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 20th 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