FORMERLY HEPP Report
Feb. 2005 Vol. 8, Issue2

ABOUT IDCR
IDCR, a forum for
correctional problem solving, targets
correctional physicians, nurses,
administrators, outreach workers, and
case managers. Published monthly
and distributed by email and fax,
IDCR provides up-to-the moment
information on HIV/AIDS,
hepatitis, and other infectious
diseases, as well as efficient ways
to administer treatment in the
correctional environment. Continuing
Medical Education credits are
provided by the Brown University
Office of Continuing Medical
Education. IDCR is
distributed to all members of the
Society of Correctional Physicians
(SCP) within the SCP publication,
CorrDocs (www.corrdocs.org).

CO-CHIEF EDITORS
Anne S. De Groot, MD
Director, TB/HIV Research Lab,
Brown Medical School
David Thomas, MD, JD
Professor and Chairman,
Department of Surgery,
Division of Correctional Medicine
NSU-COM

DEPUTY EDITORS
Joseph Bick, MD
Chief Medical Officer,
California Medical Facility, California
Department of Corrections
Renee Ridzon, MD
Senior Program Officer,
HIV, TB, Reproductive Health,
Bill & Melinda Gates Foundation

Bethany Weaver, DO, MPH
Acting Instructor, Univ. of Washington,
Center for AIDS and STD Research

SUPPORTERS

IDCR is grateful for
the support of the following
companies through unrestricted
educational grants:
Major Support: Abbott Laboratories,
Boehringer Ingelheim and
Roche Pharmaceuticals.
Sustaining: Pfizer Inc., Gilead
Sciences, Inc., GlaxoSmithKline, Merck
& Co., Schering-Plough and ViroLogic.

Brown Medical School

IDCR MISSION STATEMENT
We changed our name from HEPP Report to IDCR (Infectious Diseases in Corrections Report)
to encompass all infectious diseases that impact the correctional setting. IDCR's goal is to educate correctional health care providers about the appropriate medical management of prisoners infected with HIV, hepatitis, TB, and other infectious diseases; to encourage these
providers to improve their networks with correctional, academic or community-based infectious
disease experts; and to promote a level of infectious disease care in correctional facilities that
is equivalent to the "community standard."

TUBERCULOSIS OUTBREAK AMONG STAFF IN CORRECTIONAL
FACILITIES, FLORIDA, 2001-2004: LESSONS RE-LEARNED
David Ashkin*, MD, Florida Department of Health
Jean Malecki*, MD , Director of Palm Beach County Health Department
David Thomas*, MD, JD, NOVA University, Division of Correctional Medicine

w The prevalence of latent tuberculosis infection (LTBI) among prison inmates is four times
higher than the prevalence in the general population.
w The prevalence of LTBI among jail inmates is
17 times higher than the prevalence in the
general population.
w More than 500,000 inmates with LTBI are
released nationwide every year.
w The rate of tuberculosis (TB) infection in jails
is 15 times that seen in the general population.
w One-third of those with active TB in this
country have been recently incarcerated1,2.
While most prisons and jails are vigilant when
it comes to screening for TB infection, some
correctional facilities are not attentive to LTBI
treatment completion, thereby providing an
ideal condition in which TB outbreaks may
occur. When a TB outbreak occurs, public
health officials should initiate an investigation
of the circumstances related to the outbreak
and try to interrupt further transmission of
Mycobacterium tuberculosis (M. tuberculosis).
This report of a recent TB outbreak in two
Florida correctional facilities illustrates the
complexities of TB control in congregate settings and highlights the need for further
improvements in TB control measures in prisons and jails.
The TB Outbreak Setting
The local Health Department, in consultation
with the Florida Bureau of TB and Refugee

Providence, RI 02912

401.863.6128

Health (FBTBRH), and the Florida Department
of Corrections, investigated an outbreak of
drug-susceptible TB that occurred among staff
at two closely situated correctional facilities
(facilities A and B) during the period April September 2004.
Facility A has an inmate population of 1,375.
Correctional personnel working at the facility
include 363 correctional staff, 26 medical personnel, and 13 contracted food workers.
Facility B is located ten miles south of facility
A. This facility incarcerates 1,361 inmates, and
216 correctional staff and 38 medical personnel work at the facility. Some of the correctional facility employees periodically rotate
between the two facilities.
Approach to the Outbreak Investigation
The investigation of the outbreak was conducted in 2004 and standard TB case-based follow-up methods were used. The index patient
was defined as the first patient to receive a
Continued on page 2

