TB Notes Newsletter

No. 1, 2012

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

Amistad Binational TB Project

On October 6, 2011, Dr. David L. Lakey, Commissioner for the Texas Department of State Health Services, and Dr. Raymundo S. Verduzco-Rozan, Secretary of Health for the State of Coahuila, Mexico, came together with citizens from the states of Texas and Coahuila to sign a joint statement of cooperation.  The signing of this statement was the official beginning of their collaboration in a project that will be called the Amistad Binational Tuberculosis Project.  Dr. Sandra Guerra, Director, Texas Health Service (THS) Region 8, was the host of the signing ceremony that was held in Del Rio, Texas.  The Amistad TB Project will be a collaborative effort between THS Region 8; the Texas cities of Del Rio and Eagle Pass; and the Coahuila city of Piedras Negras in Mexico. Ms. Rita Espinoza will be the Region 8 point of contact for the Amistad Binational TB Project.

Dr. Lakey and Dr. Verduzco-Rozan signing the binational agreement.

In addition to Drs. Lakey, Verduzco-Rozan, and Guerra, several other U.S. and Mexican officials were present. These included Julia S. Goldberg, M.P.H., Acting General Manager, U.S. Section, U.S.-Mexico Border Health Commission; Dr. Francisco Elizalde Herrera, Undersecretary of Health of the State of Coahuila; Dr. Maria Teresa Zorrilla Carcaño, Mexico Section Secretary, U.S.-Mexico Border Health Commission; and Dr. R. J. Dutton, Director, Texas Dept. of State Health Service Office of Border Health.

The agreement between the two states declares their intentions to:

• Respect the standards, procedures, laws, and needs of each state, while striving to reduce the burden of TB along the Texas-Coahuila border;
• Work cooperatively to pursue joint opportunities to effectively address TB prevention and control across our shared border;
• Form a Bi-state Steering Committee on TB to seek opportunities for our respective states to work collaboratively to ensure a reduction in the mortality, morbidity, and transmission of TB across our shared border; and
• Request support of the U.S.-Mexico Border Health Commission in order to ensure the most effective and efficient use of the resources assigned by each participant for the execution of TB prevention and control as described in the agreement.

—Submitted by Charles Wallace, PhD, MPH
Manager, Tuberculosis Services Branch
Texas Department of State Health Services

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TB Experiences in “Sin City”: Collaborating with Corrections Workers in Las Vegas

Introduction
Public Health Advisors (PHAs) encounter many different challenges and experiences in the field.  My own personal experience in moving back west to Las Vegas, also known as “Sin City” and “Lost Wages,” has been filled with many new experiences and new opportunities to learn about TB. Although my role as a PHA for the Southern Nevada Health District (SNHD) consists of various day-to-day activities and duties, my main role since arriving in Las Vegas has been working with and educating private physicians, providing assistance in contact investigations in hotel/casinos, and working as a liaison for the area’s correctional facilities. The latter has definitely been a “new TB experience” and is the focus on this report.

In working with the SNHD’s TB clinic activities, I have come to understand that my greatest opportunity for making a difference here is to serve as a liaison, strengthening the local health department through communication with outside health care providers. Thus, I have been working with correctional health care staff to improve working relationships and to increase collaboration between the agencies. Ideally, increasing this communication will eventually improve case reporting, as well as the exchange of information about case management. In addition, effective communication and improved cooperation with correctional facilities staff will improve TB screening practices in facilities and will ensure continuity of care and completion of treatment. Therefore, my main function in Clark County will be to strengthen communications with these outside providers.

Procedures/Activities
During my first few weeks at SNDH, I researched and reviewed the local state policies and regulations in relation to TB control in correctional facilities. Based on guidelines from CDC (“Prevention and Control of Tuberculosis in Correctional and Detention Facilities,” CDC; MMWR) and supporting documentation in the Nevada Administrative Codes, I drafted a correctional liaison agreement for the SNDH and all of the Nevada correctional facilities. After discussing the agreement with the SNHD nursing managers and supervisor, we concluded that this agreement should be adjusted and tailored to each facility, since the facilities vary by capacity, average length of time inmates spend in facility, number of prior TB cases and population, screening process, etc. Before proceeding with tailoring each facility agreement, I contacted each facility’s medical nursing supervisor to schedule a tour of their facility and conducted a brief assessment of their current TB screening policy and practices. My goal was to better understand each site’s current screening method and discharge process, from the time the detainee is brought in, all the way through their release or transfer.

I started my first full assessment with Clark County Detention Center (CCDC).  Upon my arrival at CCDC, the nursing supervisor greeted me in the lobby and escorted me to the booking area.  This area seemed as busy as an emergency room waiting area in the early morning hours. I was shown their databases for screening assessment and for placement and reading of tuberculin skin tests (TSTs). CCDC tests every inmate coming in. When I asked for documentation of TST readings, they showed me a list of inmates with their locations in the facility and who was scheduled for a reading on that date.  The readings are done by the Medical Assistant.

