Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Hello. Welcome to this WebEx titled “Preventing and Controlling
Tuberculosis in Correctional Settings.”
This webinar was produced by the Minnesota Department of Health
Tuberculosis Program.
This is the third module of a series of webinars about preventing and
controlling tuberculosis in correctional settings and pertains to the
treatment of latent tuberculosis infection.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The objectives for this module are listed on this slide. (long pause)
•
Describe the rationale for treating latent tuberculosis infection (LTBI)
in correctional settings,
•
Identify two factors to consider before offering LTBI treatment to
offenders,
•
Discuss two ways to improve adherence to LTBI treatment, and
•
List three signs or symptoms of drug-induced hepatitis.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
This module will discuss:
1. Reasons why TB is a concern in correctional facilities,
2. Making the decision to treat LTBI,
3. The different LTBI treatment regimens,
4. What to monitor and look for in patients on LTBI treatment,
5. How to accurately document LTBI treatment, and
6. Medical release planning when patients are released prior to
completing treatment.
We will finish with a case study designed to highlight key concepts and
resources where additional information can be found.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Throughout these training modules, we will use several acronyms. Here
are several that you should be aware of:
CDC is the U.S. Centers for Disease Control and Prevention, which is
the public health agency of the United States government.
DOC stands for the Department of Corrections.
IGRA stands for interferon gamma release assay, which is a relatively
new test for the presence in the body of the bacteria that causes TB.
LTBI stands for latent TB infection. LTBI is a condition in which TB
bacteria are present in the body but are not actively growing or causing
disease.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
MDH stands for the Minnesota Department of Health, which is the public
health agency for the State of Minnesota. MDH and local PH departments
work closely together and with others to protect the public from TB.
TB is a shortcut for “tuberculosis.”
TST stands for TB skin test, sometimes referred to as the “Mantoux” or
“PPD,” which is an abbreviation for purified protein derivative.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Why do we need to be particularly mindful of the risk for TB in prisons
and jails?
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
It is because TB occurs more often in correctional facilities than in the
general public.
Unfortunately, several outbreaks of TB are reported in the media and
public health publications in the United States every year.
The greatest risk for TB is from offenders (and employees) who have
infectious TB that has not been recognized. Individuals with undiagnosed
(and therefore, untreated) TB who continue to share air space with
others continue to spread their infection to others.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The most critical reason for screening for TB in correctional facilities is to
detect active infectious TB so that the person can be isolated and treated
promptly. Early identification and successful treatment of persons with
TB disease remains the most effective means of preventing disease
transmission.
The second reason to screen for TB is to detect latent TB infection. This
ensures that you have accurate records on the baseline TB status of
everyone in the facility (including employees and offenders). It also
identifies individuals who may benefit by a course of treatment for LTBI.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
LTBI is defined as the presence of M. tuberculosis organisms (tubercle
bacilli) without symptoms or radiographic evidence of TB disease.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
It typically takes several hours of exposure to TB to become infected. Brief
exposure does not usually pose a risk.
If a person is closely exposed to the TB bacteria, there is approximately a
30-40 percent chance that they will become infected with TB (see gold
boxes).
Of those who become infected, 90 percent will remain in the latent phase for
the rest of their lives. Persons with LTBI cannot spread the infection to
others.
However, up to 10 percent will develop active TB disease. Half of the risk of
active TB occurs within the first 1 to 2 years after being infected. The
remaining 50 percent of individuals will develop active TB disease sometime
later in their lives.
Certain medical conditions, most notably HIV infection, increase the
likelihood that the person will develop active TB disease.
Persons with active TB of the lungs or respiratory track should be considered
possibly infectious until treatment has begun.
Both latent and active TB can be treated with special TB medications.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The next step is to understand the different factors to consider when
deciding to treat LTBI.
Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The rationale for treating LTBI is that it reduces the risk of progression
from LTBI to active TB disease while the person is in the facility and after
release to the community.
For example, a 9-month course of Isoniazid (INH) can reduce a person’s
chances of progressing from latent to active TB by up to 90 percent.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The principles of LTBI treatment include as follows:
1.