WHAT’S INSIDE
IDCR-o-gram
TB 101
In The News
Self-Assessment Test

fax: 401.863.6087

pg
pg
pg
pg

6
7
8
9

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February 2005

Vol. 8, Issue 2

TB OUTBREAK... (cont. from page 1)
diagnosis of TB, regardless of location of
that case. The outbreak period was
defined as the time period commencing
when the index case reported TB-associated symptoms, and concluding one week
after the last infectious patient was placed
in respiratory isolation. The potentially
infectious period for each patient was
defined as commencing on the date of
onset of symptoms consistent with TB,
and concluding when the patient was isolated from further contact with others. M.
tuberculosis isolates from case patients
were fingerprinted by IS-6110 restriction
fragment length polymorphism (RFLP) to
determine if cases were caused by the
same strain. A case was included in the
outbreak if there was a history of close
contact, defined as shared cells or work
area with another case linked to the outbreak, and/or if the subject's M. tuberculosis isolate had a matching RFLP fingerprint.i
All inmates and staff were questioned
regarding TB risk factors and tuberculin
skin tests (TSTs) were administered to all
inmates and staff, excluding members of
the staff who had a previously documented positive test or those who had a negative test within the past three months.ii
(see TB 101, page 7.)
A positive TST was defined as induration
greater or equal to 5 mm. Inmates who
had positive TST results or symptoms
suggestive of TB, regardless of TST
results, were evaluated with a chest radiograph. (see IDCR-o-gram, page 6) The
chest radiographs were conducted at the
on-site medical units. Correctional staff
members who had a positive TST or
symptoms suggestive of TB were referred
to the local DOH TB clinic for chest radiograph, medical evaluation, and treatment.
Three sputum samples were obtained
from every inmate or staff member who
demonstrated signs and symptoms suggestive of TB. Sputum smears were
examined for acid-fast bacilli (AFB), were
cultured for mycobacteria, and the
Mycobacterium tuberculosis direct (MTD)
test was performed.iii Correctional staff
members who had a positive TST or
symptoms suggestive of TB were sent to
the local health department for evaluation.
Inmates who were suspected of having
TB were placed in respiratory isolation at
the facility.

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2

Results of the 2004 Outbreak
Investigation
The 2004 outbreak investigators discovered that over a period of three years
(May 2001-September 2004), five cases
of TB were reported among correctional
staff members working at facilities A or B.
Of these five cases, four cases of TB were
identified among the correctional staff
members at facility A and one case of TB
was identified in a correctional staff member who worked at facility B. Cases 2 and

TST. Symptoms suggestive of TB were
not recorded in 2002, but a private physician who was providing treatment ordered
a chest radiograph.vi The chest radiograph
demonstrated an infiltrate and sputum
specimens were positive for AFB on
smear and M. tuberculosis in culture.
Additional investigations were not conducted, as the contact investigation
around the index case was deemed sufficient to capture this case's workplace contacts.

The single most potent
factor affecting the risk of
progression from LTBI
to TB disease is
HIV coinfection.

Case 3, an HIV-uninfected correctional
transportation officer employed at facility
B, was diagnosed with pulmonary TB in
October 2002. This individual was responsible for transporting inmates to and from
the medical units of facilities A and B.
Case 3's sputum specimen was positive
for both AFB on smear and M. tuberculosis in culture.

4 from facility A, and Case 3 from facility B
were linked to the index case by RFLP fingerprinting of isolates and contact exposure history. Case 5 from facility A was
epidemiologically linked to the other four
case, however the RFLD fingerprint did
not match with the other cases.

Case 4, an HIV-uninfected correctional
transportation officer employed at facility
A, was diagnosed with TB in March 2004.
A private physician monitoring this subject
for a history of asthma ordered a chest
radiograph in 2004 for reasons unrelated
to the TB outbreak. The chest radiograph
revealed a 1 cm nodule in the right upper
lobe. Tissue culture obtained following
excision of the upper lobe nodule was
positive for M. tuberculosis. Case 4 was
initially identified as a contact to the index
case but did not follow through with medical evaluation and treatment. Additionally,
this subject was a TST converter; his
baseline TST measured 0 mm in 2002
and 10 mm in August 2003.vii The RFLP
pattern confirmed the link between this
case, the index case, and cases 2 and 3.viii

The index case, identified as the source
case, was an HIV-infected staff member
initially diagnosed with extrapulmonary TB
in May 2001. This patient was employed
as a secretary in the medical unit in facility A and had frequent contact with
coworkers and correctional officers who
were involved in the transportation of
inmates. A private physician managed TB
treatment, TB medications were selfadministered,iv and the patient had a history of non-adherence to the prescribed
anti-TB medication regimen. No contact
investigation was performed when the
patient was first diagnosed in 2001,
because the patient was considered to be
"non-infectious".v However, in September
2002, a sputum specimen was found to be
positive for AFB on smear and M. tuberculosis in culture. At this time, pulmonary
TB was diagnosed (see Table 1, page 3.)
and a contact investigation in facility A
was conducted. A review of the patient's
medical records revealed that sputum
specimens were not obtained prior to
September 2002.
Case 2, an HIV-uninfected correctional
transportation officer employed at facility
A, was identified during the September
2002 contact investigation. This individual
had a previously documented positive

