A Report to Congress
Volume 1

The Health Status of
Soon-To-Be-Released
Inmates

Volume 1

March 2002

This project was supported by cooperative agreement 97–IJ–CX–K018 awarded by
the National Institute of Justice, Office of Justice Programs, U.S. Department of
Justice. It was awarded to the National Commission on Correctional Health Care.
Points of views in this document are those of the authors and do not represent the
official position or policies of the U.S. Department of Justice.
This report fulfills the reporting requirements of Public Law 104–208 as set forth in
the Conference Reports for HR 3610 and HR 3814.

iii

Preface

Through the mid-1990s, a number of studies, limited
in scope, found a higher prevalence of certain infectious diseases, chronic diseases, and mental illness
among prison and jail inmates. Further, each year
the Nation’s prisons and jails release more than 11.5
million inmates. The potential that ex-offenders may
be contributing to the spread of infectious disease in
the community became of increasing concern. In
addition, as these ex-offenders’ diseases get worse,
society may have to pay substantially more to treat
them than if these conditions had been treated at an
earlier stage—or prevented altogether—while these
individuals were still incarcerated.
In 1997 Congress instructed the U.S. Department of
Justice to determine whether these concerns were well
founded and, if so, to recommend solutions. The
National Institute of Justice (NIJ), the research arm
of the Department of Justice, entered into a cooperative agreement with the National Commission on
Correctional Health Care (NCCHC) to study the problem. The Health Status of Soon-To-Be-Released
Inmates report is the result of that research.
The NCCHC commissioned a series of papers
(summarized in volume 1 of this report and provided in full in volume 2) that documents indisputably that tens of thousands of inmates are being
released into the community every year with undiagnosed or untreated communicable disease, chronic
disease, and mental illness. Another set of commissioned papers clearly shows that it not only would
be cost effective to treat several of these diseases,
but in several instances, it would even save money
in the long run.

The report concludes with policy recommendations
designed to improve disease prevention, screening,
and treatment programs in prisons and jails. The recommendations have been carefully crafted. First,
they are based on a consensus among a number of
the Nation’s leading experts in correctional health
care and public health. Second, they propose interventions for which there is strong, and in many cases
overwhelming, scientific evidence of therapeutic
effectiveness. Third, they reflect a realistic consideration of what correctional systems can reasonably
be expected to accomplish.
There are serious political, logistical, and financial
barriers to improving health services in prisons and
jails. As documented in this report, however, a number of jurisdictions have found ways to overcome
some of these barriers, often through collaborations
with public health departments and national or community-based organizations.
Prisons and jails offer a unique opportunity to establish better disease control in the community by providing improved health care and disease prevention
to inmates before they are released. Implementing
the recommendations in this carefully researched
report will go a long way toward taking advantage
of this opportunity and contribute significantly to
improving the health of both inmates and the larger
community.
Edward A. Harrison, CCHP
President
National Commission on Correctional Health Care

v

Contents

Preface............................................................................................................................................................iii
Executive Summary ......................................................................................................................................ix
Introduction ................................................................................................................................................ix
History of the Project..................................................................................................................................ix
Prevalence of Communicable Disease, Chronic Disease, and Mental Illness
Among the Inmate Population ..............................................................................................................x
Improving Correctional Health Care: A Unique Opportunity to Protect Public Health...........................xii
Corrections’ Mixed Record of Compliance With National Clinical Guidelines.......................................xii
Cost-Effectiveness of Prevention, Screening, and Treatment of Disease Among Inmates......................xiii
Barriers to Effective Prevention, Screening, and Treatment—and Overcoming Them ...........................xiv
Policy Recommendations ..........................................................................................................................xv
Notes .........................................................................................................................................................xix
1. Introduction ................................................................................................................................................1
Organization of the Report ..........................................................................................................................1
Problem of Untreated Prison and Jail Inmates ............................................................................................2
Window of Opportunity ...............................................................................................................................4
Preventing and Treating Disease in Prisons and Jails Are Cost Effective ..................................................4
Need for Scientific Data on Inmate Health .................................................................................................5
Notes ............................................................................................................................................................5
2. History of the Project ................................................................................................................................9
Steering Committee .....................................................................................................................................9
Expert Panels ...............................................................................................................................................9
Prison Survey .............................................................................................................................................10
Commissioned Papers................................................................................................................................11
Need for Further Research ........................................................................................................................12
Notes ..........................................................................................................................................................12
3. Prevalence of Communicable Disease, Chronic Disease, and Mental Illness
Among the Inmate Population .........................................................................................................15
Communicable Disease..............................................................................................................................15
Chronic Disease .........................................................................................................................................20
Mental Illness.............................................................................................................................................22
Notes ..........................................................................................................................................................26
4. Improving Correctional Health Care: A Unique Opportunity to Protect Public Health .................29
Current State of Correctional Prevention, Screening, and Treatment Programs.......................................29
Corrections’ Mixed Record of Compliance With National Guidelines.....................................................31
Implications: A Significant Opportunity to Intervene ...............................................................................32
Notes ..........................................................................................................................................................33

vi

5. Cost-Effectiveness of Prevention, Screening, and Treatment of Disease Among Inmates................35
Cost-Effectiveness of Prevention, Screening, and Treatment....................................................................35
Communicable Disease..............................................................................................................................35
Chronic Disease .........................................................................................................................................38
Moving Beyond Cost-Effectiveness ..........................................................................................................39
Conclusion .................................................................................................................................................45
Notes ..........................................................................................................................................................45
6. Barriers to Prevention, Screening, and Treatment—and Overcoming Them....................................49
Barriers to Improved Prevention, Screening, and Treatment ....................................................................49
Solutions ....................................................................................................................................................53
Conclusion .................................................................................................................................................57
Notes ..........................................................................................................................................................57
7. Policy Recommendations ........................................................................................................................59
Background to the Policy Recommendations............................................................................................59
Policy Recommendations ..........................................................................................................................59
Recommended Actions by Government Agencies ....................................................................................64
Bibliography ..............................................................................................................................................64
Notes ..........................................................................................................................................................68

Appendixes
Appendix A

NCCHC/NIJ Project Participants, Author/Experts, Consultants

Appendix B

Biographies of Contributors

Appendix C

Prevalence of Chronic Diseases and Chronic Mental Disorders in Prisons:
NCCHC/NIJ Survey Instrument

Appendix D

Sample Draft Clinical Guidelines

Appendix E

Information About the National Commission on Correctional Health Care and
Its Position Statements

List of Tables
Table 3–1

National Estimates of Selected Infectious Diseases Among Inmates and Releasees and
Prevalence in U.S. Population

Table 3–2

National Estimates of Prevalence of Three Chronic Diseases Among Inmates in Prisons
and Jails and in the Total U.S. Population, 1995

Table 3–3

National Estimates of Six Psychiatric Disorders Among Prison and Jail Inmates and
Prevalence in U.S. Population, 1995

Table 4–1

States Reporting Systemwide Treatment Protocols for Chronic Disease (n = 41)

vii

List of Figures
Figure 3–1

Releasees With Selected Infectious Diseases as a Proportion of the Total U.S. Population
With Each Disease, 1996

Figure 3–2

National Estimates of Prevalence of Three Chronic Diseases Among Inmates in Prisons
and Jails and in the Total U.S. Population, 1995

Figure 3–3

Jails: Estimated Prevalence of Six Mental Illnesses Among Inmates in 1995 Compared
With Prevalence Rates for the Total U.S. Population in the Early 1990s

Figure 3–4

State Prisons: Estimated Prevalence of Six Mental Illnesses Among Inmates in 1995
Compared With Lifetime Prevalence Rates for the Total U.S. Population in the Early 1990s

Figure 3–5

Federal Prisons: Estimated Prevalence of Six Mental Illnesses Among Inmates in 1995
Compared With Lifetime Prevalence Rates for the Total U.S. Population in the Early 1990s

ix

Executive Summary

In the Omnibus Consolidated Appropriations Act of
1997, Congress instructed the U.S. Department of
Justice to set aside funding for a study of The Health
Status of Soon-To-Be-Released Inmates. As a result
of these earmarked funds, the National Institute of
Justice (NIJ), the research and evaluation arm of the
U.S. Department of Justice, entered into a cooperative agreement with the National Commission on
Correctional Health Care (NCCHC) to conduct the
study. This report is the culmination of the project’s
work. The project has shown unmistakably that a
unique opportunity exists to reduce the health risks
and financial costs to the community that are associated with releasing large numbers of inmates with
undiagnosed and untreated diseases.
Volume 1 of The Health Status of Soon-To-BeReleased Inmates has seven chapters. This summary
outlines the information presented in considerably
more detail in the following seven chapters. It is
important to read the entire volume to gain a full
understanding of the problems and opportunities
associated with the health status of inmates. Volume
2 of the report includes the papers commissioned for
the project. They form the basis for the project’s
findings and policy recommendations.

Introduction
The inmate population in the United States has been
growing rapidly since the early 1970s: As of 1999,
an estimated 2 million persons were incarcerated
in the Nation’s jails and prisons, compared with
325,400 in 1970—an increase of about 500 percent.1
Approximately 11.5 million inmates were released
into the community in 1998, most from city and
county jails.2 As explained below, these inmates
have high rates of communicable disease, chronic
disease, and mental illness. Coupled with the expanding inmate population, these high rates of disease
create a critical need for preventing, screening, and
treating illness before inmates are released into the
community.3 Why?

●

Some of the serious diseases affecting inmates,
including sexually transmitted diseases (STDs),
human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), hepatitis B
and C, and tuberculosis (TB), can be transmitted
to other inmates.

●

The Nation’s one-half million correctional
employees4—and thousands of daily visitors to
prisons and jails—may be at risk of becoming
infected from inmates with communicable
diseases if appropriate precautions are not
implemented.

●

Inmates with communicable diseases who are
released without having been effectively treated
may transmit these conditions in the community,
threatening public health.

●

Inmates who are released with untreated conditions may become a serious financial burden on
community health care systems.

Because they have a large and concentrated population of individuals at high risk for disease, prisons
and jails offer a unique opportunity for improving
disease control in the community by providing comprehensive health care and disease prevention programs to inmates.5 Prisons and jails make it possible
to reach a population that is largely underserved and
difficult to identify and treat in the general community. Because inmates are literally a “captive” audience, it is vastly more efficient and effective to screen
and treat them while they are incarcerated than it is
to conduct extensive outreach in local communities
designed to encourage at-risk individuals to go to a
clinic for testing and treatment.

History of the Project
The Health Status of Soon-To-Be-Released Inmates
project involved several components. A steering
committee coordinated the work and provided expert
guidance to the project. Three expert panels, one
each on communicable disease, chronic disease,

x

and mental illness, provided expert guidance to the
steering committee. Panel members included many
of the Nation’s most respected researchers, practitioners, and scholars in the fields of public and
correctional health care (see appendixes A and B).
Centers for Disease Control and Prevention (CDC)
staff were especially helpful in guiding the scholarly
work of the expert panels.
After identifying the specific communicable diseases, chronic diseases, and mental illnesses the
project would examine, each expert panel estimated
the extent of illness among inmates for the more
common but remediable health problems; determined the cost-effectiveness of preventing or treating these health problems; and developed public
policy recommendations for capitalizing on these
opportunities.
The steering committee conducted a mail survey
of State prison systems to collect information on
policies and procedures for discharge planning and
for providing medications to inmates with chronic
disease and mental illness when they were released.
The survey also asked about the availability of
databases on the prevalence of chronic disease
and mental illness.6
The steering committee commissioned eight papers
and two sets of presentation materials (see volume 2)
from nationally known experts in the correctional
and public health care fields. The authors estimated
the prevalence of the selected diseases in prisons and
jails and calculated whether it would save money or
be cost effective to prevent, screen for, or treat these
diseases. The papers present the principal empirical
support for the project’s policy recommendations.

Communicable disease7—prevalence
The approximate number of inmates with selected
communicable diseases in 1997 was calculated by
applying national prevalence estimates for each condition to the total number of inmates in U.S. prisons
and jails on June 30, 1997. The approximate number of releasees with these conditions was obtained
by applying the same prevalence percentages to the
total unduplicated number of persons released from
prisons and jails during 1996 (the most recent data
available at the time the estimates were done).
Because the estimates for releasees are based on
total numbers of persons released during a full year,
an especially high figure for jails, they are much
higher than the estimates for inmates, which are
based on the correctional population on a given day.
Statistics on total number of individuals incarcerated
during a full year are not available.
The estimated prevalence of selected communicable
diseases in prisons and jails is as follows:
●

An estimated 34,800 to 46,000 inmates in 1997
were infected with HIV. An estimated 98,500 to
145,500 HIV-positive inmates were released from
prisons and jails in 1996.

●

Included among the HIV-positive inmates in
1997 were an estimated 8,900 inmates with
AIDS. An estimated 38,500 inmates with AIDS
were released from prisons and jails in 1996.

●

There were an estimated 107,000 to 137,000
cases of STDs among inmates in 1997 and at
least 465,000 STD cases among releasees: 36,000
inmates in 1997 and 155,000 releasees in 1996
had current or chronic hepatitis B infection;
between 303,000 and 332,000 prison and jail
inmates were infected with hepatitis C in 1997;
and between 1.3 and 1.4 million inmates released
from prison or jail in 1996 were infected with
hepatitis C.8

●

About 12,000 people who had active TB disease
during 1996 served time in a correctional facility
during that year.9 More than 130,000 inmates
tested positive for latent TB infection in 1997.
An estimated 566,000 inmates with latent TB
infection were released in 1996.

Prevalence of Communicable Disease,
Chronic Disease, and Mental Illness
Among the Inmate Population
Different procedures were used to estimate the
prevalence of disease and mental illness among the
inmate population, but the estimates rely on wellestablished national databases.

xi

Thus, a highly disproportionate number of inmates
suffer from infectious disease compared with the rest
of the Nation’s population. During 1996, about 3 percent of the U.S. population spent time in a prison
or jail; however, between 12 and 35 percent of the
total number of people with selected communicable
diseases in the Nation passed through a correctional
facility during that same year.
●

●

●

●

●

Seventeen percent of the estimated 229,000 persons living with AIDS in the United States in
1996 passed through a correctional facility that
year.10 The prevalence of AIDS among inmates
is five times higher than among the general U.S.
population.11
The estimated 98,000 to more than 145,000
prison and jail releasees with HIV infection in
1997 represented 13 to 19 percent of all HIVpositive individuals in the United States.
The estimated 155,000 releasees with current or
chronic hepatitis B infection in 1996 indicate that
between 12 and 15 percent of all individuals in
the United States with chronic or current hepatitis B infection in 1996 spent time in a correctional facility that year.
The estimated 1.3–1.4 million releasees infected
with hepatitis C in 1996 suggest that an extremely high 29–32 percent of the estimated 4.5 million people infected with hepatitis C in the
United States12 served time in a correctional facility that year. The 17.0–18.6 percent prevalence
range of hepatitis C among inmates—probably
an underestimate—is 9–10 times higher than the
estimated hepatitis C prevalence in the Nation’s
population as a whole.13
Of all people in the Nation with active TB disease in 1996, an estimated 35 percent (12,200)
served time in a correctional facility that year.
The prevalence of active TB among inmates is
between 4 and 17 times greater than among the
total U.S. population.

