Tuberculosis contact investigation: Two years of experience in New York City correctional facilities

Volume 21

Number

1

February 1993

ARTlCLES

uberculosis contact investigation: wo years of experience in New York City correctional facilities Christine dohnsen, RN, MPH New York. New York

Background:

An increasing incidence of tuberculosis has been observed in the New York correctional system. Methods: The diagnosis of active tuberculosis in persons within the correctional setting results in an investigation, with the identification and screening of contacts. Results: Thirty-four such investigations in the past 2 years in the New York City correctional system, where all inmates are screened for tuberculosis on admission, have resulted in an overall tuberculin skin test conversion rate of 6.74% in 1306 inmates. In 21 of these investigations the index had both smears and cultures positive for Mycobacterium tuberculosis and the conversion rate was 7.37% in 719 contacts tested. In seven investigations the index patient had a culture only positive for M. tuberculosis and the conversion rate was 6.58% in 243 inmates. In six investigations in which the index patients were subsequently found to have nontuberculous pneumonia or mycobacteria other than M. tuberculosis the conversion rate was 5.52% in 344 inmates. These rates are not statistically different. CorzcEusions: Whether the observed conversions in these events or in any of the contact investigations are due to intramural spread, anergy on admission, the booster phenomenon, or incubation of disease on admission is not known. The 5.5% conversion rate in those exposed to inmates confirmed not to have tuberculosis suggests the influence of booster phenomenon and consideration of two-step testing on admission. (ATIC AM J INFECT CONTROL 1993;2 1: l-4) City

The recent increase in tuberculosis (TB) in the correctional setting’, 2 is related to an overrepreFrom York.

Montefiore

Rikers

Island

Health

Services,

Reprint requests: Christine Johnsen, RN, MPH, Coordinator, Montefiore Bikers Island Health Hazen St., East Elmhurst, New York, NY 11370. 0 1993 by the Association 0196~6553193

for Practitioners

$01 .oo + 0.10

17/46/38078

New

York,

Ipfection Services,

in Infection

New

Control 15-15

Control,

Inc.

sentation of intravenous drug users among the incarcerated3 and to their increased risk of HIV infection.4-s In addition, overcrowding and poor ventilation in these settings may facilitate intramural spread of TB9-12 The increasing incidence of TB in incarcerated populations in various geographic locations has also been observed in the Rikers Island population. This report describes the results of 28 contact investigations conducted in New York City cor-

Feoruary 1993

Joohnsen PPD wnversion

in exposed

Exposure Smear-positive case Culture-positive case Not TB case OR. Odds ratlo; CI, confidence

retional result of disease. patients diseases.

and unexposed

inmates

PPD

PPD

positive

negative

TOTAL

OR

I

53 16 19

666 227 325

719 243 344

1.36 1.21 1.0

0.75-z 46 0.52-2.77

mtewai

facilities during the past 2 years as a exposure of inmates to cases of active TB In six additional investigations, the index were ultimately found to have other

s pulation Nledical services on Rikers Island are provided by the Montefiore Medical Center through a contractual arrangement with the New York City Department of Health (NYCDOH), which has overall responsibility for inmate medical care. The infection control coordinator (ICC) of Montefiore kers Island Health Services oversees the surillance and control of communicable diseases, including TB, on Rikers Island. Rikers Island comprises 10 distinct correctional facilities, with a total average daily census for 1990 of 14,000 inmates. There were 89,867 new admission physical examinations performed in 1990. The average length of stay for all inmates, most of whom are pretrial detainees, is 47 days; for inmates who stay 14 days or more the average stay is 80 days. An estimated 34% of inmates on Rikers Island have a history of intravenous drug use.13 The seroprevalence of HIV infection in New York City’s population of intravenous drug users has been reported to be as high as .57%.3 In a blinded serosurvey conducted in January 199 1 by the New York City Department of Health on 2628 new missions to Rikers Island, 14.8% were found to HIV seropositive. (Weisfuse I, New York City partment of Health, unpublished data). As determined by 1990 Department of Corrections ata, 9 1% of New York City inmates are male, 93% are black or Hispanic, and 64% are younger than 30 years of age. Most inmates are housed in large open wards of 50 to 75 inmates each in buildings of various ages, from those built in the 1930s to modern prefabricated modules. No respiratory isolation is avail-