Case 5, an HIV-uninfected correctional
officer employed at facility A was diagnosed with pulmonary TB in April 2004.
This case's RFLP fingerprint did not
match the RFLP fingerprint obtained for
the index case or cases 2, 3, or 4, but an
epidemiological link was identified as this
case had close social contact with Case
4.ix
Records on skin tests and/or TST records,
results, and chest radiographs were not
available for the majority of correctional
staff at both facilities.
The clinical characteristics of the index
patient and the secondary cases (Cases
2, 3, 4 and 5) are listed in Table 1, page 3.
Continued on page 3

February 2005

Vol. 8, Issue 2

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3

Table 1. Clinical characteristics of the index patient and the secondary cases (Cases 2, 3, 4 and 5)
DNA
Match
Yes

Comments

Abnormal

Signs/
Symptoms
Cough

MTB+

Infiltrates in Right
Upper Lobe

Night
sweats

Yes

Negative

MTB+

Abnormal

Intermittent
Cough

Yes

3/04

Negative

No culture
performed

Non-cavitary but
consistent with TB

Cough

Yes

4/04

Positive

MTB+

Non- cavitary but
consistent with TB

Cough

No

Transportation officer
at facility A; HIV
uninfected
Transportation officer
at facility B; HIV
uninfected
Transportation officer
at facility A; HIV
uninfected
Correctional officer at
facility A; HIV
uninfected

Sputum AFB
Smear Results
Smears not
done 2000
Positive 2002

Culture
Results
MTB+*

Chest Radiograph

Positive

10/02

4

5

Case

Date Reported

Index
Case

2

History of treatment for
extra-pulmonary
TB in 5/00;
culture positive
pulmonary TB in
9/02
10/02

3

Health care secretary
at facility A; HIV
infected; frequently
received visits from
transportation officers

*MTB+ - Culture was positive for M. tuberculosis

TB OUTBREAK... (cont. from page 2)
Outbreak Investigation
During the 2004 outbreak investigation, all
movement in and out of both facilities,
including visitation, was halted for one
week, to allow initial screening of all
inmates and correctional officers. During
that one week 78 staff received TSTs and
all staff and inmates were screened using
a symptom screen and risk assessment.x
Of the staff screened/tested, 54 of these
individuals were referred to the state TB
clinic for evaluation of symptoms suggestive of TB or for follow-up evaluation of a
positive TST. TSTs were performed on all
inmates with a history of TST and chest
radiographs were obtained for 30 inmates
to further evaluate symptoms suggestive
of TB or because they had a positive TST.
Sputum specimens were obtained from 18
inmates who had abnormal chest radiographs and/or symptoms suggestive of
TB.
Follow up
As a result of this outbreak, the state and
local health departments recommended
implementation of an electronic database
for tracking serial TB screenings so that
TST conversions and appropriate recommendation of follow-up medical care will
be documented. This is the recommended
practice in all high risk settings, such as
medical and correctional facilities 3.
Quarterly skin testing of inmates and correctional staff at these facilities will contin-

ue until no further conversions are identified. At the time of this publication, no further active cases of TB disease have been
identified.
Discussion and Recommendations for
Florida Outbreak
Several lines of evidence suggest that M.
tuberculosis was transmitted from the
index patient to correctional staff at facilities A and B. The index case was a medical staff member employed in the health
care unit at facility A, who had been diagnosed with extrapulmonary TB in 2001.
This patient was not adherent with selfadministered treatment and worked with
several correctional transportation officers. Since an evaluation for pulmonary
TB was not performed in May 2001 (the
time of initial diagnosis), it is not clear if
this individual was infectious at this time.
This individual developed symptoms of
pulmonary TB in 2002, and may have
infected other correctional staff from
January 2001 to June 2002.
The long duration of exposure to the
source (index) case is also attributable to
a failure to monitor the patient's
adherence with anti-TB treatment.
Noncompliance with TB treatment is a
well-known problem4. All TB medications
should be administered by directly
observed therapy and adherence documented, as this is the current standard of
care 3. Public health investigators are
available to assist with TB case evaluation

and adherence with anti-TB medication.
Furthermore, since records on TSTs
and/or chest radiographs were not available for the majority of the correctional
staff, it was difficult to ascertain correctional staff compliance with annual TSTs.
TST conversions could not clearly be
related to the period of exposure.
Obtaining baseline TSTs in higher risk settings, such as medical and correctional
facilities, is generally recommended,iii as it
provides a point of reference for measurement of TST conversion rates.
Although mandatory screening and testing
of all employees had been implemented
three years prior to this outbreak, several
correctional staff members did not comply.
Correctional supervisors must be able to
identify employees who are not compliant
to such policies and implement appropriate education and corrective actions if
these policies are not adhered to.
Measures need to be supported (with collaboration to help design, implement, and
monitor) by public health programs to
address conditions, which foster the transmission of M. tuberculosis, identify corrective measures, and implement and monitor all follow-up.
Employers are unlikely to be aware of the
HIV
status
of
their
employees.
Educational programs for both inmates
and staff are essential for the protection of
all persons at the facility. All staff (and
Continued on page 4