Chronic disease14—prevalence
●

The prevalence of asthma among Federal, State,
and local inmates in 1995 is estimated to be
between 8 and 9 percent, for a total of more than

140,000 cases nationwide. Prevalence rates for
asthma are higher among inmates than among
the total U.S. population.
●

The prevalence of diabetes in inmates is estimated
to be about 5 percent, for a total of nearly 74,000.

●

More than 18 percent of inmates are estimated
to have hypertension, for a total of more than
283,000 inmates.

Mental illness15—prevalence
The estimated prevalence of mental illness among
jail inmates is as follows:
●

An estimated 1 percent have schizophrenia or
another psychotic disorder.

●

About 8–15 percent have major depression.

●

Between 1 and 3 percent have bipolar disorder.

●

Between nearly 2 and less than 5 percent of
jail inmates are estimated to have dysthymia
(less severe but longer-term depression).

●

Between 14 and 20 percent have some type of
anxiety disorder.16

●

Another 4 to less than 9 percent suffer from
post-traumatic stress disorder.

The estimated prevalence of mental disorders
among State prison inmates is as follows:
●

An estimated 2–4 percent have schizophrenia or
another psychotic disorder.

●

Between 13 and less than 19 percent have major
depression.

●

Between 2 and less than 5 percent have bipolar
disorder.

●

Between 8 and less than 14 percent have
dysthymia.

●

Between 22 and 30 percent have an anxiety
disorder.

●

Between 6 and 12 percent have post-traumatic
stress disorder.

xii

Improving Correctional Health Care:
A Unique Opportunity to Protect
Public Health
The large concentration of prison and jail inmates
with serious disease or mental illness affords a
unique opportunity to provide needed treatment
and prevention and to help protect public health in
general. To what extent are prisons and jails seizing
this opportunity? Many correctional agencies are
doing too little to address communicable disease,
chronic disease, and mental illness.

Communicable disease17—current state
of corrections prevention, screening, and
treatment programs
●

Few prison or jail systems have implemented
comprehensive HIV-prevention programs18 in
all their facilities.

●

On average, less than one-quarter of jail inmates
undergo routine laboratory testing for syphilis
during incarceration. In some jails, only 2–7 percent of inmates are tested.

●

More than 90 percent of State and Federal prisons, and about half of jails, routinely screen at
intake for latent TB infection and active TB disease. Particularly in jails, however, many inmates
are released before skin tests can be read. Most
prisons and jails report that they isolate inmates
with suspected or confirmed TB disease in negative pressure rooms. Some facilities, however, do
not test the rooms to ensure that the air exchange
is working properly, or they continue to use the
rooms even when the air exchange is known to
be out of order.

Chronic disease—current state of corrections
prevention, screening, and treatment programs
Of the 41 State correctional systems that responded
to a survey conducted for The Health Status of
Soon-To-Be-Released Inmates project,19 only 24
reported they had protocols for diabetes, 25 for
hypertension, and 26 for asthma. A content analysis revealed that many of these “guidelines” were
incomplete or out of date.

Mental illness—current state of corrections
prevention, screening, and treatment programs
Few jails provide a comprehensive range of mental
health services.20 Only 60 percent provide mental
health evaluations, 42 percent provide psychiatric
medications, 43 percent provide crisis intervention
services, and 72 percent provide access to inpatient
hospitalization.21 A majority of State adult prisons
provide screening and assessment for mental illness,
medication and medication monitoring, counseling
or verbal therapy, and access to inpatient care. Only
36 percent of prisons have specialized housing for
individuals with stable mental health conditions.22
Continuity of care for inmates released with communicable disease, chronic disease, and mental
illness is especially inadequate. Only 21 percent
of jails provide case management or prerelease
planning for mentally ill inmates.23

Corrections’ Mixed Record of Compliance
with National Clinical Guidelines
Many prisons and jails fail to conform to nationally
accepted clinical guidelines. For example, consider
the following:
●

A significant proportion of prisons and jails
do not adhere to CDC standards with regard to
screening for and treating latent TB infection
and active disease. About 10 percent of State and
Federal prisons, and about 50 percent of jails, do
not have mandatory TB screening for inmates at
intake and annually thereafter.24

●

Most prisons and jails fail to conform to nationally
accepted health care guidelines for mental health
screening and treatment. Seventeen percent of
jails and prisons do not provide recommended
intake screening for mental illness, and 40 percent
of jails and 17 percent of prisons do not provide
recommended mental health evaluations.25

By rectifying these gaps in prevention, screening,
and treatment services in prisons and jails, communities can take advantage of a tremendous opportunity to improve public health by reducing the
problems associated with untreated inmates returning to the community. Furthermore, addressing these
health care deficiencies would be cost effective.

xiii

Cost-Effectiveness of Prevention,
Screening, and Treatment of Disease
Among Inmates
A cost-saving intervention saves more money in
averted medical costs than is needed to implement
it. An intervention is cost effective if the benefits it
will achieve are worth the price—even if the intervention costs more than the money saved.

Cost-effectiveness findings
The members of the project steering committee and
expert panels found that several interventions would
be a cost saving or cost effective.
●

Universal screening for syphilis at intake in both
prisons and jails would be a cost saving (and,
therefore, cost effective) if at least 1 percent of
the inmates had the disease. Routine syphilis
screening and treatment would save almost $1.6
million for every 10,000 inmates screened.26

●

Routine screening of men and women in prisons
and jails for gonorrhea and chlamydia would be
cost effective. Universal screening of women for
gonorrhea and chlamydia at intake to prisons
and jails would also be a cost saving if at least
8 percent of female inmates had gonorrhea and
9 percent had chlamydia.27

●

●

For correctional systems with HIV prevalence
rates as low as 1.5 percent, an HIV-prevention
program of voluntary counseling and testing for
HIV-infected inmates in prison would be a cost
saving. Offering counseling to 10,000 prison
inmates would prevent three future cases of HIV
if 60 percent of those inmates agreed to be
counseled and tested. On the three cases alone,
$140,000 could be saved. Counseling and testing
10,000 inmates would cost the prison system
about $117,000, or approximately $39,000 per
case of HIV prevented.28
For correctional systems with HIV prevalence
rates of at least 2.3 percent—the overall infection
rate in prisons and jails nationwide—universal
screening for tuberculosis in prisons would be a
cost saving because of the heightened susceptibility to TB of individuals with HIV. The 989
cases of active TB that would be prevented for

every 100,000 inmates tested, with treatment of
those inmates found to have latent TB infection,29
would save $7,174,509, or $7,254 per case
prevented.30
●

Universal screening in prisons and jails for hypertension and diabetes would be cost effective.31

Scientifically effective interventions
Obviously, only effective medical interventions can
be a cost saving or cost effective. Fortunately, correctional agencies can introduce many scientifically
tested interventions to target inmate diseases. The
following interventions have proven to be effective
for communicable diseases:32
●

Sexually transmitted diseases: Peer-led educational sessions addressing safer sexual practices,
rapid screening for and treatment of syphilis,
and screening and treatment for gonorrhea and
chlamydia.

●

HIV/AIDS: Encouraging all inmates with risk
factors to agree to be tested, providing educational programming to help inmates avoid acquiring
and transmitting HIV/AIDS, and offering appropriate standard-of-care treatment to all inmates
with HIV infection.

●

Tuberculosis: Training correctional staff to be
alert for inmates with TB symptoms, screening
all new admissions, testing current inmates and
all staff annually, having access to properly operating negative pressure isolation rooms, providing prompt and effective treatment under direct
observation, and providing for followup in the
community when release precedes completion
of treatment.

●

Hepatitis B and C: Routinely vaccinating all
inmates, or susceptible inmates, against hepatitis
B and offering educational sessions that present
strategies to avoid acquiring and transmitting
infection.

Empirically based interventions are known to
reduce illness and death associated with several
chronic diseases, including asthma, diabetes, and
hypertension. Appendix D, “Sample Draft Clinical
Guidelines,” provides examples of these proven
interventions.33

xiv

Barriers to Effective Prevention,
Screening, and Treatment—and
Overcoming Them
Despite the compelling reasons for improving the
prevention, screening, and treatment of disease
among inmates, significant barriers may make it difficult for prisons and jails to improve these services.
Most barriers fall into one of four categories:
●

Lack of leadership, such as failure to recognize
the need for improved health care services, reluctance to consider that improving public health is
a correctional responsibility, and unwillingness of
public health agencies to advocate for improving
correctional health care or to collaborate to promote improvement.

●

Logistical barriers, such as short periods of
incarceration, security-conscious administration
procedures for distributing medications, and
difficulty coordinating discharge planning.

●

Limited resources that require difficult budgeting decisions to meet the high cost of many
health care services and some medications, and
that make it difficult to provide adequate space
for medical services.

●

Correctional policies, such as failure to specify
minimum levels of required care in contracts
with private health care vendors, delays caused
by the need to escort inmates to medical treatment, poor communication between public health
agencies and prisons and jails, and lack of adequate clinical guidelines.

Most of these barriers to improved health care for
inmates can be overcome. First, position statements
that a number of well-respected, national professional groups have developed describing appropriate
health care for inmates can be used as leverage to
encourage correctional administrators to find ways
of resolving barriers to providing adequate care.
A list of NCCHC position statements appears in
appendix E. Second, collaboration among correctional agencies, public health departments, and
community-based organizations can help overcome
the lack of correctional health care funds and staff.
Public health departments may be willing to contribute funds, staff, and expertise if they understand

that this use of their resources can advance the
cause of public health in their communities. Public
health departments in some jurisdictions already
contribute significantly to testing and screening of
inmates, providing prevention and treatment programs in prisons and jails, and following up on
inmates after release to ensure a continuum of care.
Many community-based organizations are interested
in and willing to provide services to inmates.
●

The Hampden County Correctional Center,
which serves 500,000 residents of Massachusetts’
second largest metropolitan area, has developed
a public health model of correctional health care
that focuses on disease screening, prevention,
treatment, discharge planning, and continuity of
care for releasees. The program costs about $6
per inmate day, or 9 percent of the facility’s
budget. Based on ZIP Code of residence, inmates
with HIV/AIDS and other serious medical and
mental health conditions are assigned to one of
four health teams that work jointly in the correctional center and in four community health centers. Case managers who work in both agencies
provide discharge planning services for all
inmates with HIV/AIDS and serious mental
health problems. A discharge planning nurse at
the facility provides similar services for inmates
with chronic diseases. Releasees are linked with
community-based agencies that address issues of
family reintegration, housing, employment training and readiness, and benefit programs.34

●

The Fairfax County (Virginia) Jail has overcome
the pervasive barriers to discharge planning for
mentally ill inmates. A private nonprofit organization links detainees with mental health-related
services upon release and maintains the detainee’s
family ties while the person is incarcerated. This
affords the inmate a source of additional support
after release. The organization’s eight staff provide or arrange for the following services:
— Transportation and housing assistance to
mentally ill inmates upon release.
— Teaching, mentoring, and tutoring in the
facilities.
— Teaching life skills for releasees.
— Group therapy for inmates and their families.

xv

— Support groups for families and close friends
of inmates.
— Emergency funds for families for food and
clothing while providers are in jail.35

Policy Recommendations
The expert panels assembled for The Health Status
of Soon-To-Be-Released Inmates project developed
policy recommendations for improving the health
care of prison and jail inmates. The project steering
committee refined the panels’ recommendations. The
recommendations are based on expert consensus that
there is sufficient—if not always definitive—scientific evidence to justify their implementation. Much
of this scientific evidence is presented in this report.
Many prisons and jails have implemented interventions that are not reflected in these recommendations.
That this report does not include an intervention that
correctional systems are currently implementing does
not mean that these systems should discontinue the
intervention—or that other systems should not consider introducing it. In fact, professional organizations,
including the National Commission on Correctional
Health Care, will likely develop new recommendations as clinical studies demonstrate the effectiveness
of additional interventions.
The policy recommendations to Congress, listed in
full below, are followed by actions that the steering
committee proposes that specified Federal, State,
and local agencies take in order to support implementation of the recommendations.

Surveillance36
The principal use of disease surveillance in correctional facilities is to monitor disease incidence,
prevalence, and outcomes in the inmate population.
Surveillance includes collecting health data and
evaluating the data collection system to assist correctional health officials in characterizing the health
status of the inmate population. The information
obtained from the surveillance system is used to
plan, implement, and evaluate health needs of the
inmate population and their anticipated health needs
upon release.

I. Congress should promote surveillance of selected
communicable diseases, chronic diseases, and
mental illnesses among inmates in all correctional jurisdictions. Appropriate Federal agencies in
partnership with national health-related organizations should:
A. Develop surveillance guidelines to promote uniform national reporting of selected conditions
to enhance epidemiologic research of these
conditions and assist with accurate health care
planning. Ensure that data collected in prisons
and jails as part of the surveillance program
are collected in the same manner as they are
collected in the community.37 Surveillance
guidelines should incorporate processes for
protecting confidentiality of data.
B. Create a national correctional health care
database.
1. Develop standardized definitions and measures for reporting to assess the prevalence
of selected communicable diseases, chronic
diseases, and mental illnesses.38
2. Mandate national reporting of these prevalence data.
3. Design an information system and make
it available for use by local, State, and
Federal correctional authorities to measure
and report the data with the ability to categorize the data by age, race, and gender.
C. Produce statistical reports of local, State, and
national rates of selected communicable diseases, chronic diseases, and mental illnesses
in prisons and jails to aid planning correctional and public health programs and allocate
local resources.39
D. Evaluate the utility of surveillance activities
and implement improvements as appropriate.

Clinical guidelines
Clinical guidelines provide definitions and abbreviated decision trees for the diagnosis and management of various diseases and conditions. They guide
the clinician in areas where scientific evidence of
the value of selected interventions exists to improve

xvi

survival and clinical outcomes and to reduce morbidity and the cost of care. Clinical guidelines are
widely used outside corrections.
II. Congress should promote the use of nationally
accepted evidenced-based clinical guidelines for
prisons and jails. This will help assure appropriate use of resources to prevent, diagnose, and
treat selected communicable diseases, common
chronic diseases, and mental illnesses that are
prevalent among inmates. Appropriate Federal
agencies in partnership with national healthrelated organizations should:
A. Ensure that the clinical guidelines are consistent with nationally accepted disease definitions and evidence-based guidelines used for
the nonincarcerated population.40
B. Disseminate the clinical guidelines to correctional health care professionals, public health
agencies, and public policymakers.
C. Update the clinical guidelines as often as
needed.
D. Develop standardized performance measures
for State and local correctional authorities to
determine adherence to nationally accepted
clinical guidelines.
E. Train correctional health and public health
professionals in the use of these clinical
guidelines and performance measures.
F. Develop tools for correctional systems to
assess over-prescribing and under-prescribing
of psychotropic medications.