As we walked through the facility’s hallways, we occasionally crossed line-ups of inmates facing the wall. I was next taken to the medical floor, where the negative-pressure rooms are located. There are also medical offices, a dental services area, and a nurse’s station (similar to a nurse’s station in a hospital). There I was introduced to the rest of the medical staff.  I concluded my visit by suggesting follow-up in-service training and the possibility of my revisiting the facility at a future date.

Two weeks from my initial tour at CCDC, I was back. This time my mission was to “shadow” the nurses and observe their booking and screening procedures, as well as their TST reading techniques. I was in booking from approximately 8:30 am to 12:00 noon.  It was quite a scene: I observed inmates yelling “Officer!” and banging hard on their cell doors; saw officers running and attempting to catch a troubled detainee; and heard officers yelling at the crowd in the booking area that they all had to sit down and raise a hand if they needed the restrooms or the phones.

I shadowed three busy nurses working in booking who were all conducting initial medical assessments and asking questions about medical history data, including questions about behavioral issues such as suicide risk and drugs habits. There were only a few TB-related questions: TST history, chest X-ray history, and symptoms.  In addition to the questionnaire assessment, the nurses took vital signs and placed TSTs.

Once I was finished in booking, I went upstairs with the Medical Assistant, who showed me the inmates’ quarters and dorms.  Armed with a list of inmates by location, the Medical Assistant and I visited the different floors.  Each floor had a different designation; for example, female inmates had their own floor. Also, gang-related inmates were kept separate according to their gang to avoid confrontations. I learned that more guards were needed on these floors, owing to this highly violent population. There was an inmate on this floor whose TST reaction needed to be read, and the Medical Assistant and I entered the cell to read it. As we went into the cell, an additional guard entered behind us. We visited “open” areas where the inmates were called out by the guard from a list of inmates we were seeking for TST readings.  These readings were done mainly during afternoon hours, since many of the inmates were in court during the morning hours. 

Results of Activities
During the time spent in booking, I noticed a few technical issues with mishandling and storage of the tuberculin vials. The nurses in the booking area all had their own tuberculin vials; however, of the three tuberculin vials in use, only one was marked with the date on which it was opened. One of the nurses mentioned that they place approximately 125 to 150 TSTs daily, and one vial lasts about 2 days. I noted that the tuberculin vials were not insulated or protected from the light; they were kept on the nurses’ desks near their computer screens.

A few other techniques were handled differently by all three nurses.  For example, while one nurse was placing TSTs properly, the others were placing them sometimes a bit too deeply and sometimes too shallowly. At one point, I saw tuberculin dripping from a detainee’s arm.

In the booking area, I observed an opportunity for improving the screening process. A detainee who was being transferred in from another facility mentioned that he had recently had a TST placed at the City of Las Vegas Detention Center (thus he was still within the 72-hr. period). It was obvious that his skin test reaction was positive. When the detainee was not interviewed further about his positive reaction, I asked the detainee more information on when and where he received his skin test, and about possible exposure, e.g., if he knew anyone with TB. I located a ruler with the assistance of another health care worker. We then read his skin test and documented the reading, although according to the nurse in booking, they normally do not do any readings at booking, per their CCDC procedures. Most readings are done by Medical Assistants.

When observing the Medical Assistants reading a TST, I noted that they were wearing gloves. Normally, wearing gloves is standard procedure; however, gloves hinder the touching or palpating of an inmate’s arm, and one’s sensitivity to an induration is reduced. I further noticed that 2 out of 10 TSTs were not read owing to inmates being discharged after their court hearings.  This problem could be reduced by scheduling a morning round of readings before court.

Lessons Learned
I experienced the booking process and the TST reading procedures in a correctional facility setting for the first time in my TB career.  This experience allowed me to better understand the “correctional world,” and also learn about correctional TB screening procedures.  Observing the frequent movement of inmates between various facilities and the court system provided me with the valuable perspective of how challenging it is to work with inmates and with the inmate release process. It is my hope that Clark County Detention Center management can improve the screening policies and procedures and also provide staff training.  At the same time, we at SNHD will work with the corrections system by attempting to follow up on inmates who start TB treatment in the correctional system. 

Future Plans
After my experience at Clark County Detention Center, I followed up with the Nurse Manager at the facility by sending her an e-mail summarizing my observations and recommendations. We scheduled tentative dates for TST in-service refresher training for her booking staff, which is composed of nightshift nurses, dayshift nurses, and Medical Assistants. We scheduled an early morning (6 am) short presentation for the nightshift workers, and another in-service training for the dayshift staff.  I also plan to develop and implement a general TB 101 course or a TB infectiousness course for the corrections officers, to educate them on TB transmission and to teach them how to detect inmates with TB symptoms.

I’m planning to conduct similar activities for the other SNHD correctional facilities. I will continue working on an informal agreement between SNHD and the other facilities, and I will review their current infection control plans and their TST policies.

Although I was on this TB assignment only a short time as of this report, I can say that it has definitely been a fruitful experience packed with new challenges that have put my PHA skills to work.

—Reported by Maria Galvis
CDC PHA assigned to Las Vegas, NV

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