February 2005

Vol. 8, Issue 2

TB OUTBREAK... (cont. from page 3)
therefore the potentially unknown HIVinfected or immunosuppressed staff)
should be repeatedly advised of the
increased risk with regard to TB in those
with HIV infection, the importance of TB
skin testing and completion of LTBI treatment, and should be taught to recognize
symptoms of TB. Practitioners treating correctional personnel and inmates should
have a high index of suspicion for TB and
obtain appropriate smears and cultures
whenever possible.
General Discussion and
Recommendations
There is a dangerous synergy between HIV
and TB. Prisoners, who have long been
known to have disproportionately high
rates of TB disease and TB infection,v also
have more than five times the general population's rate of AIDS, and between four
and 10 times the general population's rate
of HIV infection6. The single most potent
factor affecting the risk of progression from
LTBI to TB disease is HIV coinfection7. It is
often more difficult to detect TB in persons
with HIV/AIDS because they may not

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respond to the TST, and may present with
atypical or negative findings on chest radiographs8. It is therefore recommended that
HIV-infected patients with respiratory
symptoms undergo a sputum analysis in
addition
to
a
chest
radiograph.
Furthermore, significant drug interactions
may complicate the concurrent treatment of
HIV and TB9. In short, HIV increases the
risk of progression from TB infection to disease, makes screening for TB more difficult, and complicates the treatment of TB.
As recommended by the National
Commission on Correctional Health Care
(NCCHC), all inmates should receive TB
symptom screening on intake; anyone with
TB symptoms (chronic productive cough,
fever, weight loss, night sweats) should
immediately be moved to a negative pressure respiratory isolation room and evaluated for TB disease. TSTs should be
administered to all inmates and correctional staff members who have not had a previous documented positive TST result.
(see IDCR-o-gram, page 6.) Any patient
whose TST indicates TB infection should
receive a chest radiograph. TST may fail to
identify TB infection in high-risk patients

DISCLOSURES: *Nothing to disclose
NOTES:
i. RFLP analysis is a DNA fingerprinting method that allows public
health officials to distinguish the transmission of specific strains of
tuberculosis during an outbreak. This method is based on the detection of the copy number and location of the mobile genetic element
IS6110 in the M. tuberculosis genome. Enzymatic digestion of the
DNA produces fragments, which can be separated by electrophoresis. The fragments are immobilized on a nylon membrane, and a
specific chemoluminescence-labeled DNA probe is used to reveal
the pattern bands on x-ray film.
ii. Best practice would be to test every individual who had a negative
PPD test at the time of the outbreak investigation. However, this
practice can be difficult to enforce with correctional staff. Additional
education regarding TB exposure, testing and management could
improve TST uptake among correctional personnel.
iii. MTD tests are isothermal transcription-mediated amplification
assays used in the rapid identification of M. tuberculosis in respiratory samples. These tests produce results within two to seven hours
after sputum processing.
iv. Best practice would be to have this patient take TB medications
under directly observed therapy, especially given the patient’s history
of immunosuppression.
v. HIV-infected subjects who have extrapulmonary tuberculosis can
have undetected pulmonary infection. In general, no patient with
suspected tuberculosis can be considered non-infectious until sputum smears are also found to be negative; in the case of HIV-infected patients, culture for TB should also be performed, as sputum
smears may be negative, despite the presence of active pulmonary
tuberculosis.
vi. Any individual who has a positive TST, with or without the presence of symptoms suggestive of TB, should have a baseline chest
radiograph.
vii. Best practice would have been to perform a chest radiograph at
the time of TST conversion.

4

including inmates10 - TB control officers
may consider using on-site chest radiography to screen all inmates at entry.
Inmates and correctional staff who have
documented LTBI should complete a
course of treatment and adherence should
be monitored3. Those with a positive TST
who cannot complete treatment for LTBI
should receive regular screening for TB
symptoms; any such patient with significant
immune compromising factors should be
scrutinized for TB symptoms even more
frequently. Inmates who do not present with
TB upon initial intake screening should be
evaluated annually for TST conversion,
and more frequently if there is evidence of
recent transmission of M. tuberculosis in
the facility, or if inmates with HIV are
housed together11.
As an airborne infection, TB presents one
of the most prescient threats not only to
inmates, but also to correctional staff,
health care providers, visitors, and others
who come in close contact with TB
patients. This case illustrates that point one more time.