Immunizations
Immunizations prevent the development of a variety
of communicable diseases in individuals. In the
case of diseases such as hepatitis B, poliomyelitis,
measles, mumps, or rubella, immunizations prevent
the transmission of disease to susceptible individuals in the general population. Such immunizations
are nationally accepted and promoted by the Centers
for Disease Control and Prevention. Some immunizations are directly cost saving and others are
highly cost effective.
III. Congress should establish and fund a national
vaccine program for inmates to protect them and

the public from selected vaccine-preventable
communicable diseases.
A. The vaccination program should be similar to
the National Vaccine Program for Children.
B. The program should conform to the recommendations of the CDC’s Advisory Committee on
Immunization Practices (ACIP).41

National correctional health care literature
database
To function competently, correctional health care
clinicians require access to the medical literature,
especially as it relates to correctional health care
issues. Existing resources do not provide this level
of specificity.
IV. Congress, through appropriate Federal agencies
and health-related national organizations, should
develop and maintain a national literature database for correctional health care professionals,
including a compendium of policies, standards,
guidelines, and peer-reviewed literature.

Ethical decisionmaking
Correctional health care professionals function in
a uniquely restrictive environment with limited
opportunity for peer review of medical policies and
administrative actions. A national forum is needed
to discuss issues, such as confidentiality, informed
consent, clinical management of hepatitis C42 and
HIV, and the availability of biomedical research.
V. Congress should establish a national advisory
panel on ethical decisionmaking among correctional and health authorities to assist those authorities
in addressing ethical dilemmas encountered in
correctional health care.

Eliminate barriers to inmate health care
In correctional facilities, health care professionals
face unique barriers to the delivery of health services. These include constraints on policy, budgets,
priorities, and staffing. Correctional institutions are
positioned to provide individual care to inmates and
protect the public health through aggressive health
promotion and disease prevention efforts. At all levels of government, public policymakers should recognize that eliminating barriers to health care for
inmates provides long-term public health benefits.

xvii

VI. Congress, through appropriate Federal and State
agencies and health-related national organizations,
should identify and eliminate barriers to the successful implementation of public health policy.
A. Reduce obstructions to effective public
health programs within correctional facilities and in the community.
B. Promote continuity of inmate health care by
maintaining Medicaid benefits for eligible
inmates throughout their incarceration.
C. Promote continuity of ex-offender health
care by mandating immediate Medicaid eligibility upon release.
D. Provide incentives to jails and prisons to
expand their alcohol and other drug treatment
programs. These services should be gender
specific and made available to inmates from
admission through release, with special
attention paid to inmates with both mental
illness and substance abuse problems.

Correctional health care research
Too little is known about the epidemiology of
disease in correctional populations and too little
has been done to evaluate programs designed to
improve inmate health.
VII. Congress, through appropriate Federal agencies
and health-related national organizations, should
support research in correctional health care to
identify and address problems unique to correctional settings.
A. Fund projects to evaluate models that
emphasize creative, cost-effective options
for continuity of care following release.
B. Fund research programs to define effective
health education and risk reduction strategies for inmates. These strategies need to
deal with relevant differences between
inmate and noninmate populations. The
research programs should work through
public, private, and community-based
health care agencies.
C. Fund research programs to identify correctional system barriers that prevent correctional health care staff from implementing
prudent medical care and public health
recommendations.

Improve delivery of health care
For a variety of reasons, the scope and content of
correctional health care services vary. The quality
of care is not as high as it might be, resulting in
unnecessary morbidity, premature mortality, and
increased costs.
VIII. Congress, through appropriate Federal agencies
and medically based accrediting organizations,
should promote improvements to the delivery
of inmate health care.43
A. Require Federal, State, and local correctional systems to adhere to nationally recognized standards for the delivery of health
care services in corrections.44 These standards should include access to care, quality
of care, quality of service, and appropriate
credentialing of health care professionals.
B. Provide sufficient resources for correctional
systems to adhere to national standards.
C. Weigh the correctional system’s adherence
to national standards for health care delivery whenever determining funding levels
for the system.

Disease prevention
Primary prevention is designed to keep disease from
occurring. Examples include lifestyle choices and
vaccination against selected communicable diseases.
Primary prevention is widely believed to be the best
and most cost-effective use of health care dollars.
In some cases, it is also a cost saving—that is, the
prevention program saves more money than it costs
to implement. Secondary prevention (screening) is
the early detection of disease that already exists but
may not be apparent to the patient.45
IX. Congress, through appropriate Federal agencies
and national organizations, should encourage primary and secondary disease prevention efforts.
A. Promote primary disease prevention measures by requiring Federal, State and local
correctional agencies to:
1. Provide all inmates with a smoke-free correctional environment. Offer tobacco cessation programs for all staff and inmates as a
method of achieving tobacco-free facilities.

xviii

2. Offer heart-healthy choices on institutional
menus and in commissaries.
3. Make daily aerobic exercise available to all
inmates.
4. Consistent with the recommendations of
the ACIP, make hepatitis B vaccines available to all inmates, even when their length
of incarceration is short or indeterminate.
5. Screen all females for pregnancy. Test
women found to be pregnant for hepatitis,
HIV infection, syphilis, gonorrhea, and
chlamydia. Provide HIV treatment to HIVinfected mothers to prevent transmission
of the disease to the newborn.
6. Although not a correctional system
responsibility, administrators should seek
to collaborate with community health care
providers to ensure the timely immunization of all infants born to mothers who test
positive for hepatitis B.
7. Offer scientifically based risk reduction
education on HIV infection and STD to
all inmates.
B. Promote secondary disease prevention measures by using nationally accepted evidencebased clinical guidelines as appropriate.
1. Provide hypertension, obesity, asthma, and
seizure disorder screening for all prison
inmates.
2. Provide diabetes and hyperlipidemia
screening for jail and prison inmates at
high risk.
3. Provide suicide prevention programs,
including timely screening for inmates
at high risk for suicide.
4. Prevent the spread of tuberculosis.
a. Consistent with nationally accepted
guidelines,46 routinely screen inmates for
TB disease and infection, and provide
preventive treatment for inmates with
latent TB infection.
b. Promote the use of short-course preventive therapy (delivered over 2 months)
in correctional settings.

c. Strengthen the link of TB control
efforts between correctional facilities
and public health departments.
d. On employment and annually thereafter,
screen all correctional staff who have
inmate contact for latent TB infection.
5. Prevent the spread of HIV infection.
a. Encourage voluntary HIV counseling
and testing of inmates.
b. Provide appropriate treatment for HIVpositive, pregnant inmates to prevent
HIV transmission to their babies.47
6. Screen inmates for syphilis, gonorrhea, and
chlamydia routinely upon reception at prisons and jails, and treat inmates who test
positive for these infections.48

Prerelease planning
Many inmates are released into the community while
still being treated for communicable and chronic
diseases or mental illness. Ensuring continuity of
care upon release can reduce health risks to the public, such as in cases of tuberculosis and sexually
transmitted diseases. Continuity of care upon release
for inmates with co-occurring mental illness and
substance abuse disorders can reduce the risk of
illicit drug use in the community. It is cost effective
to the community to provide continuity of care on
release for inmates with chronic disease.
X. Congress, through appropriate Federal agencies
and national organizations, should encourage
Federal, State and local correctional facilities to
provide prerelease planning for health care for all
soon-to-be-released inmates.
A. Address the medical, housing, and postrelease
needs of inmates in prerelease planning and
make use of appropriate resources and new
technologies.
B. Coordinate discharge planning efforts between
appropriate public agencies—such as correctional, parole, mental health, substance abuse,
and public health agencies—to prevent disease
transmission and to reduce society’s costs
from untreated and undertreated illness.

xix

Recommended actions by government
agencies
The steering committee and expert panels recognized
that many Federal agencies have a role in affecting
the health status of soon-to-be-released inmates.
Within the U.S. Department of Health and Human
Services (DHHS), for example, agencies such as the
Centers for Disease Control and Prevention (CDC),
the Health Resources and Services Administration
(HRSA), the Substance Abuse and Mental Health
Services Administration (SAMHSA), the National
Institute on Drug Abuse (NIDA), the Office of
Women’s Health (OWH), the Public Health Service
(PHS), the Indian Health Service (IHS), and the
Office of Minority Health (OMH) are actively
engaged in health services programs that impact on
inmates. In addition, within the U.S. Department
of Justice (DOJ), agencies such as the National
Institute of Justice (NIJ), the Immigration and
Naturalization Service (INS), the Bureau of Prisons
(BOP) including the National Institute of Corrections
(NIC), the Corrections Program Office (CPO), and
the Office of Justice Programs (OJP) conduct programs and activities that ultimately influence
inmate health. Finally, the Office of the Surgeon
General (OSG) and the White House Executive
Office of National Drug Control Policy (ONDCP)
also impact the health care of inmates.
The steering committee and expert panels recommend
that Congress provide the necessary authorization,
funding, and other assistance to the appropriate agencies to implement the following recommendations.
I. The Secretary of DHHS should direct appropriate agencies to collaborate with other agencies
in analyzing the potential economic benefits to
the community of early diagnosis and treatment
of communicable diseases, chronic diseases,
and mental illnesses.
II. The Secretary should direct CDC to collaborate
with NIJ, NIC, CPO, and other DOJ divisions in
developing tools to assist State and local agencies in deciding when and whom to screen for
communicable diseases in correctional settings.
III. The Secretary should direct all appropriate
agencies within the department to work toward
reducing interagency regulatory and bureaucratic

barriers to testing and counseling for HIV, TB,
and STDs among inmates.
IV. The Secretary and the Attorney General should
involve correctional health professionals in public health planning and the evaluation of correctional health care programs.
V. The Secretary and the Attorney General should
direct appropriate agencies to support field tests
of innovative medical information systems to
improve the continuity of care for inmates transferred between correctional facilities or released
into the community. These efforts should concentrate on removing barriers that impede the
transfer of appropriate medical information.
VI. The Secretary and the Attorney General should
direct appropriate agencies to develop educational programs to inform policymakers and the
public about the public health and social benefits of investing in health care for inmates.
VII. A Federal interagency task force, currently
established and co-chaired by CDC and NIJ,
should report annually to the Secretary and the
Attorney General on the status of correctional
health care in the Nation and on progress made
toward implementing the recommendations
included in this report.

Notes
1. Beck, A.J., Prisoners in 1999, Bulletin, Washington,
DC: U.S. Department of Justice, Office of Justice
Programs, Bureau of Justice Statistics, August 2000,
NCJ 183476.
2. Beck, Allen, U.S. Department of Justice, Bureau of
Justice Statistics, personal interview, May 15, 2000.
3. Corrections departments also have a legal obligation
to treat inmates. The most important single ruling has
been the U.S. Supreme Court’s 1976 finding in Estelle v.
Gamble, 429 U.S. 97, that “deliberate indifference” (not
mere medical malpractice) to “serious medical needs”
of inmates violates the eighth amendment’s prohibition
against cruel and unusual punishment.
4. An estimated 339,070 people were employed in State
and Federal correctional facilities in 1995 and 165,500
were employed in jails. See Stephan, J.J., Census of State
and Federal Correctional Facilities, 1995, Bureau of
Justice Statistics Executive Summary, Washington, DC:

xx

U.S. Department of Justice, Bureau of Justice Statistics,
August 1997, NCJ 166582; and Perkins, C.A., J.J.
Stephan, and A.J. Beck, Jails and Jail Inmates, 1993–94,
Bulletin, Washington, DC: U.S. Department of Justice,
Bureau of Justice Statistics, April 1995, NCJ 151651.
5. See, for example, Glaser, J.B., and R.B. Greifinger,
“Correctional Health Care: A Public Health Opportunity,”
Annals of Internal Medicine 118 (2) (1993): 139–145.
6. Hornung, C.A., B.J. Anno, R.B. Greifinger, and S.
Gadre, “Health Care for Soon-To-Be-Released Inmates:
A Survey of State Prison Systems,” paper prepared for
the National Commission on Correctional Health Care,
Chicago, IL, n.d. (Copy in volume 2 of this report.)
7. Hammett, T.M., P. Harmon, and W. Rhodes, “The
Burden of Infectious Disease Among Inmates and
Releasees From Correctional Facilities,” paper prepared
for the National Commission on Correctional Health
Care, Chicago, IL, May 2000. (Copy in volume 2 of this
report.)
8. The U.S. Department of Justice, Bureau of Justice
Statistics, is preparing a report for release in 2002 on the
prevalence of hepatitis among correctional populations,
based on data from the 2001 census of State and Federal
adult correctional facilities.
9. This figure was derived by applying the prevalence of
TB disease among inmates in prisons (0.04 percent) and
jails (0.17 percent) to the estimated number of releasees
from prisons and jails. The estimate of releases was calculated by applying a point prevalence rate for inmates
(i.e., the percentage of inmates who were under treatment for TB disease on a given day in 1997) to the total
number of releasees during all of 1996. The estimate suggests that about 12,000 people who were released from a
correctional facility during 1996 had TB disease at some
time during that year, but it does not mean that they all
had TB disease at the time of their release from prison or
jail. Most of them probably did not have TB disease at
the time of their release because, if properly treated, TB
disease typically lasts only a short time. The denominator
(34,000) is an estimate of the total number of persons
with TB in the United States during 1996. The Centers
for Disease Control and Prevention’s TB Registry Reports,
which provided the numbers of cases in a given year,
were discontinued in 1994. The only report for subsequent years is CDC’s TB surveillance report, which
provides incident (new) cases each year. Therefore, an
average ratio of incident cases to prevalent cases was
calculated for the last 3 years in which Registry Reports

were available (1992–94). This ratio (0.627) was then
applied to the number of incident cases for 1996 (21,337)
to obtain the estimate of 34,000 prevalent cases in 1996.
10. Centers for Disease Control and Prevention, HIV/AIDS
Surveillance Report, 1997, Atlanta, GA: U.S. Department
of Health and Human Services, Centers for Disease
Control and Prevention, 1997.
11. A more recent study concluded that the 1996 AIDS
rate for incarcerated persons was at least six times the
national rate. See Dean-Gaitor, H.D., and P.L. Fleming,
“Epidemiology of AIDS in Incarcerated Persons in the
United States, 1994–1996,” AIDS 13 (17) (1999):
2429–2435.
12. Based on the prevalence estimate in McQuillan,
G.M., M.J. Alter, L.A. Moyer, S.B. Lambert, and H.S.
Margolis, “A Population-Based Serologic Survey of
Hepatitis C Virus Infection in the U.S.,” in Rizzetto, M.,
R.H. Purcell, G.L. Gerin, and G. Verme (eds.), Viral
Hepatitis and Liver Disease, Turin, Italy: Edizioni
Minerva Medica, 1997: 267–270.
13. Hammett, Harmon, and Rhodes, “The Burden of
Infectious Disease Among Inmates and Releasees” (see
note 7). The 17.0–18.6 percent estimate is probably very
low, given that studies conducted in individual prison
systems have found prevalence rates of 30–40 percent.
14. Hornung C.A., R.B. Greifinger, and S. Gadre, “A
Projection Model of the Prevalence of Selected Chronic
Disease in the Inmate Population,” paper prepared for
the National Commission on Correctional Health Care,
Chicago, IL, n.d. (Copy in volume 2 of this report.)
15. Veysey, B.M., and G. Bichler-Robertson, “Prevalence
Estimates of Psychiatric Disorders in Correctional
Settings,” paper prepared for the National Commission
on Correctional Health Care, Chicago, IL, May 1999.
(Copy in volume 2 of this report.)
16. Dysthymia and anxiety range from completely disabling (e.g., agoraphobia) to not even mildly incapacitating (e.g., generalized anxiety disorder). Depending on
the severity of their condition, many individuals with
dysthymia and anxiety do not require medical treatment.
17. Hammett, T.M., P. Harmon, and L.M. Maruschak,
1996–1997 Update: HIV/AIDS, STDs, and TB in
Correctional Facilities, Issues and Practices, Washington,
DC: U.S. Department of Justice, National Institute of
Justice, July 1999, NCJ 176344.

xxi

18. A comprehensive HIV-prevention program provides
HIV counseling and testing, instructor-led education,
peer-based programs, and multisession HIV-prevention
counseling in each correctional facility.
19. Hornung, Anno, Greifinger, and Gadre, “Health Care
for Soon-To-Be-Released Inmates” (see note 6).
20. Steadman, H.J., and B.M. Veysey, Providing Services
for Jail Inmates With Mental Disorders, Research in
Brief, Washington, DC: U.S. Department of Justice,
National Institute of Justice, January 1997, NCJ 162207.
21. Ibid.
22. Manderscheid, R.W., and M.A. Sonnenschein
(eds.), Mental Health, United States, 1992, Rockville,
Maryland: U.S. Department of Health and Human
Services, 1992.
23. Steadman and Veysey, Providing Services (see note 20).
24. Hammett, Harmon, and Maruschak, 1996–1997
Update (see note 17).