2.
3.
4.
To provide the safest and most effective therapy in the shortest time,
To assess risks and benefits of treatment for each individual,
To rule out active TB before starting LTBI therapy,
To ensure that the individual takes the medication as prescribed and
complete treatment,
5. To regularly monitor patients during therapy, and
6. To prioritize candidates for treatment
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
There are various factors to consider when initiating LTBI
treatment
The first step is to identify if the individual falls into one of the
groups that have the highest risk of developing active TB disease.
• Is the person HIV-infected?
• Are they a recent contact of a active TB patient?
• Do they have fibrotic changes on chest X-ray consistent with
previous TB disease?
• Have they had an organ transplant and other immunocompromising conditions and receive the equivalent of ≥ 15
mg/day of prednisone for ≥ 1 month?
These are the persons that benefit the most by taking LTBI
treatment.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The second step is to assess whether the person will be able to
tolerate the medication.
• Do they have other medical conditions that may interact with
the TB treatment?
• Do they have risk factors for developing liver toxicity?
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The third step is to consider how likely it is that this person will
complete treatment without repeated interruptions.
Factors such as the length of incarceration and social issues such
as substance abuse, homelessness, and mental health problems
may influence the choice of regimen.
For example, if someone will be incarcerated for a short time or if
they have certain social risk factors, it would be better to select a
regimen that can be completed before they are released from jail
or prison.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The fourth and final step is to consider whether the resources to
support the chosen regimen are available.
These include drug availability, resources for providing Directly
Observed Therapy (DOT), if needed, and to do regular patient
monitoring.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Next, let’s look at the different LTBI treatment regimens
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The three medications that are most often used to treat LTBI are:
1. Isoniazid (INH),
2. Rifampin (RIF), and
3. a combination of Isoniazid and Rifapentine (INH/RPT).
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Isoniazid is the most common LTBI drug.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The preferred regimen for LTBI treatment is once daily isoniazid
(INH) for 9-months.
Once daily INH for 6-months is less effective but may be used if
the person is unable to complete 9 months. This 6-month regimen
is not recommended for HIV-infected persons.
INH may also be given intermittently (twice weekly) via directly
observed therapy (DOT). We’ll discuss DOT later in this
presentation.
INH may be given with or without a small amount of food.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
For the four INH regimens, treatment can be considered complete when
the following criteria are met:
1. For the 9 month daily INH regimen, 270 doses must be taken within
12 months).
2. For the 9 month twice/weekly INH regimen, 76 doses must be taken
by DOT within 12 months.
3. For the 6 month daily INH regimen, 180 doses must be taken within 9
months).
4. And finally, for the 6 month twice/weekly INH regimen, 52 doses must
be taken via DOT within 9 months.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Rifampin is another medication used to treat LTBI.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Once daily rifampin for 4 months is an acceptable alternative when
treatment with INH is not feasible.
Like, INH, rifampin may be given with or without a small amount of
food.
If rifampin cannot be used for example, in HIV-infected persons
taking certain antiretroviral drugs, rifabutin may be substituted.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Rifampin treatment can be considered complete when 120 doses
at taken within 6 months.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
A combination of Isoniazid and Rifapentine is the newest addition to the
options for treating LTBI.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
This regimen is administered in 12 weekly doses via directly
observed therapy (DOT).
A person must complete 12 doses within 16 weeks to be considered
completely treated.
One of the benefits is that it shortens and simplifies treatment,
however, the regimen is not for everyone.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
This 12-week regimen cannot be used for
• Persons <12 years of age,
• Pregnant women,
• HIV positive persons taking antiretroviral therapy, and
• Those infected with INH -or rifampin-resistant TB.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Directly Observed Therapy, or DOT for short, is when a health care
worker (or a trained assistant under their supervision) observes the
patient swallow each dose of TB medication and records each dose.
This is recommended for:
• Persons taking the INH/RPT regimen,
• HIV+ or medically high-risk persons, and
• Persons on intermittent dosing.