viii. Active tuberculosis should be considered whenever any individual who works in a higher risk setting, such as a medical facility or
correctional facility, presents with a pulmonary infiltrate. TST should
be performed and sputum specimens should be obtained for AFB
smear and culture.
ix. There can be "background" cases even in the face of an outbreak. These types of cases could possibly be the next source case
of a future outbreak. Vigilance for anyone with symptoms suggestive of TB need to be identified and evaluated early.
x. Best practice is to perform risk assesment, symptom screening
and TSTs on all staff. However, staff have the right to refuse testing
on-site and may receive TSTs from private physicians.
REFERENCES:
1. National Commission on Correctional Health Care. "The Health
Status Of Soon-To-Be-Released Inmates". A Report to Congress.
2002. Full document accessible at:
http://www.ncchc.org/pubs/pubs_stbr.vol1.html
2. Health Standards of the American Correctional Association.
"Standards for Adult Correctional Institutions, 4th Edition". 2003.
3. CDC. MMWR 2000; 49(No. RR-6): 1-39.
4. Sbarbaro, John, Burman William, Cornelis Rietmeijer, et al. Chest
1997; 111(5): 1151-3.
5. CDC. MMWR 1996; 45(No. RR-8): 1-27.
6. Hammett, TM; Rhodes, W; Harmon P. National HIV Prevention
Conference 1999. Atlanta, GA. Abstract 571.
7. CDC. MMWR 2000; 49(46): 1041-4.
8. Burman WJ, Gallicano K, Peloquin C. Clin Infect Dis 1999 28(3):
419-29.
9. Spradling P, McLaughlin S, Drociuk D, et al. XIII International
AIDS Conference 2000. Durban, South Africa. Abstract ThPeB5188.
10. Zoloth SR, Safyer S, Rosen J, et al. Am J Public Health 1993;
83(5): 749-51.
11. Perlman DC, el-Sadr WM, Nelson ET, et al. Clin Infect Dis 1997;
25: 242-6.

February 2005

LETTER

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Vol. 8, Issue 2

FROM THE

Faculty Disclosure

EDITOR

This month we bring you an exciting tale of a TB outbreak in a correctional setting; Drs. David
Ashkin, Jean Malecki, and David Thomas report on a tuberculosis outbreak among staff in two
Florida correctional facilities. Outbreaks are invariably caused by lapses in tuberculosis control,
where a case of infectious pulmonary tuberculosis has been unrecognized or inappropriately managed. Recognition or suspicion of an outbreak may be through diagnosis of the index case, evidence of clustering of cases or positive tuberculin skin tests, or unusual trends in epidemiologic
data, as shown in this example.
Outbreak investigations should include case finding and identification of exposed contacts so that
tuberculin skin testing and screening for tuberculosis disease can be performed. Contact investigations are usually performed using a concentric circle approach, where contacts with the greatest exposure, such as household members, are identified and tested. If the rate of Mycobacterium
tuberculosis infection is greater than expected, the investigation should move to the next highly
exposed circle of contacts, such as work or school contacts. Subsequent concentric circles of contacts should be tested until the rate of infection is thought to be equal to that of the surrounding
community.
Outbreaks represent experiments of nature, and while the first duty is interruption of transmission
and identification and testing of exposed contacts, outbreaks also are an opportunity to learn valuable lessons. Examining missed opportunities that may have lead to the outbreak can point out
areas within a tuberculosis control program in need of improvement or strengthening. This is clearly the case for the Florida Department of Corrections, and important steps have been taken to
improve TB control.
In addition, new information about the pathogenesis and transmission of M. tuberculosis can be
learned from outbreak investigations. Examples of lessons learned from outbreak investigations
include that children, who were thought not to transmit infection, can be highly infectious; that M.
tuberculosis can be transmitted through improperly disinfected bronchoscopes; and that in those
with HIV infection, the time to development of tuberculosis disease after infection is accelerated
when compared to those without HIV infection. In all cases, suspected outbreaks of tuberculosis
should be reported promptly to public health authorities and investigations should be performed in
conjunction with state and local tuberculosis control programs.
The algorithms included in this issue depict how to proceed when someone presents with suspected TB in the correctional setting, and the TB 101 details how to classify the tuberculin skin test
reaction. At the conclusion of this issue, readers will be more familiar with TB treatment guidelines
and how to prevent TB outbreaks in the correctional setting, know more about who should be tested for tuberculosis, and be aware of different tuberculin skin test reactions, and their implications.
Let's all hope that this TB update prevents a few outbreaks of TB in the future.

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IDCR fax/email newsletter.

David Paar, MD
Associate Professor of Medicine,
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Infectious Disease Supervisor
PHS-Rikers Island
Ralf Jürgens
Consultant,
HIV/AIDS, Human Rights, Drug Policy and
Prisons
Joseph Paris, PhD, MD, FSCP, CCHP
Medical Director,
Georgia Dept. of Corrections
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Chief Medical Officer,
New York State Dept. of Correctional Services
Dean Rieger, MD
Medical Director,
Indiana Dept. of Corrections
Neil Fisher, MD
Medical Director, Chief Health Officer,
Martin Correctional Institute
William Cassidy, MD
Associate Professor of Medicine,
Louisiana State University Health Sciences
Center

FACILITY:

Physician Assistant
Medical Director/Administrator

CITY:

FAX:

PHONE:

Steven F. Scheibel, MD
Regional Medical Director
Prison Health Services, Inc
David A. Wohl, MD
Associate Professor of Medicine
University of North Carolina
AIDS Clinical Research Unit

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Kimberly Backlund-Lewis
The Corrections Connection

Nurse/Nurse Practitioner
HIV Case Worker/Counselor

ADDRESS:

Josiah Rich, MD
Associate Professor of Medicine and
Community Health
Brown University School of Medicine,
The Miriam Hospital

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The Corrections Connection

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EMAIL:

Associate Editors
Rick Altice, MD
Director of Clinical Research,
Director, HIV in Prisons Program,
Director, Community Health Care Van,
Associate Professor of Medicine
Yale University AIDS Program

Barry Zack, MPH
Executive Director, Centerforce

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Physician
Pharmacist

In accordance with the Accreditation Council for
Continuing Medical Education Standards for
Commercial Support, the faculty for this activity have
been asked to complete Conflict of Interest
Disclosure forms. Disclosures are listed at the end of
articles. All of the individual medications discussed
in this newsletter are approved for treatment of HIV
and hepatitis unless otherwise indicated. For the
treatment of HIV and hepatitis infection, many physicians opt to use combination antiretroviral therapy
which is not addressed by the FDA.

Editorial Board
Louis Tripoli, MD, FACFE
Correctional Medical Institute,
Correctional Medical Services

Sincerely,
Renee Ridzon, MD

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February 2005

Vol. 8, Issue 2

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6

IDCR-O-GRAM: Suspected TB in the Correctional Setting
HIV + Cough
HIV + CXR Infiltrate
PPD + Cough
PPD + CXR Infiltrate

Inmate with Suspected TB

Isolate Inmate

Repeat CXR if necessary or indicated

3 Sputums for AFB + Culture (Culture and sensitivity)

Sputum Low Suspicion CXR, low
suspicion clinical presentation

Sputum High Suspicion CXR or high
to moderate clinical suspicion

Discharge from isolation
Medical follow-up
PPD propylaxis,
as indicated

Treat for TB
until month 6
or longer if indicated

Sputum + and/or
High Suspicion CXR

No Cavitation

Cavitation

Treat for TB
until month 6
or longer if indicated

Treat for TB
until month 9
or longer if indicated

All TB treatment begins with isoniazid, rifampin, pyrazinamide, and ethambutol for the initial 2 months. A repeat smear
and culture should be performed after 2 months of treatment. Normally, the continuation phase of treatment should consist
of isoniazid and rifampin daily or twice weekly for 4 months to complete a total of 6 months of treatment. If cavitation was
present on the initial chest radiograph and the culture at the time of completion of 2 months of therapy is positive, the continuation phase should be lengthened to 7 months (total of 9 months of treatment).
If the patient has HIV infection and CD4 <100/ul, the continuation phase should consist of daily or three times weekly isoniazid and rifampin. In HIV-uninfected patients having no cavitation on chest radiograph and negative AFB smears at completion of 2 months of treatment, the continuation phase may consist of either once weekly isoniazid and rifapentine, or
daily or twice weekly isoniazid and rifampin, to complete a total of 6 months. Patients receiving isoniazid and rifapentine,
and whose 2 months cultures are positive, should have treatment extended by an additional 3 months (total of 9 months).

February 2005

Vol. 8, Issue 2

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7

Who Should Be Tested for TB
w People with HIV infection (the AIDS virus)
w People in close contact with those known to be infectious with TB
w People with medical conditions that make the body less able to protect itself from disease (for example: diabetes, the
dust disease silicosis, or people undergoing treatment with drugs that can suppress the immune system, such as long-term
use of corticosteroids)
w Foreign-born people from countries with high TB rates
w Some racial or ethnic minorities
w People who work in or are residents of long-term care facilities (nursing homes, prisons/jails, some hospitals)
w Health care workers and others such as prison guards
w People who are mal-nourished
w Alcoholics and IV drug users
CDC. Division of Tuberculosis Elimination. Available at: http://www.cdc.gov/nchstp/tb/faqs/qa_latenttbinf.htm#Infection1

When is a Tuberculin Skin Test (TST) Reaction Positive?
5 or more millimeters

10 or more millimeters

15 or more millimeters

An induration of 5 or more millimeters is considered positive for:

An induration of 10 or more
millimeters is considered positive
for:

An induration of 15 or more
millimeters is considered positive
for:

w Foreign-born persons

w People with no risk factors

w People with HIV infection
w Close contacts
w People who have had TB disease
before
w People who inject illicit drugs and
whose HIV status is unknown

w HIV-negative persons who inject
illicit drugs
w Low-income groups
w People who live in residential facilities (nursing homes, prisons/jails)
w People with certain medical conditions
w Children younger than 4 years old
w People in other groups as identified by local public health officials

Adapted by IDCR from CDC. Division of Tuberculosis Elimination.