30. Taylor, Z., and C. Nguyen, “Cost-Effectiveness of
Preventing Tuberculosis in Prison Populations,” presentation prepared for the National Commission on
Correctional Health Care, Chicago, IL, n.d. (Copy in
volume 2 of this report.)
31. Tomlinson, D.M., and C.B. Schechter, “CostEffectiveness Analysis of Annual Screening and Intensive
Treatment for Hypertension and Diabetes Mellitus
Among Prisoners in the United States,” paper prepared
for the National Commission on Correctional Health
Care, Chicago, IL, n.d. (Copy in volume 2 of this report.)
32. Shuter, J., “Communicable Diseases in Inmates:
Public Health Opportunities,” paper prepared for the
National Commission on Correctional Health Care,
Chicago, IL, n.d. (Copy in volume 2 of this report.)
33. Draft clinical guidelines submitted to the National
Commission on Correctional Health Care, Chicago,
Illinois, currently under consideration for adoption.
(Copy in appendix D of this volume.)
34. Hammett, Harmon, and Maruschak, 1996–1997
Update (see note 17).

25. Steadman and Veysey, Providing Services (see note 20).
26. Kraut, J.R., A.C. Haddix, V. Carande-Kulis, and R.B.
Greifinger, “Cost-Effectiveness of Routine Screening
for Sexually Transmitted Disease Among Inmates in
United States Prisons and Jails,” paper prepared for the
National Commission on Correctional Health Care,
Chicago, IL, February 2000. (Copy in volume 2 of this
report.)
27. Ibid.
28. Varghese, B., and T.A. Peterman, “Cost-Effectiveness
of HIV Counseling and Testing in U.S. Prisons,” paper
prepared for the National Commission on Correctional
Health Care, Chicago, IL, n.d. (Copy in volume 2 of this
report.)
29. American Thoracic Society and the Centers for
Disease Control and Prevention, “Targeted Tuberculin
Testing and Treatment of Latent Tuberculosis Infection,”
American Journal of Respiratory and Critical Care
Medicine 161 (2000): 221S–247S; American Thoracic
Society and the Centers for Disease Control and
Prevention, “Diagnostic Standards and Classification of
Tuberculosis in Adults and Children,” American Journal
of Respiratory and Critical Care Medicine 161 (2000):
1376–1395.

35. Morris, S.M., H.J. Steadman, and B.M. Veysey,
“Mental Health Services in United States Jails: A
Survey of Innovative Practices,” Criminal Justice
and Behavior 24 (1) (1997): 3–19.
36. Surveillance is the ongoing systematic collection,
analysis, and interpretation of health data.
37. See, for example, National Center for Health
Statistics, National Health and Nutrition Examination
Survey III [NHANES–III], Atlanta, GA: U.S. Department
of Health and Human Services, Centers for Disease
Control and Prevention, 1997.
38. The definitions of mental disorders and presentation
of their prevalence in American Psychiatric Association,
Diagnostic and Statistical Manual of Mental Disorders,
4th ed., Washington, DC: American Psychiatric Press,
1994, are a good illustration of the standardized definitions and measures that are needed in the field of correctional health care.
39. “Summary of Notifiable Diseases, United States,
1998,” Morbidity and Mortality Weekly Report 47 (53)
(December 31, 1999).

xxii

40. See, for example, “Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents,”
Rockville, MD: U.S. Department of Health and Human
Services, available at http://www.hivatis.org/guidelines/
adult/Apr23_01/pdf/AAAPR23S.PDF (updated April 23,
2001); American Diabetes Association, “Standards for
Medical Care for Patients With Diabetes Mellitus,”
Clinical Practice Recommendations 2000, Diabetes Care
(supp. 1) (2000): 1–23; American Diabetes Association,
“Management of Diabetes in Correctional Institutions,”
Clinical Practice Recommendations 2000, Diabetes Care
21 (supp. 1) (2000): 1–3; National Institutes of Health,
National Asthma Education and Prevention Program,
Expert Panel Report 2: Guidelines for the Diagnosis and
Management of Asthma, Bethesda, MD: National Heart,
Blood, and Lung Institute, February 1997; National
Institutes of Health, “Sixth Report of the Joint National
Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure,” Bethesda, MD:
National Heart, Lung, and Blood Institute, November
1997; “Clinical Guidelines: Report of the NIH Panel to
Define Principles of Therapy of HIV Infection and Guidelines for the Use of Antiretroviral Agents in HIV-Infected
Adults and Adolescents,” Bethesda, MD: National
Institutes of Health (updated May 5, 1999); and Centers
for Disease Control and Prevention, “Clinical Guidelines:
1999 USPHS/IDSA Guidelines for the Prevention of
Opportunistic Infections in Persons Infected With Human
Immunodeficiency Virus,” Morbidity and Mortality
Weekly Report 48 (RR–10) (August 20, 1999): 1–59,
61–66.
41. The recommendations of the CDC’s Advisory Committee on Immunization Practices can be found at CDC’s
Web site: http://www.cdc.gov/nip/publications/ACIPlist.htm.

42. See the Centers for Disease Control and Prevention,
“Recommendations for Prevention and Control of
Hepatitis C Virus (HCV) Infection and HCV-Related
Chronic Disease,” Morbidity and Mortality Weekly
Report 47 (RR–19) (October 16, 1998): 1–39.
43. For a comparison of accreditation services for correctional institutions, see Anno, B. J., Correctional Health
Care: Guidelines for the Management of an Adequate
Delivery System, Washington, DC: U.S. Department of
Justice, National Institute of Corrections (in press).
44. See National Commission on Correctional Health
Care, Standards for Health Services in Prisons, and
Standards for Health Services in Jails, Chicago, IL:
Author (in press).
45. A detailed discussion of the differences between
primary and secondary prevention may be found in
Last, J.M., Public Health and Human Ecology, 2d ed.,
Stamford, CT: Appleton & Lange, 1998.
46. An excellent source for a tuberculosis clinical guideline is the Centers for Disease Control and Prevention at
their Web site: www.cdc.gov.
47. See U.S. Department of Health and Human Services,
“Guidelines for the Use of Antiretroviral Agents” (see
note 40).
48. The Centers for Disease Control and Prevention
have prepared “HIV Prevention Through Early Detection
and Treatment of Other Sexually Transmitted Diseases—
United States. Recommendations of the Advisory Committee for HIV and STD Prevention,” Morbidity and
Mortality Weekly Report 47 (RR–12) (July 31, 1998).

1

Chapter 1. Introduction

This report presents the results of a 2-year study of
the health status of prison and jail inmates.1 The
study demonstrates that improving the health care
of inmates can benefit public health in two important ways:
(1) By reducing the transmission of communicable disease to others in the community
from inmates who are released with untreated
conditions and without having participated in
disease prevention programs.
(2) By reducing the financial burden on the
public associated with treating released
inmates who return to the community with
undiagnosed or untreated communicable
disease, chronic disease, and mental illness,
thereby freeing up resources for other worthy
public health initiatives.
In the Omnibus Consolidated Appropriations Act of
1997, Congress instructed the U.S. Department of
Justice (DOJ) to set aside money to fund The
Health Status of Soon-To-Be-Released Inmates
study. As a result, the National Institute of Justice
(NIJ), DOJ’s research and evaluation arm, entered
into a cooperative agreement with the National
Commission on Correctional Health Care (NCCHC)
to conduct the study. This report represents the culmination of the project’s work.
There are many reasons why inmate health should
be appropriately addressed. The Health Status of
Soon-To-Be-Released Inmates examines only certain
diseases and illnesses with serious implications for
public health. The omission of diseases and illnesses from the study and the report does not mean that
it is not important to address these conditions. The
project is not intended to be a full-scale study of all
aspects of inmate health care.

Chapter 1, Introduction, reviews the urgency of
addressing inmate health care needs, the unique
opportunity that addressing these needs provides
for improving public health, and the need for reliable data on the health status of inmates in order
to develop effective correctional health care policy
recommendations.
Chapter 2, History of the Project, describes the
steps The Health Status of Soon-To-Be-Released
Inmates project followed in producing this report.
Chapter 3, Prevalence of Communicable Disease,
Chronic Disease, and Mental Illness Among the
Inmate Population, estimates the number and proportion of inmates with selected communicable
diseases, chronic medical conditions, and mental
illnesses. The chapter compares the prevalence of
these conditions among inmates to their prevalence
among the population as a whole.
Chapter 4, Improving Correctional Health Care:
A Unique Opportunity to Protect Public Health,
describes the current status of prevention, screening,
and treatment programs in prisons and jails for
communicable disease, chronic disease, and mental
illness. The chapter documents difficulties many
correctional agencies have experienced in meeting
nationally accepted guidelines for correctional health
care. These findings suggest that a tremendous—
and, as yet, largely unexploited—opportunity exists
to benefit public health by improving correctional
health care practices.

Organization of the Report

Chapter 5, Cost-Effectiveness of Prevention,
Screening, and Treatment of Disease Among
Inmates, establishes that implementing interventions for selected communicable and chronic diseases would be cost effective and, in some cases,
save money. The chapter identifies interventions
with proven efficacy to help reduce or eliminate
the risks associated with communicable and
chronic disease.

Volume 1 of The Health Status of Soon-To-BeReleased Inmates has seven chapters.

Chapter 6, Barriers to Effective Prevention,
Screening, and Treatment—and Overcoming

2

Them, identifies the barriers to providing health care
in prisons and jails and well-documented approaches
to overcoming these barriers.
Chapter 7, Policy Recommendations, identifies
steps that correctional systems and Federal, State,
and local agencies can take that will reduce health
risks to the community by improving the prevention,
screening, and treatment of disease and mental illness
among inmates.
Appendixes to volume 1 include the list of authors,
experts, and consultants who participated in the
project, brief biographies of these individuals, the
survey instrument used to collect information from
State departments of corrections, sample clinical
guidelines for correctional health care, and an introduction to the National Commission on Correctional
Health Care and its position statements.
Volume 2 of the report includes the eight papers and
two presentations commissioned for the project (see
chapter 2, “History of the Project”).
This chapter makes clear that a unique opportunity
exists to reduce the health risks and financial costs
to the community—and to correctional staff and

visitors—associated with the large numbers of undiagnosed, underdiagnosed, untreated, and undertreated inmates returning to the community from the
Nation’s prisons and jails. The chapter explains the
need for empirical data to support policy recommendations for addressing the health care needs of
inmates and the critical role this project plays in
identifying and generating this scientific information. This chapter’s main points are summarized in
“The Rationale for Improving Health Care for
Inmates Before They Are Released.”

Problem of Untreated Prison and
Jail Inmates
The inmate population in the United States has been
growing rapidly since the early 1970s: As of 1999,
an estimated 2 million persons were incarcerated in
the Nation’s jails and prisons compared with 325,400
in 1970—an increase of almost 600 percent.2 Approximately 11.5 million inmates were released
into the community in 1998, most from city and
county jails.3 As documented in chapter 3, these
inmates are at higher risk for many serious diseases and mental illness than are nonincarcerated
individuals.

The Rationale for Improving Health Care for Inmates Before They Are Released
1. There are high rates of serious disease and mental illness among prison and jail inmates—in some
cases, much higher rates than in the general public.
2. Untreated inmates with communicable disease who are released into the community may transmit
these conditions to members of the public at large.
3. Releasing inmates with untreated serious communicable disease, chronic disease, and mental illness is
likely to create a financial burden on the local community’s public health system.
4. As a result, prisons and jails offer a uniquely important opportunity for establishing better disease
control in the community by providing health care and prevention interventions to inmates while
they are still incarcerated.
5. Preventing and treating inmates with serious communicable and chronic disease is cost effective—
that is, the benefits outweigh the expense. For some diseases, prevention or screening can even save
money.
6. Barriers to providing prevention, screening, and treatment services to inmates can be overcome.
7. Correctional administrators and public health officials need accurate information about the health of
inmates in order to select appropriate and cost-effective interventions. These data have been lacking.
The Health Status of Soon-To-Be-Released Inmates project has been able to develop scientifically
based policy recommendations for improving correctional health care.

3

●

The prevalence rates for several serious communicable diseases are significantly higher among
inmates and releasees than in the total U.S.
population. Seventeen percent of the estimated
229,000 persons living with AIDS in the country
in 1996 passed through a correctional facility that
year.4 An extremely high 29–32 percent of the
estimated 4.5 million people infected with hepatitis C in 1996 in the United States served time in
prison or jail that year.5

●

Inmates have high rates of some serious chronic
diseases, including asthma, diabetes, and hypertension. Prevalence rates for asthma are higher
among inmates than among the total U.S. population.6

●

The prevalence of mental illness is higher among
inmates than among the rest of the population.
An estimated 2.3 to nearly 4 percent of inmates
in State prisons have schizophrenia or another
psychosis compared with 0.8 percent among the
population of the Nation as a whole.7

These high rates of communicable disease, chronic
disease, and mental illness among an expanding
inmate population create a critical need for prevention, screening, and treatment services before these
individuals are released into the community.8 Why?
First, serious diseases affecting inmates can be
transmitted to other inmates. Absent appropriate
screening and isolation for contagious individuals,
tuberculosis (TB) transmission is a serious possibility in prisons and jails because of poor ventilation
and overcrowding.9 HIV transmission has been documented within correctional facilities, albeit at low
rates.10 In addition, the many inmates with poor overall health have an increased susceptibility to disease.