And may continue after patient is released.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
DOT is important because it promotes adherence by establishing a
routine of medication administration.
The regular interaction with the patient also provides opportunity for
ongoing education.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The health care provider has the important responsibility of
regularly monitoring persons on LTBI treatment to ensure safe and
efficacious treatment.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Careful monitoring starts with the pre-treatment evaluation. Obtaining a
detailed medical history will help identify persons who need closer
monitoring.
Persons at a greater risk for hepatitis should have baseline liver function
tests before starting LTBI treatment. This includes persons:
• With liver disorders or take other medications that affect the liver,
• Who abuse alcohol,
• Who are infected with HIV, and
• Women who are pregnant or in the immediate post partum period.
If baseline liver function tests are abnormal and LTBI treatment is
started, follow-up testing should be done monthly during therapy.
Persons without risk factors for liver toxicity do not routinely need liver
function testing unless they develop symptoms during treatment.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The second step of monitoring while on LTBI treatment includes a
physical evaluation to:
• Assess for signs and symptoms of adverse effects,
• Assess for signs and symptoms of active TB, and
• Monitor adherence.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The first component of monitoring while on LTBI treatment is to watch
for adverse effects.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Continued treatment may be possible with minor side effects such as
• Itching with or without rash,
• Nausea, loss of appetite, and
• Mild hepatitis or elevation in liver tests.
However, serious side effects may need to be evaluated and require
discontinuation of treatment.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
About 10-20 percent of persons taking INH experience asymptomatic
elevation of liver enzymes.
Unless liver enzymes rise above a certain level or the person develops
signs of liver toxicity, they can continue INH treatment.
Levels usually return to normal after completion of treatment.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Clinical hepatitis is less common than originally thought.
Although more often associated with INH, liver toxicity presenting
as transient asymptomatic increase in alkaline phosphatase and
total bilirubin may occur in 0.6 percent of persons taking rifampin
or rifapentine.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The risk of liver toxicity is uncommon in persons younger than 20 yrs. of
age and higher in persons:
• Between 50-64 years of age,
• Persons with underlying liver disease,
• Persons who consume alcohol heavily, and
• Persons who take other medications that are metabolized in the liver.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Persons taking the medication, the nurse supervising treatment and the
provider should watch for the signs and symptoms of drug-induced
hepatitis. These include:
• Nausea,
• Vomiting,
• Abdominal pain,
• Jaundice, and
• Very dark urine.
If these symptoms occur, the medication should be held and the
individual should have a medical evaluation.
Liver function tests should be drawn as soon as possible after the
medication is held.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
It is generally recommended that INH be withheld if a person’s liver
function test results are 3 times the upper limit of normal in the
presence of symptoms of toxicity OR 5 times the upper limit of normal
in the absence of symptoms.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Approximately 6 percent of persons taking rifampin or rifapentine
experience itching, with or without rash. Rash is not as common with
INH but may occur and can be managed based on severity.
• Mild rash and itching is generally self-limited and treatment can often
be continued with symptomatic relief.
• Petechial rash (pinpoint sized red dots under the surface of the skin
caused by leakages of capillaries) is caused by RIF/RPT
hypersensitivity. Hold medications and schedule a medical evaluation.
Platelet count should be drawn as soon as possible. If the platelets are
below normal stop and do not restart the medication.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Peripheral neuropathy is a much less common side effect, occurring in
0.2 percent of people taking INH. It characterized by numbness or
tingling, most often in toes or fingers, sensitivity to touch, and stabbing
pain.
Neuropathy is more likely to be seen in persons with conditions such as
malnourishment, diabetes, HIV, renal failure, alcoholism, and pregnant
and breastfeeding women.
Persons with these conditions who are taking INH should take Vitamin B6
to prevent peripheral neuropathy.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Hypersensitivity reactions to rifampin and rifapentine are very rare and
present as
• Hypotension
• Thrombocytopenia, and/or
• Flu-like syndrome, including fever, headache, dizziness, and
musculoskeletal pain
Continued treatment may be possible after evaluation by a provider.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Isoniazid, Rifampin and rifapentine may also cause gastrointestinal
upset. This is rarely severe enough to discontinue treatment.