RESOURCES
NEW! Treating the HIV and TB Co-infected Patient in the Correctional Setting course
Available at: www.umdnj.edu/ntbcweb/hivtbcd.htm
CDC Division of Tuberculosis Elimination Fact Sheets
Available at: www.cdc.gov/nchstp/tb/pubs/dtbefax.htm
Charles P. Felton National TB Center at Harlem Hospital.
Addressing HIV/AIDS Issues in TB Contact Investigation: A Guide for Contact Investigators, Managers, and Trainers. 2004.
Charles P. Felton National Tuberculosis Center at Harlem Hospital
Improving Treatment Completion for Latent Tuberculosis Infection Among Health Care Workers. 1999.

February 2005

Vol. 8, Issue 2

SAVE THE
DATES
Conference on Retroviruses and
Opportunistic Infections
February 22-25, 2005
Boston, MA
Visit: www.retroconference.org/
2005
IUALTB Challenges to TB
Control
February 23-26, 2005
Vancouver, British Columbia,
Canada
Call: 604.732.5864
Email: biagtan@bc.lung.ca
Improving the Management of
HIV Disease Regional CME
Courses
Atlanta, GA: March 11, 2005;
New York, NY: March 17, 2005;
Los Angeles, CA: April 16, 2005;
Chicago, IL: May 2, 2005;
Washington, DC: May 2005;
San Francisco: May or June 2005:
Registration for this course
will open soon.
Visit: www.iasusa.org/registration/
index.html
Management of HIV/AIDS in the
Correctional Setting: A Live
Satellite Videoconference Series
"The Triply Diagnosed Patient:
HIV, Mental Health & Substance
Use"
March 9, 2005
12:30-2:30 p.m. EST
Call: 518.262.4674
Email: ybarraj@mail.amc.edu
Visit: www.amc.edu/patient/hiv/
hivconf/index.htm
World TB Day
March 24, 2005
Visit: www.cdcnpin.org/scripts/
spotlight/spot_wtd05.asp
for World TB Day activities
ACHSA Diminishing Resources:
The New Reality
March 31-April 3, 2005
Oakland, CA
Visit: www.achsa.org
NCCHC Updates in Correctional
Health Care
April 9-12, 2005
Las Vegas, Nevada
Visit: www.ncchc.org
AMFAR National HIV/AIDS
Update Conference
April 10-13, 2005
Oakland, CA
Visit: www.amfar.org

visit IDCR online at www.IDCRonline.org

8

IN THE NEWS
Study Details Effects of ART on Liver
Disease
Liver disease has emerged as a leading cause
of death among persons co-infected with HIV
and HCV. A recent study estimated the burden
of liver disease and evaluated determinants of
liver fibrosis and necroinflammatory activity
among HIV/HCV co-infected patients receiving
antiretroviral therapy (ART). One-hundred
twelve randomly selected and 98 referred HCVinfected patients undergoing care in an HIV clinic were studied. All patients had liver biopsies
performed between April 2001 and July 2002,
and had not received treatment for HCV infection prior to biopsy. Sixty-four percent of patients
were receiving ART at the time of liver biopsy
and 12% of patients had a previous episode of
grade 3 or 4 ART-associated liver enzyme elevation. No hepatic fibrosis was detected in 33%
of individuals, 41% had fibrosis restricted to the
portal tracts, and bridging fibrosis and cirrhosis
were noted in 9% and 17% of individuals,
respectively. The median necroinflammatory
activity score was 3, and 58 individuals had
activity scores of 5 or higher. Individuals with
persistently elevated ALT and/or AST levels,
defined as having more than 1 in every 3 ALT or
AST measurements >100ul, had a five-fold
greater risk of bridging fibrosis or cirrhosis, compared with persons with lower liver enzyme levels. While this study found no evidence that
ART caused serious histological liver disease, it
was found that individuals with longer cumulative exposure to ART had significantly less
necroinflammatory activity.
Hepatology. 41(1); January 2005.
FDA Approves New 500mg Invirase
The FDA recently approved a new 500mg, filmcoated tablet formulation of the HIV protease
inhibitor Invirase (generic name, saquinavir),
designed for use in combination with ritonavir
and other anti-HIV drugs for the treatment of
HIV infection. The approval was based on data
that show that similar drug levels are achieved
with Invirase 500mg tablets and Invirase 200mg
tablets, when each is administered with ritonavir
100mg and taken with food. The new formulation of Invirase will reduce pill count from five
pills to two, twice daily, in hopes of improving
patient adherence.
www.natap.org
Research: Low Rate of Treatment Failure
with Tenofovir, Lamivudine, Zidovudine
Triple NRTI regimens combining tenofovir,
lamivudine (3TC), and abacavir or didanosine
have recently shown high rates of virologic failure, most often associated with the K65R resistance mutation. However, the inclusion of
zidovudine may be protective against virologic
failure and selection of the K65R mutation.
Data was collected retrospectively from 40
patients who had previously been prescribed