Finally, the threat of releasing untreated inmates
with contagious diseases involves more than the
possibility of infecting other people in the community. Inmates who are released with untreated conditions—including communicable disease, chronic
disease, and mental illness—may also become a
serious financial burden on community health care
systems. An illustration suggests the seriousness of
this danger:
Outbreaks of multidrug/resistant tuberculosis
that have occurred in prisons have spread into
the community as inmates with the disease
have been released, resulting in deaths and
enormous public costs to control the infection.12
Efforts to control the resurgence of tuberculosis in the early 1990s—fueled at least in part
by released inmates—cost New York City
alone more than $1 billion.13
The danger and expense to the community of
releasing untreated inmates are likely to grow for
several reasons.
●

Prison and jail populations are increasing. The
number of inmates is growing about 5 percent
per year and is now more than 1.9 million. Each
week, the Nation must add more than 1,100
prison beds to keep up with the rapidly growing
inmate population.14

●

Certain diseases are more common among substance abusers than among the rest of the population, including HIV/AIDS, hepatitis B and C, and
tuberculosis.15 At the same time, an increasing
proportion of inmates are substance abusers. In
1985, only 38,900—8.6 percent—of State prison
inmates were serving time for drug offenses as
their most serious crime committed. By 1995,
that number had increased almost sixfold to
224,900—22.7 percent of all inmates.16 This
change has brought more individuals into the
corrections system who are at very high risk for
acquiring and transmitting HIV, hepatitis, and
tuberculosis.17

●

Even though correctional populations are still
younger than the national average, the Nation’s
prison and jail populations are aging. In 1997,
almost 30 percent of inmates in State or Federal
prisons were between the ages of 35 and 44, compared with 23 percent in 1991. The rise was offset

Second, the Nation’s 500,000 correctional employees11—and the thousands of daily visitors to prisons
and jails—may be exposed to disease unless appropriate precautions are taken. These employees and
visitors in turn may infect family members and others in the community.
Third, inmates with communicable diseases who
are released without having been effectively treated
may transmit these conditions in the community,
threatening public health.

4

by a decline in the percentage of inmates aged
18–34. (The percentage of inmates 55 years old
or older did not change—about 3 percent in both
years.)18 A similar phenomenon is occurring in
jails.19 As the inmate population gets older, chronic
diseases associated with increasing age, such as
diabetes and hypertension,20 can be expected to
increase among correctional populations.

Window of Opportunity
Prisons and jails offer uniquely important opportunities for improving disease control in the community by providing health care and disease prevention
programs to a large and concentrated population
of individuals at high risk for disease.21 Prisons and
jails make it possible to reach a population that is
largely underserved and difficult to identify and
treat in the general community. Inmates often have
little interaction with the health care system before
and after being incarcerated.22 Most inmates come
from poor communities where health care services,
other than hospital emergency rooms, are largely
inaccessible or underutilized.23 For a variety of reasons, many inmates do not seek diagnosis or treatment for illness before arriving in prison or jail.24
Because inmates are literally a “captive” audience,
it is vastly more efficient and effective to screen and
treat them while incarcerated than to conduct extensive outreach in local communities designed to
encourage at-risk individuals to go to a clinic for
testing and treatment. By introducing routine prevention, screening, and treatment into prisons and
jails, incarceration offers an opportunity for an
underserved high-risk population to receive prevention and treatment services.
There is another important advantage to reaching
this population while it is still incarcerated. Many
illnesses that are prevalent among inmates are
linked to a number of other health problems. There
are high rates of coinfection with HIV/AIDS, sexually transmitted diseases, hepatitis B and C, and
tuberculosis.25 Substance abusers are at very high
risk for HIV, hepatitis, and other infectious and
chronic diseases.26 Unless adequately treated, people
with mental illness often “medicate” themselves
with alcohol or illicit drugs.27 By preventing or
treating one of the conditions these individuals
suffer from, the development of several other
conditions may be averted.

Finally, correctional facilities offer this population
access to prevention and treatment services at a time
when their thinking is less likely to be clouded by
active drug use or by pressing survival concerns,
such as the need for employment, housing, or food.

Preventing and Treating Disease in
Prisons and Jails Are Cost Effective
Most inmates have not had access to routine health
care before being incarcerated. Correctional systems pay the consequences of this lack of preincarceration prevention and treatment. Because inmates
may not have had eye examinations before they
went to prison or jail that might have detected
treatable incipient diabetes, the correctional system
must pay for addressing the medical consequences
of their untreated diabetes. Nevertheless, it is cost
effective for correctional systems to implement
proven approaches to preventing, screening for, and
treating disease among inmates. The reduction in
adverse health consequences to society that correctional agencies can achieve is unquestionably worth
the cost of providing these services. Analyses conducted expressly for The Health Status of Soon-ToBe Released Inmates project document that screening
for syphilis28 and latent tuberculosis infection,29 and
providing counseling and testing for HIV infection,30
will save more money in averted medical costs than
would be needed to implement the interventions.
Corrections agencies can most effectively limit the
number of untreated inmates they release into the
community by addressing diseases that (1) are highly
prevalent among inmates, (2) pose a serious threat
to public health, and (3) can be effectively prevented or treated. On the one hand, these are the conditions that, if untreated, are most likely to spread in
prisons and jails and to pose a threat to public
health as inmates are released. On the other hand,
these are the conditions that the correctional health
care system is best equipped to prevent or treat.
Many correctional systems have experienced difficulties in attempting to improve their health care
services for the most prevalent, serious, and preventable or treatable diseases and mental disorders
among inmates. Correctional systems have faced the
following barriers:

5

●

Leadership barriers. Many administrators and
other decisionmakers in correctional systems and
in the community are not aware of the need or
the opportunity to improve correctional health
care, while others lack the political will or commitment to take the lead.

●

Logistical barriers. The short stay of many jail
inmates increases the challenge to identify quickly
inmates with serious conditions, particularly
communicable diseases.

●

Financial barriers. Correctional administrators
may feel they cannot provide adequate medical
care for all inmates because other prison or jail
services have a higher priority for the limited
funds available.

●

For many health care policy questions, substantial
evidence often demonstrates how various interventions can be expected to affect health outcomes.
This is usually not the case for inmate health. There
has been a severe gap in the data available regarding the health status of inmates in prisons and jails,
and therefore a lack of information regarding costeffective means of improving inmates’ physical and
mental health. A survey of 41 State departments
of corrections conducted as part of this project31
documented this gap.
●

Fewer than one-half of the departments reported
having data on the number of inmates with chronic
diseases, such as diabetes, asthma, or hypertension.

●

Only 17 out of 41 departments could report the
number of inmates taking selected medications;
even fewer could report the number of inmates
taking inhaled asthma medications, insulin or
medications for low blood sugar, or antihypertension medicines; fewer still could provide the
number of inmates taking medications prescribed
for heart disease. Collecting and having quick
access to reliable pharmaceutical data is crucial
to determining which inmates are or should be
taking medication and improving quality of care.

●

Just more than one-half of the responding departments reported having data on the number of
mentally ill inmates in their systems.

Policy barriers. Many correctional systems will
not allow mentally ill inmates with substance
abuse problems to participate in outpatient and
residential drug treatment programs if they continue to use prescription medications to treat their
mental disorders.

As chapter 6 explains, the local community—in particular, local public health departments—contributes
to the barriers correctional systems face in providing
health care by not sharing responsibility for improving correctional health care services. As the chapter
demonstrates, however, there are well-documented
ways of overcoming these barriers through collaborations between correctional and public health agencies.

Need for Scientific Data on
Inmate Health
The principal goal of The Health Status of Soon-ToBe-Released Inmates project is to provide public
policy recommendations whose implementation will
help reduce health risks and health care costs resulting from the release of undiagnosed or untreated
inmates. Correctional health administrators, public
health officials, and government policymakers need
accurate correctional health data to establish priorities, allocate resources, and select the most costeffective health care interventions. Correctional
health care programs should be based on the best
available information on the efficacy and costs of
competing health care priorities and intervention
strategies.

The cooperative agreement between the National
Institute of Justice and the National Commission on
Correctional Health Care charged the Commission
with providing this missing empirical evidence
regarding inmate health. The Commission was then
charged with using the information to develop scientifically based policy recommendations related to
prevention, screening, and treatment of disease and
mental illness among inmates in prisons and jails.
The following chapter provides the history of this
collaboration.

Notes
1. Inmates refer to individuals incarcerated in a prison or
jail. Releasees are individuals discharged from a prison
or jail.
2. Beck, A.J., Prisoners in 1999, Bulletin, Washington,
DC: U.S. Department of Justice, Office of Justice

6

Programs, Bureau of Justice Statistics, August 2000,
NCJ 183476.
3. Beck, Allen, U.S. Department of Justice, Bureau of
Justice Statistics, personal interview, May 15, 2000.
4. Hammett, T.M., P. Harmon, and W. Rhodes, “The Burden
of Infectious Disease Among Inmates and Releasees From
Correctional Facilities,” paper prepared for the National
Commission on Correctional Health Care, Chicago, IL,
May 2000. (Copy in volume 2 of this report.)

Summary, Washington, DC: U.S. Department of Justice,
Bureau of Justice Statistics, August 1997, NCJ 166582;
and Perkins, C.A., J.J. Stephan, and A.J. Beck, Jails
and Jail Inmates, 1993–94, Washington, DC: U.S.
Department of Justice, Bureau of Justice Statistics,
April 1995, NCJ 151651.
12. Valway, S.E., S.B. Richards, J. Kovacovich, R.B.
Greifinger, J.T. Crawford, and S.W. Dooley, “Outbreak of
Multi-Drug-Resistant Tuberculosis in a New York State
Prison,” American Journal of Epidemiology 88 (1994):
113–122.

5. Ibid.
6. Hornung, C.A., R.B. Greifinger, and S. Gadre, “A
Projection Model of the Prevalence of Selected Chronic
Diseases in the Inmate Population,” paper prepared for
the National Commission on Correctional Health Care,
Chicago, IL, 1998. (Copy in volume 2 of this report.)
7. Veysey, B.M., and G. Bichler-Robertson, “Prevalence
Estimates of Psychiatric Disorders in Correctional
Settings,” paper prepared for the National Commission
on Correctional Health Care, Chicago, IL, n.d. (Copy in
volume 2 of this report.)
8. Corrections departments have a legal obligation to treat
inmates. A number of suits brought by individual inmates
have resulted in important court rulings. The most important single ruling was the U.S. Supreme Court’s finding
in Estelle v. Gamble, 429 U.S. 97 (1976), that “deliberate
indifference” (not mere medical malpractice) to “serious
medical needs” of inmates violates the eighth amendment’s prohibition against cruel and unusual punishment.
The Court ruled that “deliberate indifference” could be
evidenced in a number of ways, such as a correctional
officer’s intentional denial or delay of medical care, or
a physician’s indifference.
9. Centers for Disease Control and Prevention,
“Prevention and Control of Tuberculosis in Correctional
Facilities: Recommendations of the Advisory Council
for the Elimination of Tuberculosis,” Morbidity and
Mortality Weekly Report 45 (RR–08) (June 7, 1996).
10. Hammett, T.M., P. Harmon, and L.M. Maruschak,
1996–1997 Update: HIV/AIDS, STDs, and TB in
Correctional Facilities, Issues and Practices, Washington,
DC: U.S. Department of Justice, National Institute of
Justice, July 1999, NCJ 176344.
11. There were an estimated 339,070 employees in State
and Federal correctional facilities in 1995 and 165,500
employees in jails. See, Stephan, J.J., Census of State and
Federal Correctional Facilities, 1995, Executive

13. Satcher, D., “Tuberculosis—Battling an Ancient
Scourge,” Journal of the American Medical Association
282 (1999): 1996.
14. Beck, Prisoners in 1999 (see note 2).
15. Selwyn, P.A., D. Hartel, V.A. Lewis, E.E.
Schoenbaum, S.H. Vermund, R.S. Klein, A.T. Walker,
and G.H. Friedland, “A Retrospective Study of the Risk
of Tuberculosis Among Intravenous Drug Users With
Human Immunodeficiency Virus Infection,” New
England Journal of Medicine 320 (1989): 545–550.
16. Skolnik, A., “‘Collateral Casualties’ Climb in Drug
War,” Journal of the American Medical Association 271
(1994): 1638–1639.
17. Glaser, J., and R.B. Greifinger, “Correctional Health
Care: A Public Health Opportunity,” Annals of Internal
Medicine 118 (1993): 139–145.
18. Beck, Prisoners in 1999 (see note 2).
19. Harlow, C.W., Profile of Jail Inmates 1996, Special
Report, Washington, DC: U.S. Department of Justice,
Bureau of Justice Statistics, April 1998, NCJ 164620.
20. National Center for Health Statistics, National Health
and Nutrition Examination Survey III [NHANES–III],
Atlanta, GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention,
1997.
21. See, for example, Glaser and Greifinger, “Correctional
Health Care: A Public Health Opportunity”(see note 17).
22. Ibid.
23. Ibid.
24. Ibid.

7

25. Selwyn et al., “A Retrospective Study of the Risk of
Tuberculosis” (see note 15).
26. Ibid.
27. Khantzian, E.J., “The Self-Medication Hypothesis of
Substance Use Disorders: A Reconsideration and Recent
Applications,” Harvard Review of Psychiatry 4 (5)
(1997): 231–244.
28. Kraut, J.R., A. Haddix, V. Carande-Kulis, and R.B.
Greifinger, “Cost-Effectiveness of Routine Screening
for Sexually Transmitted Diseases in Inmates of U.S.
Correctional Facilities,” paper prepared for the National
Commission on Correctional Health Care, Chicago, IL,
February 7, 2000. (Copy in volume 2 of this report.)

29. Taylor, Z., and C. Nguyen, “Cost-Effectiveness of
Preventing Tuberculosis in Prison Populations,” presentation prepared for the National Commission on
Correctional Health Care, Chicago, IL, n.d. (Copy in
volume 2 of this report.)
30. Varghese, B., and T.A. Peterman, “Cost-Effectiveness
of HIV Counseling and Testing in U.S. Prisons,” paper
prepared for the National Commission on Correctional
Health Care, Chicago, IL, n.d. (Copy in volume 2 of this
report.)
31. Hornung, C.A., B.J. Anno, R.B. Greifinger, and S.
Gadre, “Health Care for Soon-To-Be-Released Inmates:
A Survey of State Prison Systems,” paper prepared for
the National Commission on Correctional Health Care,
Chicago, IL, 1998. (Copy in volume 2 of this report.)