able. Infectious hospital. TB screening

patients

are

sent

out

to

the

protocol

As part of the new admission physical examination, all inmates receive an intradermal purified protein derivative of tuberculin (PPD) skin test,14 which is read in 4 person with a 10 mm induratio ra5to9mm induration and a diagnosis of V infection is considered to have a positive res for chest x-ray examination. with an abnormal chest x-ray referred to the hospital to rule ou In this high-risk population there is concern about false-negative PPD results from anergy.“5-17 Persons with negative PPD results who are HIV seropositive or have risk factors for HIV infection receive an anergy panel comprising 0.1 ml intradermal injections of mumps, tetanus, Can&da, and Trichophyton antigens. 5 mm response to any one of these antigens is nsidered a positive test result.” If there is no response to any of these common antigens, the person tested is considered to be anergic. Anergic persons are screened by chest radi.ography. Exposure

protocol

According to protocol, if there has been an exposure to an active case of negative inmates undergo a baseline Ma test. The test is repeated again after 8 to I2 weeks.g In the absence of a recent chest radiography PPDpositive inmates undergo chest x-ray examination. Because of frequent intrafacility and interfacility transfers, many contacts are lo to follow-up and no retrospective tracking syste is available. RESULT In a 24-month period ther investigations conducted on which sputum smear and culture Information is available. A total of 1306 inmates were skin tested

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21.

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JohnseE

1

and 88 conversions were identified, a 6.74% conversion rate (Table 1). The group exposed to smear-positive patients had the highest conversion rate (7.4%); those exposed to culture-positive only index patients had a conversion rate of 6.6%. In six investigations in which the index patients were ultimately found to have nontuberculous pneumonia or mycobacteria other than A4. tuberculosis, the conversion rate was 5.5%. These rates are not statistically different and the x2 test for trends did not reach statistical significance. In six of these contact investigations, the nursing supervisor of one of the facilities implanted anergy panels along with the PPD implantation for 227 exposed inmates. Fifteen anergic persons were identified, for a 6.6% rate of anergy. There were no conversions among the nursing and medical staff related to these exposures. The mean age of the index patients was 3.5 years; 72% were aged 30 years or older. Ninety-seven percent of the patients were black or Hispanic. Although HIV status or drug history is not known for most of the index patients, 87% (85/98) of current or recent patients with TB were documented as HIV seropositive and 80% (78/98) had a documented history of intravenous drug use. One index patient was female. Information on the inmates with conversions is not available. ISCUSS

In this natural experiment, six contact investigations were conducted because of strongly suspected cases of TB that were subsequently found to be caused by pathogens other than M. tuberculosis. The skin test conversion rate in these six investigations was not statistically different from the conversion rate in the investigations surrounding documented cases of TB. That the conversion rates were not statistically different may be explained by a number of factors: anergy, the booster phenomenon, incubating disease at admission, and intramural spread. Because in most instances the inmates’ admission PPD result served also as the baseline PPD for the contact investigation, these conversion rates are uninterpretable. There is no reason to suspect that these factors are differentially distributed among the groups here, that is, inmates exposed to smear- and culture-positive patients and inmates exposed to patients with confirmed nontuberculous disease. The “unexposed” group experienced a 5.5% conversion rate, which may reflect boosting as a result of a second PPD. If this level of boosting occurred

Table

2. Recommendations in correctional facilities

for TB screening

Mantoux PPD for all PPD-negative new admissions twostep method preferred (1 week apart) a Positive PPD (first or second test) if 10 mm or greater (5 mm or greater if HIV infected or at high risk for H!V) l Chest x-ray examination of all with positive PPD or TB history; consider chest x-ray examination for HIV infected, intravenous drug abuse history and detoxification populations * New admission with symptoms: Isolate in respiratory isolation if available or hospitalize until TB is ruled out by negative results of sputum tests