Patients can be encouraged to increase fluid intake, take the medication
closer to meal time and with a small snack.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Rifampin and Rifapentine often cause orange discoloration of body fluids
such as tears, urine, and saliva. Soft contact lenses and dentures may be
permanently stained.
This is harmless and persons taking these medications should be to be
advised about this beforehand.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
For HIV-infected individuals being treated with antiretroviral medications:
• Rifapentine is contraindicated and should not be used.
• RIF should be used with caution in individuals taking certain
antiretroviral medications, and
• Substitution of rifabutin for RIF in the 4-month regimen many be
considered for such patients.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Severe adverse events leading to hospitalization or death associated with
the use of any LTBI regimen should be reported to:
• MDH (651-201-5414) for inclusion in CDC’s adverse events
surveillance system,
-AND• FDA MedWatch at http://www.fda.gov/medwatch.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The second component of monitoring includes watching for signs and
symptoms of active TB that may develop during LTBI treatment.
This is important because if active TB develops and the person continues
treatment with only one drug, they may develop drug-resistant TB.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Since active TB can develop during LTBI treatment it is important to
teach the patient to watch for the following signs and symptoms:
• Cough,
• Night sweats,
• Weight loss/poor appetite,
• Chest pain,
• Hemoptysis (bloody sputum),
• Fever/chills,
• Fatigue, and
• Enlarged lymph nodes.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
If these occur, withhold treatment and notify the provider as soon as
possible.
Move the offender to airborne isolation and schedule a medical
evaluation to rule out active TB. If you do not have an airborne isolation
room, you may need to transfer the offender to a different facility.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The final component of monitoring while on LTBI treatment includes
assessing adherence to the medication regimen.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
It is important to understand that the circumstances surrounding each
person may affect his or her ability to complete therapy.
The case manager needs to work with each person to identify barriers to
adherence.
Barriers
•
•
•
can be:
Patient-related,
Treatment-related, or
System-related.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Patient-related barriers include:
• Disbelief in the accuracy of the TST/IGRA,
• Belief that the BCG vaccine caused their positive TST/IGRA,
• Absence of any signs of illness,
• Personal or cultural beliefs and stigma related to TB,
• Chemical dependency,
• Mental illness, and
• A mistrust of legal authorities, public health workers or health
care system.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Treatment-related barriers include:
• Lack of knowledge about why treatment is needed,
• Medication side effects (feeling ill when taking the medication),
and
• Lengthy treatment duration (4,6,9 months).
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
System-related barriers include:
• Lack of language interpreters for persons who don’t speak
English,
• The offender being released from incarceration before treatment
is completed, and
• Referrals not being made to local public health agencies to
continue treatment after release.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Strategies to improve adherence include:
• Respecting the person’s cultural beliefs,
• Using interpreters and/or translated education materials, if indicated,
• Protecting confidentiality,
• Promptly addressing adverse drug effects,
• Providing directly observed therapy (DOT) when applicable, and
• Establishing a routine of medication administration.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Additional strategies include:
• Coordinating release planning with local public health,
• Offering free TB medications upon release, and
• Using incentives and/or enablers.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Despite efforts to promote adherence, persons taking LTBI therapy may
miss doses.
Occasional, intermittent missed doses can be managed by extending
therapy.
If there has been a gap of more than 2 months, the offender should be
examined by a medical provider to rule out active TB.
Provide close supervision of therapy (DOT if feasible is preferred for
high-risk individuals).
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
If interruptions were frequent and if the individual is NOT at high risk for
active TB, therapy may be stopped.
Review signs and symptoms of active TB and instruct offender to seek
medical care immediately if these develop.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Completion of therapy is based on the total number of doses
administered, not on duration alone.
For example, the 9 month daily INH regimen should consist of 270
doses taken within 12 months.