9

Chapter 2. History of the Project

This chapter describes how The Health Status of
Soon-To-Be-Released Inmates project was conducted. The project involved three expert panels, a mail
survey of State departments of corrections, commissioned papers, and the development of policy recommendations based on empirical evidence of need
and effectiveness. A Steering Committee coordinated the work.

Steering Committee
The cooperative agreement between the National
Institute of Justice (NIJ) and the National Commission on Correctional Health Care (NCCHC) was
signed in spring 1997. Shortly thereafter, NCCHC
established a steering committee to guide the project. The members, identified in “Steering
Committee Members,” met six times to set priorities, develop and update a project work plan, and
monitor progress toward project goals.

During the planning stages of the project, several
NIJ staff members helped significantly in developing the project work plan. These staff included
Cheryl Crawford, Deputy Director, Office of
Development and Communication; Sally Hillsman,
Deputy Director, NIJ; Pamela Lattimore, Director,
Criminal Justice and Criminal Behavior Division;
and Laura Winterfield, Director, Criminal Justice
and Criminal Behavior Division.
The steering committee and NIJ staff made an early
decision to form three expert panels, one each on
communicable disease, chronic disease, and mental
illness, that would meet periodically to provide
expert guidance to the steering committee.

Expert Panels
Appendix A identifies the members of the three
expert panels.1 Panel members include many of the

Steering Committee Members
B. Jaye Anno, Ph.D., CCHP–A, Consultants in Correctional Care
R. Scott Chavez, M.P.A., PA–C, Vice President, National Commission on Correctional Health Care,
Project Coordinator of The Health Status of Soon-To-Be-Released Inmates Project
Cheryl Crawford, M.P.A., J.D., Deputy Director, Office of Development and Communication, National
Institute of Justice, U.S. Department of Justice
Andrew L. Goldberg, M.A., Social Science Analyst, National Institute of Justice, U.S. Department of
Justice
Robert B. Greifinger, M.D., Chief, The Bromeen Group, Principal Investigator of The Health Status of
Soon-To-Be-Released Inmates Project
Edward A. Harrison, President, National Commission on Correctional Health Care
John R. Miles, M.P.A., Special Assistant for Corrections and Substance Abuse, National Center for HIV,
STD, and TB Prevention, Centers for Disease Control and Prevention, U.S. Department of Health and
Human Services
Marilyn Moses, M.S., Social Science Analyst, National Institute of Justice, U.S. Department of Justice
Laura Winterfield, Ph.D., Director, Criminal Justice and Criminal Behavior Division, National Institute of
Justice, U.S. Department of Justice

10

Nation’s most respected researchers, practitioners,
and scholars in the fields of public and correctional
health care. Centers for Disease Control and
Prevention (CDC) staff helped guide the scholarly
work of the expert panels.
The steering committee asked each expert panel to:
●

●

Estimate the extent of illness among inmates
for the more common but remediable health
problems.
Identify the threat to the health status of the
community from the release of inmates with
untreated or undertreated illness.

●

Determine the cost-effectiveness of preventing
or treating these health problems.

●

Identify public health opportunities among
soon-to-be-released inmates.

●

Develop public policy recommendations for
capitalizing on these opportunities.

During these 2-day meetings held in August and
September 1997, the expert panels identified the
illnesses the project would examine using three
criteria developed by the steering committee. The
panels selected illnesses that:

The mental illness panel decided to look at six
disorders:
●

Schizophrenia and other psychoses.

●

Major depression.

●

Bipolar disease.

●

Dysthymia.

●

Post-traumatic stress disorder.

●

Anxiety.

At the direction of the steering committee, the
panels identified experts to conduct research and
prepare papers addressing these conditions (see
The Health Status of Soon-To-Be-Released Inmates,
volume 2).
In 1999, the steering committee reassembled the
expert panels to review the draft papers that had
been commissioned and the results of a survey of
State departments of corrections. The panels developed policy recommendations based on the papers’
and survey’s conclusions. The steering committee
distilled the panels’ recommendations and prepared
them in their final form (see chapter 7, “Policy
Recommendations”).

●

Were prevalent among prison or jail inmates.

Prison Survey

●

Involved a threat to public health or burden on
public health expenditures.

●

Could be effectively prevented or treated.

While some data existed about the prevalence of
HIV/AIDS, sexually transmitted diseases (STDs),
and tuberculosis (TB) in the prison and jail population, little had been published in 1997 about the
prevalence of hepatitis B or C and still less about
the prevalence of chronic disease and mental illness
among inmates. As a result, the steering committee
commissioned a survey of State prison systems to
collect information on the prevalence of four chronic
medical conditions—asthma, diabetes, hypertension, and heart disease—and mental illness in the
inmate population. The survey was also intended to
identify the availability of the following information
from State departments of corrections:

Based on these criteria, the communicable disease
panel elected to study seven diseases:
●

Syphilis, gonorrhea, and chlamydia.

●

Hepatitis B and C.

●

HIV/AIDS.

●

Tuberculosis.

The chronic medical conditions panel chose to
study three conditions:2,3
●

Asthma.

●

Diabetes.

●

Hypertension.

●

Policies and procedures for discharge planning
and providing medications to inmates when they
are released.

●

Databases on the prevalence of chronic disease
and mental illness.

11

Papers Commissioned for the Study on The Health Status of Soon-To-BeReleased Inmates
Prevalence studies
The Burden of Infectious Disease Among Inmates and Releasees From Correctional Facilities
(Theodore M. Hammett, Patricia Harmon, and William Rhodes)
A Projection Model of the Prevalence of Selected Chronic Diseases in the Inmate Population
(Carlton A. Hornung, Robert B. Greifinger, and Soniya Gadre)
Prevalence Estimates of Psychiatric Disorders in Correctional Settings (Bonita M. Veysey and Gisela
Bichler-Robertson)

Cost-effectiveness studies
Cost-Effectiveness of Routine Screening for Sexually Transmitted Diseases Among Inmates in United
States Prisons and Jails (Julie R. Kraut, Anne C. Haddix, Vilma Carande-Kulis, and Robert B. Greifinger)
Cost-Effectiveness of Preventing Tuberculosis in Prison Populations (overhead slides) (Zachary Taylor
and Cristy Nguyen)
Cost-Effectiveness of HIV Counseling and Testing in U.S. Prisons (Beena Varghese and Thomas A.
Peterman)
What Is the Value of Immunizing Prison Inmates Against Hepatitis B? (overhead slides) (Robert Lyerla)
Cost-Effectiveness Analysis of Annual Screening and Intensive Treatment for Hypertension and Diabetes
Mellitus Among Prisoners in the United States (Donna M. Tomlinson and Clyde B. Schechter)
Providing Psychiatric Services in Correctional Settings (Bonita M. Veysey and Gisela Bichler-Robertson)

Other paper
Communicable Diseases in Inmates: Public Health Opportunities (Jonathan Shuter)

●

Information about the health status of inmates
recently released into the community.

In December 1997, the National Commission on
Correctional Health Care sent a mailback questionnaire (see appendix C), designed by a member of
the steering committee,4 to corrections officials
in each State, the District of Columbia, and the
Federal Bureau of Prisons. At least two calls were
made to departments that did not return the questionnaire to request their participation in the survey
again. Responses were received from 41 of 52 systems.5 Four public health experts analyzed and
reported on the survey results.6

Commissioned Papers
The steering committee commissioned eight papers
and two presentations from nationally known
experts in the correctional and public health care
fields, some of whom were already members of the
expert panels. The papers and presentations focused
on three areas:
●

Estimating the prevalence of the selected diseases
in prisons and jails.

●

Identifying effective prevention, screening, and
treatment programs that could be implemented in
prisons and jails to address these diseases.

12

●

Determining whether it would save money or be
cost effective to prevent, screen for, or treat these
diseases.

“Papers Commissioned for the Study on The Health
Status of Soon-To-Be-Released Inmates,” lists the
papers and presentations that were commissioned.
Volume 2 of this report provides the complete set of
papers. The papers represent the principal empirical
support for the policy recommendations the project
developed.

Need for Further Research
The survey of departments of corrections was originally designed as the first phase of a two-stage survey research plan. The information provided by the
first phase of the survey was expected to enable the
steering committee to identify State prison systems
with the most comprehensive data on the health
status of their inmate populations and on the health
status of inmates whom they had recently released
into the community. The second phase of the survey
research plan called for selecting a sample of prison
facilities in these departments at which selected
medical records could be reviewed to collect comprehensive data on the health status of a sample of
inmates who had recently been released into the
community. The review would have focused on the
prevalence of communicable disease, chronic disease, and mental illness, and provisions for continuity of health care.
The planned second phase of the survey was not
conducted because the steering committee determined that obtaining a representative national sample
of medical records would require a massive study
beyond the project’s available time and resources.
The steering committee believes, however, that
a national program for surveillance and reporting
systems for tracking these conditions is of critical
importance for quality management and research
in correctional health care (see chapter 7, “Policy
Recommendations”).

Notes
1. Appendix B provides brief biographies of all
those who contributed to the project.
2. The steering committee concluded that it might
still be cost effective to address hypertension and
diabetes, even though these diseases might be less
prevalent among inmate populations than among
other adults (e.g., because of inmates’ younger average age). The committee came to this decision for
three reasons. First, the inconvenience and cost of
being diagnosed or treated are negligible to inmates.
Although there may be copayments for some acute
and chronic disease services, inmates do not lose
income or have to give up leisure time while using
health care system resources for screening or treatment of these conditions. Second, followup and
adherence to dietary and medical regimens for these
conditions can be encouraged in the prison or jail
environment to a greater extent than outside. Third,
it is cost effective to diagnose and treat these diseases in terms of the many years these inmates will
be in the community following release (Tomlinson,
D.M., and C.B. Schechter, “Cost-Effectiveness
Analysis of Annual Screening and Intensive
Treatment for Hypertension and Diabetes Mellitus
Among Prisoners in the United States,” paper prepared for the National Commission on Correctional
Health Care, Chicago, IL, n.d. (Copy in volume 2 of
this report.)
3. The steering committee initially considered
examining heart disease among inmates. The committee concluded that, because of the low prevalence of manifest disease, it was more important to
concentrate on preventing chronic disease. See the
policy recommendations related to chronic disease
in the executive summary and chapter 7.
4. B. Jaye Anno.
5. No response was obtained from the Federal
Bureau of Prisons or from 10 States that together
at the time housed 200,000 inmates. The responses
received from 40 States and the District of Columbia

13

were of limited value. Several of the States provided
very few reliable data; either questions were not
answered or clearly erroneous answers were provided. Instead of providing the number representing the
proportion of the total inmate population with asthma, several systems provided a number representing
the ratio of asthma patients to other patients who
were currently in the hospital. Other systems reported that fewer than 10 inmates in a prison population
of more than 10,000 suffered from asthma. Several
considerations may account for missing or incomplete data. The departments of corrections may not
have had the data or had it accessible; they may

have lacked confidence in the reliability of their
data; or their health care units may not have had
data analysts with the expertise to collect, store,
analyze, or report the data properly. Some surveys
may have not reached correctional staff with access
to the requested data.
6. Hornung, C.A., B.J. Anno, R.B. Greifinger, and
S. Gadre, “Health Care for Soon-To-Be- Released
Inmates: A Survey of State Prison Systems,”
paper prepared for the National Commission on
Correctional Health Care, Chicago, IL, 1998. (Copy
in volume 2 of this report.)

15

Chapter 3. Prevalence of Communicable
Disease, Chronic Disease, and Mental Illness
Among the Inmate Population
This chapter presents estimates of the prevalence of
selected communicable diseases, chronic diseases,
and mental illnesses among inmates in the Nation’s
prisons and jails.1 When The Health Status of
Soon-To-Be-Released Inmates project began, there
appeared to be several possible methods of collecting prevalence data. The best approach would have
been to interview and physically examine a statistically valid sample of inmates across the Nation.
This type of survey would have been far beyond the
resources available for the project. A second option
would have been to abstract medical records for a
sample of inmates. In addition to being expensive
and complex, this approach would have potentially
been invalid: because of significant differences in
the information systems among correctional institutions (e.g., prisons, jails, prerelease centers, work
camps), it would have been impossible to identify
a sample of medical records that would have been
representative of all prison inmate records.
A third approach, which was selected for this project,
was to estimate the prevalence of selected diseases
from limited but valid data sets collected and published periodically by Federal agencies. The project
steering committee (see chapter 2, “History of the
Project”) concluded that this was the best approach
given limited resources. The steering committee
therefore commissioned established correctional and
public health researchers, practitioners, and scholars
to examine these existing databases and generate estimates of the prevalence of selected communicable
diseases, chronic diseases, and mental illnesses
among inmates. The remainder of this chapter summarizes the results of these analyses. For each of
the three major disease categories, the prevalence
estimates are preceded by a brief summary of the
methodology used to arrive at the estimates. The
full papers from which the findings and estimation
methodologies have been summarized below may
be found in volume 2 of this report.

Communicable Disease
The Health Status of Soon-To-Be-Released Inmates
project examined the following communicable diseases: human immunodeficiency virus (HIV) infection, acquired immunodeficiency syndrome (AIDS),
syphilis, gonorrhea, chlamydia, hepatitis B and C,
and tuberculosis (TB) infection and disease. The
complete analysis may be found in Theodore M.
Hammett, Patricia Harmon, and William Rhodes,
“The Burden of Infectious Disease Among Inmates
and Releasees From Correctional Facilities,” in volume 2 of this report. “Definitions of Communicable
Diseases Examined,” provides capsule definitions of
each of the diseases examined.

Methodology
Estimates of the prevalence of HIV infection and
AIDS in State and Federal prisons, and estimates
of HIV infection in jails, rely primarily on surveys
of correctional systems conducted by the U.S.
Department of Justice, Bureau of Justice Statistics.2
The methodology for estimating HIV infection in
prisons adjusts the prevalence figures reported to
the Bureau of Justice Statistics upward, taking into
account that for most State correctional systems the
figures are based on voluntary testing, which does
not identify all HIV-infected inmates. There are no
national surveys of AIDS in jails. The national AIDS
(AIDS only, not all HIV infection) prevalence estimate of 0.5 percent for prison inmates in 1996 was
applied to the total jail population.
The prevalence estimates for syphilis, gonorrhea,
chlamydia, and TB rely in part on 1996–97 national
surveys of correctional systems conducted by Abt
Associates Inc. and sponsored by the Centers for
Disease Control and Prevention (CDC) and the
U.S. Department of Justice, National Institute of
Justice (NIJ). The estimates are also based on other

16

Definitions of Communicable Diseases Examined
HIV/AIDS

A virus transmitted through sexual relations and exposure to blood. Acquired immunodeficiency syndrome (AIDS) results when human immunodeficiency virus (HIV) attacks the
body’s immune system, leaving the individual highly susceptible to a range of infections,
cancers, and other illnesses. HIV infection also attacks the central nervous system, causing progressive dementia, and it may lead to a serious wasting syndrome.