l

in all groups, an estimation of the true conversion rate among exposed persons is about 2%. Use of the two-step skin testing method”s* l9 would address the problem of the booster effect as well as temporary anergy, and in some instances would identify inmates who are incubating disease at admission. In correctional institutions where inmates are housed for as long as 5 days in new admission housing areas before being transferred to other housing areas, two-step admission testing is not possible. In addition as many as 20% of inmates are transferred daily for security reasons to different areas, making follow-up difficult. Host factors play a central role in the transmission of disease. Many of the selection factors for incarceration -prostitution, drugs, violence, and poverty- have resulted in a concentration of persons at increased risk of disease. This aggregation of immunocompromised persons provides a su stantial pool of highly susceptible persons, as well as a large reservoir of those who may be infected and transmitting an array of diseases including TB. Environmental factors may act to promote or inhibit the development of infection. Such problems as old facilities, poor or absent ventilation systems, and overcrowding are not easily amenable to change yet play a major role in the spread of disease by direct contact or airborne transmission. The construction of new facilities should incorporate good ventilation systems, as well as the installation of ultraviolet lights in the duct system.*’ It is imperative that every correctional facility have a well-defined TB control program (Table 2). In communities where TB is hyperendemic, a high suspicion of TB must be maintained. If appropriate respiratory isolation” is not available, patients in whom TB is suspected should be sent out to the

Femmy

Job-men

hospital until TB is effectively ruled out or 2 weeks of chemotherapy have elapsed and clinical improvement has been obtained. Contact investigations should be conducted on all exposed persons. In the prison setting, which is not as dynamic as that of the detention center, the two-step skin test may be the most sensitive new admission screening method. We are observing an increase in TB infection and disease in an inner city population of childbearing age at a time when funding for social and rnedical services are being curtailed. Increased efforts to control the spread of infection within the jail, as well as outreach efforts within the community to ensure screening of exposed family memers, are needed.

10.

11. 12.

13.

1. Braun MM, Truman BI, Maguire B, et al. Increasing incidence of tuberculosis in a prison inmate population: association with HIV infection. JAMA 1989;261:393-7. 2. Spencer SS, Morton AR. Tuberculosis surveillance in a state prison system. Am J Public Health 1989;79:507-9. 3. Centers for Disease Control. AIDS and human immunodeficiency virus infection in the United States: 1988 update. MMWR 1989;38(Suppl):l-38. 4. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med 1989;320:545-50. 5. Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB. Tuberculosis as a manifestation of the acquired immunodeficiency syndrome. JAMA 1986;256: 362-6. 6. Chiasson RE, Schecter GF, Theuer CP, Rutherford GW, Echenberg DF, Hopewell PC. Tuberculosis in patients with the acquired immunodeficiency syndrome: clinical features, response to therapy, and survival. Am Rev Respir Dis 1987;136:570-4.

Bound

volumes

available

14. 15.

16. 17.

18.

19.

20.

American Thoracic Society, medical section of the American Lung Association. Mycobacterioscs and the acquired immunodeficiency syndrome. Am Rev Respir Dis 1987; 1361492-6. Friedman LN, Sullivan GM, Bevilaqua RI?, Loscos R. Tuberculosis screening in alcoholics and drug addicts. Am Rev Respir Dis 1987;136:1188-92. Benenson AS, ed. Control of communicable diseases in man. Washington, DC: American Public Iiealtb Association, 1990:457-66. Centers for Disease Control. Prevention and control of tuberculosis in correctional institutions: recommendations of the Advisory Committee for the Elimination of Tuberculosis. 1989;38:313-25. Stead WW. Undetected tuberculosis in prison: source of infection for community at large. JAMA 1978;240:2544-7. Brennen C, Muder RR, Maraca PW. Occult endemic tuberculosis in a chronic care facility. Infect Control Hosp Epidemiol 1988;9:548-52. Alcabes P, Zoloth S, Michaels D. Preincarceration drug use among New York City inmates. 116th Annual Meeting, American Public Health Association, Boston, November 1988. Snider DE. The tuberculin skin test. Am Rev Respir Dis 1982;125(Suppl):108-18. Morse DL, Hansen RE, Grabau JC, Cauthen G, Redmond SR, Hyde RW. Tuberculin conversions in Indochinese refugees: an assessment of boosting and anergy. Am Rev Respir Dis 1985;132:516-9. Bobrowitz ID. Active tuberculosis undiagnosed until autopsy, Am J Med 1982;72:650-8. Stead WW, Lofgren JP, Warren E, Thomas C. Tuberculosis as an endemic and nosocomial infection among the elderly in nursing homes. N Engl J Med 1985;312:1483-7. Thompson NJ, Glassroth JL, Snider DE, Farer LS. The booster phenomenon in serial tuberculin testing. Am Rev Res Dis 1979;119:587-97. Snider DE, Anderson HR, Bentley SE. Current tuberculosis screening practices. Am J Public Health 1984;74: 13.53-6. Centers for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. M~WR 1990;39: l-29.

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1993

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