The 6 month daily INH regimen includes 180 doses taken within 9
months.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Since the length of LTBI treatment ranges from 3 to 9 months it is
important to document detailed monitoring information.
Good documentation minimizes time spent tracking down old
records either through corrections or the health department.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Maintain documentation of the following and store it in the offender’s
medical record:
• Pre-treatment evaluation,
• Monthly monitoring evaluation, and
• Review of adverse effects, signs and symptoms of active TB, and
adherence.
LTBI monitoring form is available from MDH for you to adapt. Using this
form is optional.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
This is a screen shot of an LTBI Monitoring Flow Sheet, which can be
downloaded from the MDH TB website.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Medical release planning is extremely important for continuity of
care.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
As mentioned in Module one, comprehensive medical release planning is
a “Best Practice” and is very important to effective TB control efforts
within the community to which offenders return.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Medical release planning, also known as “discharge planning,” and casemanagement strategies should begin during detention and continue after
release for offenders at high risk of developing active TB if infected.
It is also important to have a plan in place for an unscheduled release or
transfer!
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Collaboration is an important component of TB control efforts. Local and
state public health departments, health care providers, and correctional
system partners should join forces to plan release for offenders.
Working together maximizes the effectiveness of efforts started in the
correctional facility through continuity of care. This may improve post
release adherence and completion of therapy.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Comprehensive medical release planning is especially critical in the
following situations:
• Transfer to another facility,
• Release to the community, and
• Immigration and Customs Enforcement (ICE).
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
First, let us explore the aspects of transfer to another facility.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Transfer to another facility should be coordinated with staff members of
the receiving facility and the local or state health department.
Most importantly, the discharging facility should:
• Communicate with the receiving facility about the upcoming transfer,
• Fax information to the receiving facility,
• Coordinate DOT if needed,
• Inform local public health agency if needed,
• Send documentation with offender, and
• Notify MDH TB Program if they are providing medication for the
offender.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The second scenario is when the offender who has not completed LTBI
therapy is released to the community.
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Management should be coordinated with the local or state health
department to ensure continuation of LTBI treatment and medical followup:
• Obtain locating and contact information from offender in advance,
• Plan for other support services in advance of release to help offenders
meet basic needs. This might include coordination of substance abuse
treatment or scheduling appointments for follow-up medical care,
• Notify the appropriate local public health agency that the individual is
being released to the community by calling and faxing information to
the receiving public health agency,
• Send documentation with offender, and
• Notify MDH TB Program if they are providing medication to the
correctional facility.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
In addition, make sure that the offender has the following:
• Information on how to contact their local public health agency, and
• Documentation of their screening and LTBI treatment plan, so that
they have that information in case they are required to be tested for
TB in the future.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Finally, some offenders may be released to the Immigrations and
Customs Enforcement.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Because ICE detainees are mobile, they may leave and reenter the U.S.
while on LTBI treatment, and are at an increased risk for interruptions in
therapy.
Thus ensuring treatment completion is important to eliminating TB in the
U.S.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Correctional facility staff should:
• Identify offenders who are ICE detainees, and
• Work with MDH to enroll detainees in programs that facilitate
continuation of LTBI therapy after release.
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The MDH provides free TB medications.
• Is free of charge for residents of Minnesota,
• Available while incarcerated and after release, and
• Sent monthly to correctional facility or local public health agency.
Additional information available at MDH website:
www.health.state.mn.us/divs/idepc/diseases/tb/medications.html.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Now let us look at an LTBI case study.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
This is a 32-year-old Caucasian male who moved to U.S. from
Central America 4 years ago.
He was admitted to a county correctional facility. He denied having
a prolonged cough, weight loss, night sweats or other TB
symptoms.
He was diagnosed with diabetes 3 years ago and stated that he’d
never had a TST.
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First Question:
•
What are this offender’s risk factors for TB?
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His foreign-born status puts him at a higher risk of being exposed
to TB and diabetes increases his risk of developing active TB, if
infected.
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Testing is performed:
• TST result is 13 mm induration, which is positive, and
• CXR is normal.