Syphilis

An acute and chronic sexually transmitted disease (STD) characterized initially by an
ulcer in the genital area followed within weeks by a secondary eruption of the skin and
mucous membranes. Long periods of latency then occur followed by, in one-third of cases,
often irreparable damage to the skin, bone, nervous system, and cardiovascular system.
Syphilis can be easily tested for and treated. Syphilis, like gonorrhea and chlamydia
(see below), enhances the transmission of HIV because of ulcers, bleeding, or inflammatory discharges.

Gonorrhea

An acute STD with different manifestations in men and women. In men, infection is usually characterized by painful urination and discharge from the penis. In women, infection
of the cervix often leads to severe pelvic inflammatory disease (infection of the upper
genital tract) followed by infertility, ectopic pregnancy (a fetus developing outside the
uterus, which results in fetal and sometimes maternal death), and chronic pelvic pain.
Newborns are easily infected; eye infection and death may occur. Initial infection without
symptoms is common in men and women. Gonorrhea can be easily tested for and treated.

Chlamydia

An acute and chronic STD that mimics many of the manifestations of gonorrhea. Because
symptoms are milder than with gonorrhea, infection commonly remains undetected. As a
result, infection is more widespread in the population, and the damage caused by pelvic
inflammatory disease, while more subtle than with gonorrhea, is more common. Newborns
are easily infected; eye infection and pneumonia may occur. Chlamydia can be easily
tested for and treated.

Tuberculosis

A communicable disease caused by bacteria. Tuberculosis (TB) manifests itself in pathological alterations of tissue, most commonly of the lung. People with latent TB infection
may be totally free of symptoms, and therefore unable to spread the disease for a long
time—sometimes for a lifetime. They are, however, at risk of developing active tuberculosis, which is contagious and a progressive disease. TB is the only disease discussed in
this report that is transmitted by an airborne route. The vast majority of patients with
active TB can be cured with a 6- to 12-month course of medications. Preventive therapy
dramatically reduces the risk that latent TB infection will lead to active TB disease.

Hepatitis

An infection of the liver caused by viruses. Hepatitis B can develop into a chronic disease
that is responsible for 5,000 deaths annually in the United States, most from cirrhosis of the
liver. Complications of infectious hepatitis account for an estimated 25,000 deaths annually
in the United States—1 percent of all deaths in the United States. Hepatitis C is the leading
reason for liver transplantation in the United States.* Both hepatitis viruses are acquired
through exposure to contaminated blood products, especially during injection drug use.
Sexual transmission is another important route for hepatitis B but less so for hepatitis C.
A vaccine provides immunity to hepatitis B; there is no vaccine for hepatitis C.

* “Management of Hepatitis C,” NIH Consensus Statement 15 (3) (March 1997): 24–26.

17

published and unpublished studies conducted in
specific correctional systems.
No agency has identified and tabulated hepatitis B
and C virus infections among the Nation’s jail or
prison populations. The prevalence of hepatitis B
was estimated based on a small number of studies
conducted in individual corrections systems. Prevalence estimates for hepatitis C were developed
indirectly, by multiplying the estimated prevalence
of the infection among injection drug users (IDUs)
in the United States by the estimated percentage of
prison inmates with histories of injection drug use.

Prevalence estimates
The discussion below, summarized in table 3–1,
presents the estimated number of inmates and
releasees with the selected communicable diseases.
HIV/AIDS. The study estimates that 35,000 to
47,000 inmates in 1997 were infected with HIV.
These included 28,000 to 36,300 prison inmates and
6,800 to 10,200 jail inmates. An estimated 98,000 to
145,000 HIV-positive inmates were released from
prisons and jails in 1996, including about 11,600 to
15,000 released from Federal and State prisons and
about 87,000 to 130,400 released from jails. The
estimated rates for these communicable diseases are
much higher for releasees than for current inmates
largely because of the rapid turnover and short
lengths of stay in jails. Among HIV-infected inmates,
an estimated 8,900 inmates had AIDS in 1997: 6,000
in State and Federal prison and 2,800 in jails.3 An
estimated 39,000 inmates with HIV were released
from prisons and jails in 1996, about 2,500 from
prisons and 36,000 from jails.
Sexually transmitted diseases: syphilis, gonorrhea,
and chlamydia. The total number of inmates or
releasees infected with any one STD cannot be determined because an inmate could have more than one
infection. It is safe to conclude, however, that in 1997
the Nation’s prisons and jails held, or released into
the community, at least 200,000 individuals with an
STD. There were an estimated 107,000 to 137,000
cases of STDs among inmates and between 465,000
and 595,000 STD cases among releasees in 1997.
As shown in table 3–1, most of these inmates and
releasees were infected with syphilis.4

Hepatitis B and C. More than 36,000 prison and
jail inmates in 1997 and 155,000 releasees in 1996—
an estimated 2 percent of prison and jail inmates
and releasees—had current or chronic hepatitis B
infection. At least 303,000–332,000 prison and jail
inmates were infected with hepatitis C in 1997.
Between 1.3 and 1.4 million inmates released from
prison or jail in 1996 were infected with hepatitis C.5
Tuberculosis infection and disease. An estimated
131,000 inmates tested positive for latent TB infection in 1997—more than 90,000 prison inmates
and more than 41,000 jail inmates. An estimated
566,000 inmates with latent TB infection were
released in 1996, including more than 37,000
inmates from prisons and nearly 529,000 inmates
from jails. In 1996, an estimated 1,400 inmates had
active TB disease, including nearly 500 from prisons and over 950 from jails. About 12,000 persons
released from a correctional facility during 1996
had TB disease during that year.6

Burden of communicable disease among
inmates and releasees
The prevalence rates for these communicable diseases are significantly higher among inmates and
releasees than among the total U.S. population
(see figure 3–1). During 1996, about 3 percent of
the U.S. population spent time in a prison or jail;
however, between 12 and 35 percent of the total
number of people in the Nation with selected communicable diseases passed through a correctional
facility during that year.7 Specifically:
●

Almost 39,000 prison and jail releasees in 1996
had AIDS. Seventeen percent of the estimated
229,000 persons living with AIDS in the United
States in 1996 passed through a correctional
facility that year.8 The prevalence of AIDS among
inmates is five times higher than among the total
U.S. population.9

●

The estimated 98,000 to more than 145,000 prison
and jail releasees with HIV infection in 1996 represented 13–19 percent of all HIV-positive individuals in the United States.

●

The estimate of 155,000 releasees with current
or chronic hepatitis B infection in 1996 indicates
that between 12 and 15 percent of all individuals
in the Nation with chronic or current hepatitis B

18
Table 3–1. National Estimates of Selected Infectious Diseases Among Inmates and Releasees
and Prevalence in U.S. Population

Estimated
Prevalence
Among
Inmates, %

Disease

Prevalence
in U.S.
Population,
1996, %

Estimated
Number
of Inmates
w/Condition,
1997

Releasees With
Estimated
Condition as
Number of
Number in
% of Total in
Releasees w/ U.S. Population U.S. Population
Condition,
w/Condition,
w/Condition,
1996
1996
1996

Prisons

Jails

AIDS

0.5a

0.5a

0.09

8,900

39,000

229,000b

17.0

HIV Infection
(non-AIDS)

2.3–
2.98c

1.2–
1.8d

0.3

35,000–
47,000

98,000–
145,000

750,000e

13.1–19.3

2.6–4.3

2.6–4.3

N/A

46,000–
76,000

202,000–
332,000

N/A

——

Chlamydia

2.4

2.4

N/A

43,000

186,000

N/A

——

Gonorrhea

1.0

1.0

N/A

18,000

77,000

N/A

——

Hepatitis B
Infection

2.0

2.0

N/A

36,000

155,000

1,000,000–
1,250,000g

12.4–15.5

Hepatitis C
Infection

17.0–
18.6f,h

17.0–
18.6h

1.8

303,000–
332,000

1,300,000–
1,400,000

4,500,000i

28.9–32.0

Tuberculosis
Disease

0.04j

0.17k

0.01

1,400

12,000

34,000l

35.0

Tuberculosis
Infection

7.4

7.3

N/A

131,000

566,000

N/A

——

Syphilis
Infection

a

f

More than 5 times the prevalence in the U.S. population (0.09%).

b

Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report 9 (2) (1997): 1–43.

c

Eight to ten times the prevalence in the U.S. population (0.3%).

d

Four to six times the prevalence in the U.S. population (0.3%).

e

CDC estimate, based on midpoint of 1993 estimate in Rosenberg, P.S., “Scope of the AIDS Epidemic in the United States,” Science 270
(Nov 24, 1995): 1372–1375.
f

Current or chronic.

g

Centers for Disease Control, “Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal
Childhood Vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP),” Morbidity and Mortality Weekly Report
40 (RR–13) (1991): 1–19.

h

Nine to 10 times the prevalence in the U.S. population (1.8%).

i

Based on prevalence estimate in McQuillan G.M., M.J. Alter, L.A. Moyer, S.B. Lambert, and H.S. Margolis, “A Population-Based Serologic Survey of
Hepatitis C Virus Infection in the U.S.” In M. Rizzetto, R.H. Purcell, G.L. Gerin, and G. Verme, eds., Viral Hepatitis and Liver Disease, Turin, Italy:
Edizioni Minerva Medica, 1997, pp. 267–270.

j

Four times the prevalence in the U.S. population (0.01%).

k
l

Seventeen times the prevalence in the U.S. population (0.01%).

Estimated from CDC, TB Registry Reports, 1992–94.

Source: (Unless otherwise noted in the footnotes): Hammett, T.M., P. Harmon, and W. Rhodes, “The Burden of Infectious Disease Among Inmates
and Releasees from Correctional Facilities,” paper submitted to the National Commission on Correctional Health Care, Chicago, Illinois, May 2000.
(Copy in volume 2 of this report.)

19

Figure 3–1. Releasees With Selected Infectious Diseases as a Proportion of the Total U.S.
Population With Each Disease, 1996

Tuberculosis Disease

35%
65%

Releasees

Hepatitis B Infection

Total Population

Hepatitis C Infection

12%
29%

71%

88%

Releasees

Total Population

AIDS

Total Population

Releasees

HIV Infection

13%

17%

87%

83%

Releasees

Total Population

Releasees

Total Population

Source: Hammett, T.M., P. Harmon, and W. Rhodes, “The Burden of Infectious Disease Among Inmates and Releasees from Correctional Facilities,”
paper submitted to the National Commission on Correctional Health Care, Chicago, Illinois, May 2000. (Copy in volume 2 of this report.)

20

infection in 1996 spent time in a correctional
facility that year.
●

●

The estimate of 1.3–1.4 million releasees infected with hepatitis C in 1997 suggests that an
extremely high 29–32 percent of the estimated
4.5 million people infected with hepatitis C in the
United States10 served time in a correctional facility that year. The 17.0–18.6 percent prevalence
range of hepatitis C among inmates—probably
an underestimate—is 9–10 times higher than the
estimated hepatitis prevalence in the Nation’s
population as a whole.11
An estimated 35 percent (12,200) of all those in
the Nation who had TB disease during 1996
served time in a correctional facility during that
year. This estimate was calculated by applying a
point prevalence rate for inmates (i.e., the percentage of inmates who were treated for TB disease
on a given day in 1997) to the total number of
releasees during all of 1996. The estimate suggests
that about 12,200 people who were released from
a correctional facility during 1996 also had TB
disease during that year; it does not mean, however, that they all had TB disease at the time of their
release from prison or jail. Most of them probably
did not have TB disease at the time of their release
because, if properly treated, TB disease typically

lasts only a short time. Nevertheless, the estimate
indicates the congruence between populations
likely to be incarcerated and those likely to have
TB. The prevalence of TB disease among inmates
is between 4 and 17 times greater than among the
total U.S. population.

Chronic Disease
The project examined three chronic diseases: asthma,
diabetes, and hypertension (see “Definitions of the
Chronic Conditions Examined” for brief descriptions
of these diseases).12 The complete analysis may be
found in Carlton A. Hornung, Robert B. Greifinger,
and Soniya Gadre, “A Projection Model of the
Prevalence of Selected Chronic Diseases in the
Inmate Population,” in volume 2 of this report.
Inmates with chronic disease create serious demands
on the correctional health care system. When released,
these inmates can burden the health care system in
the general community through increased demand
for acute care and costly hospitalization. The inmate
whose diabetes is poorly managed while incarcerated
is more likely to use costly health care services,
such as dialysis for kidney failure, limb amputation,
or emergency room visits for glucose (sugar) control when released into the community. Untreated
hypertension, the most common chronic illness among

Definitions of the Chronic Conditions Examined
Asthma

A chronic inflammatory disease of the airways that can make breathing difficult. Asthma,
one of the most common chronic diseases in the United States, is increasing nationally.
Five thousand individuals die each year in the United States because of asthma, and
470,000 are hospitalized. The effects of asthma are largely preventable with improved
patient education and medical management.

Diabetes

A chronic disease involving insulin metabolism, causing, among other problems, excessive sugar in the blood. Diabetes can lead to blindness, kidney failure, heart disease,
and disease of the blood vessels. Controlling blood sugar levels can prevent acute and
long-term consequences of diabetes. Diabetes is the most common cause of blindness
in people under age 60 in the United States.

Hypertension A chronic disease expressed by elevated blood pressure. Untreated, it leads to significant
heart disease and ultimately organ failure and death. Fifty million adult Americans have
hypertension. A large proportion are unaware of it. Seventy percent of adult Americans
with hypertension are not controlling their blood pressure. Blood pressure control is
associated with a substantial reduction in heart disease and stroke.

21

adults (and inmates), can eventually require expensive health care services because it is a major risk
factor for coronary heart disease, kidney failure,
stroke, and blood vessel disease.

Methodology
There are no direct data sources on the prevalence
of chronic disease among inmates. As a result, the
prevalence of the three target diseases was estimated using data from the 1988–94 National Health and
Nutrition Examination Survey III (NHANES–III)
sponsored by the U.S. Departments of Health and
Human Services and Agriculture.13 The survey estimates the number and percentage of persons in the
Nation who have selected diseases or are at risk
for developing these diseases. Because inmates are
more likely to be economically disadvantaged than
the average citizen, inmate prevalence rates for asthma, diabetes, and hypertension were estimated from
the NHANES–III figures for the lowest one-fourth
of the Nation in socioeconomic status. These estimates were further adjusted for age, gender, and
race differences between the 1995 inmate population and the NHANES–III respondents.

Prevalence estimates
Table 3–2 and figure 3–2 summarize the prevalence
of the three chronic diseases among inmates in
1995. As shown, the overall prevalence of asthma
among Federal, State, and local inmates is estimated
to be 8.5 percent, or 140,738 cases nationwide. The

prevalence of diabetes (defined as a blood glucose
level of 126 mg/dL or higher) is estimated to be 4.8
percent. The prevalence rate for hypertension among
inmates (defined as more than 140 mmHg systolic or
more than 90 mmHg diastolic) is projected to be
more than 18 percent, representing a total of
283,105 inmates.