ART consisting of tenofovir, 3TC, and zidovudine. Baseline was considered the time immediately before each patient switched to the ART
regimen consisting of tenofovir, 3TC, and
lamivudine. At baseline, 27 patients' (group 1)
HIV RNA levels were undetectable (<50
copies/ml) and 13 patients (group 2) had
detectable HIV RNA levels ranging from 200398,000 copies/ml. At the time of analysis, all
patients had completed at least 24 weeks after
initiation of treatment. Upon analysis, HIV RNA
level was less than 50 copies/ml in 23 of 27
patients who had undetectable HIV RNA at
baseline, and in 8 of 13 patients with detectable
HIV RNA levels at baseline. The median CD4
cell counts in group 1 and 2 increased from 415
cells/ul to 595 cells/ul and from 354 cells/ul to
407 cells/ul, respectively. All nine patients who
showed a virologic failure on tenofovir, 3TC, and
lamivudine were genotyped for resistance. Two
patients admitted to not having taken medication regularly. Of the seven remaining patients,
the K65R mutation was detected in only one
patient.
AIDS. 19(1); January 2005.
FDA Recommends Not Using Indinavir in
Pregnant Women
The clinical pharmacology section of the
Crixivan (Indinavir, IDV) label has been revised
to include pharmokinetic data from a study in
HIV-infected pregnant women, that showed
results of significantly reduced IDV concentrations in women at 30-32 weeks gestation compared to levels post-partum. Based on these
data, IDV is not recommended in HIV-infected
pregnant patients.
FDA issued report; Dec 27, 2004.
CDC Recommends HIV Drugs for All Those
Exposed
The CDC recently issued new recommendations that people exposed to HIV from nonoccupational exposure, such as sexual assault,
accidents, occasional drug use, or unsafe sex,
receive antiretroviral medications to stave off
HIV infection. Previously, the recommendations
for emergency drug treatment were only for
healthcare workers who with parenteral exposure through needlestick injuries, splashed to
mucous membrane, or other occupational exposure. This recommendation was first made in
1996. However, the CDC has stated that "the
severity of the HIV epidemic dictates we use all
available tools to reduce infection." The new
approach, called non-occupational post-exposure prophylaxis (NPEP) involves taking a daily
antiretroviral regimen, which must begin within
72 hours after exposure and continue for 28
days. While NPEP is an important expansion of
current HIV prevention strategies, it should not
be viewed as the first line defense against HIV.
www.natap.org

February 2005

Vol. 8, Issue 2

visit IDCR online at www.IDCRonline.org

SELF-ASSESSMENT TEST

FOR

9

CONTINUING MEDICAL EDUCATION CREDIT

Brown Medical School designates this educational activity for one hour in category one credit toward the AMA Physician’s Recognition
Award. To be eligible for CME credit, answer the questions below by circling the letter next to the correct answer to each of the questions.
A minimum of 70% of the questions must be answered correctly. This activity is eligible for CME credit through July 31, 2005.
The estimated time for completion of this activity is one hour and there is no fee for participation.

1. A TST is considered positive at 10 mm or more for the
following persons:
A. Children younger than 5 years old
B. Inmates
C. People with HIV infection
D. A and B
E. All of the above
2. The following statements about RFLP are all true, except:
A. RFLP stands for restriction fragment life polymorphism
B. RFLP detects the copy number and location of the
IS6110 element in the M. tuberculosis genome.
C. RFLP was used in the Florida TB outbreak investigation
to link cases.
D. During RFLP analysis, DNA is enzymatically digested to
produce DNA fragments, which can then be separated by
electrophoresis.
3. If a patient has HIV/TB co-infection and CD4 count is less
than 100/ul, the continuation phase of TB treatment should consist of daily or three times weekly isonizaid and rifapentine. True
or false?
A. True
B. False
4. The following statements are all true, except:
A. MTD tests are assays used in the rapid identification of
M. tuberculosis; results are obtained within two to seven
hours after processing.
B. Any individual who has a positive TST, with or without
the presence of symptoms suggestive of TB, should have a
chest radiograph.
C. Persons with HIV/TB coinfection often present with
typical findings on chest radiographs.
D. Best practice is for patients to take anti-TB medications
under directly observed therapy.

IDCR EVALUATION
5 Excellent

4 Very Good

3 Fair

2 Poor

1 Very Poor

1. Please evaluate the following sections with respect to:
Main Article

educational value
5 4 3 2 1

clarity
5 4 3 2 1

In the News

5 4 3 2 1

5 4 3 2 1

Save the
Dates

5 4 3 2 1

5 4 3 2 1

2. Do you feel that IDCR helps you in your work?
Why or why not?

3. What future topics should IDCR address?

4. How can IDCR be made more useful to you?

5. Do you have specific comments on this issue?

5. TB symptoms may include chronic cough, weight loss, fever,
and night sweats. True or false?
A. True
B. False

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OF CONTINUING MEDICAL EDUCATION • BOX G-A2 • PROVIDENCE, RI 02912
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