioritize close contacts and keep the number of high-priority contacts to a manageable number. First priority was assigned to any cellmate of Case A or Case B, or a pod mate of Case B in July and August, when he was believed to be most infectious (n=92). Second priority was assigned to pod mates of Case B in April, May, or June (n=49), and third priority to any pod mate of Case A, all other jail inmates identified as contacts, and all employees (314). Missouri’s TB Program attempted contact with all first- and second-priority discharged inmates multiple times. The logbooks for the jails included some locating data, which were used for contact purposes. Inmates were considered evaluated when they either had a negative TST 8–10 weeks postexposure or if TST positive, had completed a CXR and medical exam. Ten-dollar gift cards were offered as an incentive to inmates who completed evaluation. This generated interest and increased contact response and completion of the testing. Despite the increased results with incentive use, the evaluation rate for priority one and two contacts was 50%. The TST positivity rate was 47% for first-priority contacts and 17% for second-priority contacts. Owing to high recidivism rates, it became obvious that the most effective approach for finding contacts was to wait for them to reenter the jail system. We changed our strategy to checking county jail logbooks several times a week in Jasper County and surrounding areas. This approach was less time intensive and has yielded more contacts than other methods employed, and is consistent with findings in other jail outbreak settings.

Review of Genotyping Data

National genotype testing began in 2004 and has greatly advanced investigations of TB outbreaks through DNA analysis of a TB strain, which aids in linking cases that did not have any association on previous investigation. In this case we were able to rule out transmission between Case A and Case B or C because Case A’s isolate had a different genotype from the other two. When we compared those genotypes with the state records to find matches, we were surprised to find other genotype matches to B’s and C’s strain across the state and in Kansas. Spoligotype and MIRU numbers match exactly to the cases found in Jasper County Jail.

(Kansas) Match #1: The index case in a jail outbreak 2 years ago in Kansas, described in the CDC publication “Tuberculosis transmission in multiple correctional facilities---Kansas, 2002–2003,” (MMWR August 20, 2004; 53[32]:734-738).

(Kansas) Match #2: Cell mate and secondary case to Match #1, incarcerated in Jasper County Jail for 3 days with Case B in 2002. He was diagnosed with pulmonary TB disease a few months later, but is not believed to have been infectious at the time of exposure to Case B.

(Missouri) Match #3: Pulmonary TB disease diagnosed in Jackson County, Missouri (Kansas City). This client has extensive prison histories in Kansas and is HIV positive.

(Missouri) Match #4: A stroke patient in a hospital in St. Louis, Missouri. He was unable to communicate at the time of his TB diagnosis, thus little personal information is known, except for medical records showing alcohol and drug abuse. There is no history of incarceration in Jackson County Jail, Jasper County Jail, Missouri Department of Corrections, or Kansas Department of Corrections.

Other states also have records of cases matching the spoligotype and MIRU numbers of Missouri cases. Maryland had multiple matches. However, all case patients in that state were of Hispanic origin, with unknown corrections history and no known epidemiological links to Missouri. Arkansas had three patients with matches, one who is an Arkansas corrections inmate whose father lives in St. Louis. Another patient in Arkansas is believed to be a secondary case to the first Arkansas case, and was infected outside the corrections environment. The third matching case patient is an Arkansas resident who often travels to casinos in northern Oklahoma, close to the Southwest Missouri border. Kentucky had no matches. Texas had one spoligotype and MIRU match in a woman from Puerto Rico with no corrections history.

Several factors distinguish this outbreak from outbreaks in urban jails described in the literature. In this rural Missouri jail, there is no policy for performing routine TSTs on inmates or employees. With only one full-time nurse, the jail would be unable to keep up with the daily influx and release of inmates. No computerized tracking system of inmates was available, requiring manual checking for recidivists. This manual system of recording inmate information also made it difficult to find contacts because of incorrect entries or illegible handwriting. Some contacts were difficult to find for testing because of questionable immigration status. Finally, no negative pressure isolation rooms are available in the jail for suspected TB patients. In this instance, Case A was transferred immediately to the Missouri Department of Corrections (MO-DOC), and Case B was transferred to a hospital, then later to MO-DOC. If these patients had not been legally eligible for transfer to MO-DOC, there would have been no available isolation resources.

Currently there is no state rule requiring county jails to test employees or inmates for TB. Some county jails across the state conduct testing, regardless; others do not. At the time of the outbreak in Jasper County, no testing had been done on either employees or inmates despite recommendations from the MDHSS and CDC guidelines regarding testing. The easy answer in this situation is to change state rules and require all county jails to conduct inmate and employee testing regularly. Considering how crowded the jails are and how few resources they have makes implementing a rule such as this impractical. Unfortunately, given the high-risk populations that mix in this facility, Jasper County Jail remains a prime place for another TB outbreak.

Thankfully, Jasper County Jail personnel are willing and ready to make the changes necessary to prevent another outbreak. They are in the process of implementing tuberculin skin testing every 6 months on all employees, above the yearly testing that MDHSS is recommending. They have agreed to hire another nurse to assist the one full-time LPN. They will strive to skin test inmates who have been incarcerated for 14–30 days, but with 5000 inmates passing through their doors each month, the practicality of this is questionable. The jail staff members have also requested a visit from an industrial hygienist or NIOSH representative to determine if further environmental changes can be implemented. Three questions specifically relating to TB have been added to the medical questionnaire given to new inmates. Those inmates who report TB symptoms on the questionnaire will be interviewed by the jail nurse, who will conduct a more intensive review and take further actions as needed. Additional recommendations include a computerized system of the medical records and the jail census. Unfortunately, because Missouri is a low-incidence state, with only 108 cases statewide in 2005 (including the cases above), many county jails do not feel aggressive TB prevention is necessary. According to the Jasper County Sheriff’s Officer, Captain Gilbert, "You never think something like a TB outbreak will happen in your jail, but it can, and it is our job to prevent it from happening again.” As TB becomes less visible, it will become more of a challenge to promote TB control in county jails. It is necessary to work with county jails on their terms and adapt to the challenges they face.

Acknowledgments

MU Sinclair School of Nursing: Louise Miller, Community Health Class Coordinator.

Missouri Department of Health and Senior Services: Harvey Marx, TB Program Manager; Diana Fortune, State TB Nurse, Joplin Health Department; Ryan Talken, Epidemiology Specialist; Maggie Holt, TB Nurse.

Jasper Health Department: Nan Westhoff, TB Nurse.

Jasper County Jail Staff: Melissa Fisher, Jail Nurse; Capt. Gilbert, Sheriffs Officer.

Maryland, Arkansas, Oklahoma, Kentucky, Kansas, Florida and Texas State TB Control Programs

CDC: Dr. Thomas Weiser, MD, MPH; Bao-Ping Zhu, MD, MS.

—Submitted by Caitlin Tremblay, RN, BSN
Project Specialist,
Missouri Department of Health and Senior Services
2005 Graduate, MU Sinclair School of Nursing

Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

 
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