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Question two:
• What is the next appropriate step for this offender?
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Medical provider needs to examines the offender to rule out active TB
disease.
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The provider ruled out active TB disease. This offender has latent TB
infection based on the positive TST, normal chest X-ray, and absence
of signs and symptoms of active disease.
And he is a high-priority candidate for treatment because of his
diabetes.
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Questions four
• The provider orders treatment with INH. Does this person need
Vitamin B6 supplementation?
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Vitamin B6 supplementation is recommended to prevent peripheral
neuropathy in persons with diabetes who are taking INH and other
disorders that lead to peripheral neuropathy.
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Next steps
• Talk to offender about the importance of LTBI therapy. Try to identify
any barriers to treatment completion.
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Question five:
How will you obtain the INH and Vitamin B6 for this offender?
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You can:
• Obtain drugs from a pharmacy, or
• Order drugs from MDH
• To order drugs from MDH, download and complete order form
from MDH TB Program website.
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The next step is to:
• Download the LTBI monitoring sheet from MDH TB Program website,
• Initiate therapy, and
• Monitor the offender carefully and closely.
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Lessons learned:
• It is important to consider risk factors for TB infection and progression
to active TB when deciding whether to offer an offender LTBI
treatment.
• Identify barriers to LTBI treatment initiation or completion prior to
starting therapy.
• Offenders should be monitored carefully for side effects of LTBI
therapy including hepatitis and peripheral neuropathy.
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To summarize this presentation, I’d like to review a few key points:
• The purpose of LTBI treatment is to reduce the risk that someone
infected with M. tuberculosis organisms will develop active TB while in
a correctional setting or after discharge to the community.
• It is important to think about whether the offender falls into one of the
high-risk groups for TB when initiating LTBI treatment.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
When initiating LTBI treatment it is important to consider the ability of
the offender to physically tolerate therapy and to complete therapy
without interruptions.
Treatment guidelines recommend monthly monitoring for adherence, side
effects, and signs and symptoms of active TB in offenders taking
medication for LTBI.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
And finally, correctional facilities should collaborate with public health to
continue LTBI therapy upon release to other facilities, the community or
ICE.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The following slides list the various resources available.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Our primary resource regarding TB control in correctional facilities was
published in 2006 and is titled: “Prevention and Control of Tuberculosis in
Correctional Facilities: Recommendations from CDC.”
This document can be downloaded from the website listed on this slide.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
Our primary LTBI resource was published in 2013 and is titled:
“Latent Tuberculosis Infection: A Guide for Primary Health Care
Providers.”
This document can be downloaded from the website listed on this slide
and also ordered from the CDC website.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The Stop TB poster describes how TB is spread and the difference
between latent TB infection and TB disease. It is available in both English
and Spanish and can be ordered at no cost from the CDC website.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
CDC also can supply you with an educational poster called “Think TB!”
These can be ordered at no cost from the CDC’s web site.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
You may also find the Minnesota Department of Health TB patient
education fact sheets useful.
They are available in English and 15 other languages and can be
downloaded from MDH’s website.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The web address for Minnesota Department of Corrections is
www.doc.state.mn.us and the address for MDH’s TB Program is
www.health.state.mn.us/tb. The home page for CDC’s TB pages is
www.cdc.gov/tb.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
If you are interested in obtaining a certificate of participation that
includes nursing credits, please go to the web address listed on this
slide. After completing a brief evaluation, you will be directed to your
certificate. We appreciate your honest feedback about this webinar.
Questions about obtaining your certificate should be directed to Beth
Kingdon at MDH’s TB Program. Her contact information is noted on this
slide.
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Preventing and Controlling Tuberculosis in Correctional Settings: Module III
The MDH TB Program extends its thanks and gratitude to the Minnesota
Department of Corrections, local public health agencies throughout
Minnesota, and the Correctional Health Division of the Minnesota
Sheriff’s Association for their assistance in creating this webinar.
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I’d like to close by sincerely thanking you for the work you do every day
to help prevent and control TB in Minnesota.
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