Burden of chronic disease among inmates
The prevalence estimates for asthma, diabetes, and
hypertension among inmates presented in this chapter suggest that large numbers of people with these
conditions are in correctional populations (see table
3–2). Prevalence rates for asthma are higher among
inmates than among the total U.S. population (8.5
percent versus 7.8 percent), in part because of the
low socioeconomic status and disproportionately
minority composition of inmate populations, segments
of the overall population in which asthma and other
chronic diseases are more commonly found.14
The estimated prevalence rates for diabetes and
hypertension are lower for inmates than for the total
U.S. population (4.8 percent versus 7.0 percent for
diabetes, more than 18 percent versus more than 24
percent for hypertension). These inmate prevalence
rates are still high, however, considering that inmates
are a relatively young population (despite the aging
of the prison population) and that these two diseases
are much likelier to afflict older individuals, who
are relatively underrepresented among inmates.

Table 3–2. National Estimates of Prevalence of Three Chronic Diseases Among
Inmates in Prisons and Jails and in the Total U.S. Population, 1995
Condition

Estimated Prevalencea
Among Inmates (%)

Estimated Number of
Inmates

8.5

140,738

Asthma
Diabetes

7.8

4.8

79,873

7.0

18.3

283,105

24.5

c

Hypertension

Prevalence in Total U.S.
Populationb (%)

a

Based on lowest socioeconomic status.

b

Based on baseline U.S. population.

c

Using new definition of fasting serum glucose of >126 mg/dL.

Source: Hornung, C.A., R.B. Greifinger, and S. Gadre, “A Projection Model of the Prevalence of Selected Chronic Diseases in the Inmate Population,”
paper submitted to the National Commission on Correctional Health Care, Chicago, Illinois, n.d. (Copy in volume 2 of this report).

22

Figure 3–2. National Estimates of Prevalence of Three Chronic Diseases
Among Inmates in Prisons and Jails and in the Total U.S. Population, 1995
Prevalence (%)
25
Inmates*

Total U.S. Population**

20

15

10

5

0
Asthma

Diabetes***

Hypertension

Chronic Disease
* Based on lowest socioeconomic status.
** Based on baseline U.S. population.
*** Using new definition of fasting serum glucose of >126 mg/dL.
Source: Hornung C.A., R.B. Greifinger, and S. Gadre, “A Projection Model of the Prevalence of Selected Chronic Diseases in the Inmate Population,”
paper submitted to the National Commission on Correctional Health Care, Chicago, Illinois, n.d. (Copy in volume 2 of this report.)

Mental Illness
The extent of mental illness among inmates has
been difficult to estimate. Because of rapid inmate
turnover, identifying the number of different inmates
with a mental illness in jails at any time is especially
difficult. Epidemiological studies of jail populations,
therefore, should be made on admission (i.e., bookings).15 Prisons present fewer problems in gathering
data and estimating the need for services because
they have more stable populations. Most estimates
of mental illness in prisons, as in jails, are based on
inmates who have used mental health services.16

Methodology
The Health Status of Soon-To-Be-Released Inmates
project used the United States National Comorbidity
Survey to generate estimated prevalence rates for

various psychiatric diagnoses among the incarcerated population. Conducted in the early 1990s, this
landmark investigation, mandated by Congress, is
the first survey to administer a structured psychiatric interview to a nationally representative sample
(8,098 persons aged 15–54) using trained interviewers and focused on a community sample (i.e., noninstitutionalized individuals).17
The project examined six different diagnoses from
the National Comorbidity Survey data: nonaffective
psychosis, major depression, bipolar mania, dysthymia, post-traumatic stress disorder, and anxiety.18
The complete analysis of these conditions may be
found in Bonita M. Veysey and Gisela BichlerRobertson, “Prevalence Estimates of Psychiatric
Disorders in Correctional Settings,” in volume 2 of

23

Definitions of the Six Mental Illness Diagnoses Examined
Schizophrenia/Other Disorders of the thought process. Psychotic disorders typically include
Psychotic Disorders hallucinations or delusions, and may include disorganized speech and grossly
disorganized behavior lasting more than 6 months.
Major Depression

A disorder of mood. The essential feature of major depressive disorder is one or
more periods of at least 2 weeks during which there is either depressed mood or
loss of interest or pleasure in nearly all activities. Individuals must also experience at least four additional symptoms from a list that includes changes in
appetite or weight, changes in sleep, decreased energy, feelings of worthlessness
or guilt, and difficulty thinking, concentrating, or making decisions. Up to 15
percent of individuals with the condition commit suicide, but all patients with
major depression are at some risk of suicide.

Bipolar Disorder

A major disorder of mood. The essential feature of this mood disorder is one or
more manic episodes—distinct periods of at least 1 week during which there is
an abnormally and persistently elevated, expansive, or irritable mood that may
include inflated self-esteem, distractibility, or increased involvement in goaldirected activities. Bipolar disorder may also involve periods of time lasting at
least 1 week in which the individual experiences rapidly alternating moods (e.g.,
sadness, irritability, euphoria). Ten to 15 percent of people with bipolar disorder
commit suicide.

Dysthymic Disorder

A chronically depressed mood that lasts for most of the day on most days for at
least 2 years. Other symptoms may include poor appetite or overeating, insomnia
or excessive sleep, low energy or fatigue, low self-esteem, and feelings of hopelessness. Usually dysthymic disorder is characterized by chronic, less severe
depressive symptoms that have been present for many years, while major depressive disorder (see above) consists of one or more discrete major depressive
episodes that can be distinguished from the person’s usual functioning.

Post-Traumatic
Stress Disorder

A major disorder of feeling. The essential feature of this disorder is the
development of characteristic symptoms following exposure to direct personal
experience (as a participant, witness, or someone who learns about the experience) with an event that involves a threat to the person’s or someone else’s physical integrity, such as sexual or physical abuse. The person’s response to the event
involves intense fear, helplessness, or horror. Characteristic symptoms include
persistent reexperiencing of the event.

Anxiety Disorders

A group of disorders that includes panic disorder, agoraphobia (anxiety about
being in places or situations from which escape might be difficult or help might
not be available), obsessive-compulsive disorder, generalized anxiety disorder,
and other conditions. General anxiety disorder is characterized by at least 6
months of persistent and excessive anxiety and worry.

Adapted from American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM–IV), Washington,
D.C.: American Psychiatric Press, 1994.

24

this report. “Definitions of the Six Mental Illness
Diagnoses Examined” describes each illness briefly.
Three adjustments were made to the National
Comorbidity Survey data to arrive at the closest
possible approximation of the number of inmates
with each of these illnesses.
1. Prevalence estimates were first calculated for all
inmates. Inmates, however, are disproportionately
from the lowest socioeconomic stratum of society, and poverty and mental illness appear to be
correlated. Therefore, a subsample of respondents with a reported income below the poverty
line was used to provide a second estimate of
prevalence rates for State prison and jail inmates.
2. Because the vast majority of inmates abuse alcohol or other drugs, the analysis generated a third
set of estimated prevalence rates for a subsample
of State and jail inmates who were substance
abusers as well as poor.
3. All the resulting estimated rates for each mental
illness were then weighted according to the 1995
age, race, and gender distributions of inmates in
prisons and jails.

Most major mental illnesses have periods of quiet
and other periods of activity. The rates at any point
in time—for example, during a short jail stay—are
lower than lifetime prevalence rates. To reflect
this consideration, the calculations based on the
National Comorbidity Study used 6-month prevalence rates for jail inmates and lifetime prevalence
rates for prison inmates.

Prevalence Estimates
As shown in table 3–3 and figures 3–3, 3–4, and
3–5, separate prevalence estimates for mental illness
were developed for inmates in jails, State prisons,
and Federal prisons.
●

Jails. On any given day, an estimated 1.0–1.1
percent of offenders booked into U.S. jails have
schizophrenia or another psychotic disorder,
7.9–15.2 percent have major depression, and
1.5–2.6 percent have bipolar disorder (manic
episode). Between 2.7 and 4.2 percent of jail
inmates are estimated to have dysthymia, and
between 14.1 and 20.0 percent have some type
of anxiety disorder,18 not including another 4.0–
8.3 percent with post-traumatic stress disorder.

Table 3–3. National Estimates of Six Psychiatric Disorders Among Prison and Jail Inmates
and Prevalence in U.S. Population, 1995
Jail (6-month
estimated
prevalence)
(n = 500,483 inmates)
Disease

State Prison
Federal Prison
(estimated
(estimated
Total U.S.
lifetime
lifetime
Total U.S.
Population
prevalence)
prevalence)
Population
(6-month (n = 1,010,228 inmates) (n = 91,506 inmates)
(lifetime
prevalence)
prevalence)
n
%
n
%

n

%

4,955–
5,589

1.0–1.1

0.4

22,994–
39,262

Major
Depression

39,690–
76,229

7.9–15.2

8.4

132,619–
188,259

Bipolar (Manic)

7,755–
12,920

1.5–2.6

1.0

21,468–
43,708

2.1–4.3

Dysthymia

13,644–
21,040

2.7–4.2

2.0

85,018–
135,121

Post-Traumatic
Stress Disorder

19,770–
41,509

4.0–8.3

3.4

70,613–
100,098

14.1–20.0

14.6

Schizophrenia/
Psychosis

Anxiety

2.3–3.9

763–
2,326

0.8–2.5

0.8

13.5–15.7

18.1

1,393–
2,475

1.5–2.7

1.5

8.4–13.4

6,253–
10,652

6.8–11.6

7.1

62,388–
118,071

6.2–11.7

4,466–
6,257

4.9–6.8

7.2

222,147–
303,936

22.0–30.1 16,638–
21,079

18.2–23.0

N/A

13.1–18.6 12,378–
14,363

Source: Veysey, B.M., and G. Bichler-Robertson, “Prevalence Estimates of Psychiatric Disorders in Correctional Settings,” paper submitted to the
National Commission on Correctional Health Care,” Chicago, Illinois, October 1999. (Copy in volume 2 of this report.)

25

Figure 3–3. Jails: Estimated Prevalence of Six Mental Illnesses Among Inmates in 1995
Compared With Prevalence Rates for the Total U.S. Population in the Early 1990s*
Prevalence (%)
20

Low

High

U.S.

15

10

5

0
Schizophrenia/
Psychosis

Major
Depression

Bipolar (Manic)

Dysthymia

Post-Traumatic
Stress Disorder

Anxiety

Mental Illness
* “The National Comorbidity Survey,” Kessler, R.C., International Review of Psychiatry 6 (1994): 365–376.
Source: Veysey, B.M., and G. Bichler-Robertson, “Prevalence Estimates of Psychiatric Disorders in Correctional Settings,” paper submitted to the National
Commission on Correctional Health Care, Chicago, Illinois, May 1999. (Copy in volume 2 of this report.)

●

●

State prisons. On any given day, between 2.3
and 3.9 percent of inmates in State prisons are
estimated to have schizophrenia or other psychotic disorder, between 13.1 and 18.6 percent major
depression, and between 2.1 and 4.3 percent
bipolar disorder (manic episode). A substantial
percentage of inmates exhibit symptoms of other
disorders as well, including between 8.4 and 13.4
percent with dysthymia, between 22.0 and 30.1
percent with an anxiety disorder, and between 6.2
and 11.7 percent with post-traumatic stress disorder.
Federal prisons. Federal inmates are estimated
to have lower rates of mental illness than State
prison inmates across all diagnostic categories.
Between 0.8 and 2.5 percent are estimated to
have schizophrenia or other psychotic disorder,

between 13.5 and 15.7 percent major depression,
and between 1.5 and 2.7 percent bipolar disorder.
Between 6.8 and 11.6 percent are predicted to
have dysthymia, and between 18.2 and 23.0 percent have an anxiety disorder, not including
another 4.9 to 6.8 percent with post-traumatic
stress disorder.

Burden of mental illness among inmates
It would be inaccurate simply to add the number
of inmates with each of the six mental illnesses to
come up with the total number and percentage of
mentally ill inmates because inmates may suffer
from more than one of these conditions at the same
time. As shown in table 3–3 and figures 3–3, 3–4,
and 3–5, however, prevalence rates of many mental

26

Figure 3–4. State Prisons: Estimated Prevalence of Six Mental Illnesses Among Inmates in 1995
Compared With Lifetime Prevalence Rates for the Total U.S. Population in the Early 1990s*
Prevalence (%)
35
Low

High

U.S.

30

25

20

15

10

5

0
Schizophrenia/
Psychosis

Major
Depression

Bipolar (Manic)

Dysthymia

Post-Traumatic
Stress Disorder

Anxiety**

Mental Illness
* “The National Comorbidity Survey,” Kessler, R.C., International Review of Psychiatry 6 (1994): 365–376.
** No data for total U.S. population.
Source: Veysey, B.M., and G. Bichler-Robertson, “Prevalence Estimates of Psychiatric Disorders in Correctional Settings,” paper submitted to the National
Commission on Correctional Health Care, Chicago, Illinois, May 1999. (Copy in volume 2 of this report.)

illnesses among inmates are higher than the rates for
these conditions among the U.S. population as a whole.
This chapter has demonstrated that inmates suffer
from higher rates of communicable disease, chronic
disease, and several mental illnesses than the U.S. population as a whole. This large concentration of infected
and mentally ill persons in prisons and jails provides a
unique opportunity to provide needed treatment and
prevention services and to help protect the larger public health. The natural question to ask, given these
findings, is: To what extent are prisons and jails seizing this opportunity? The following chapter discusses
the extent of current prevention, screening, and treatment efforts in the Nation’s correctional systems.

Notes
1. Jails are locally operated correctional facilities that
confine persons before or after adjudication. Inmates sentenced to jail usually have a sentence of a year or less,
but jails also incarcerate persons in a wide variety of
other categories.
2. Some inmates—especially jail inmates—are incarcerated more than once in a year. In order not to count these
individuals more than once, the methodology divides the
number of inmates by a factor of l.38 to arrive at the
number of different people who are incarcerated during a
year. For an explanation of the use of this correction factor, see pages 3–4 of Hammett, T.M., P. Harmon, and W.
Rhodes, “The Burden of Infectious Disease Among

27

Figure 3–5. Federal Prisons: Estimated Prevalence of Six Mental Illnesses Among Inmates in 1995
Compared With Lifetime Prevalence Rates for the Total U.S. Population in the Early 1990s*
Prevalence (%)
25
Low

High

U.S.

20

15

10

5

0
Schizophrenia/
Psychosis

Major
Depression

Bipolar (Manic)

Dysthymia

Post-Traumatic
Stress Disorder

Anxiety**

Mental Illness
* “The National Comorbidity Survey,” Kessler, R.C., International Review of Psychiatry 6 (1994): 365–376.
** No data for total U.S. population.
Source: Veysey, B.M., and G. Bichler-Robertson, “Prevalence Estimates of Psychiatric Disorders in Correctional Settings,” paper submitted to the National
Commission on Correctional Health Care, Chicago, Illinois, May 1999. (Copy in volume 2 of this report.)

Inmates and Releasees From Correctional Facilities,”
in volume 2 of this report.
3. Findings in a recent paper indicate that 9,370 cases of
AIDS among inmates were reported to the Centers for
Disease Control and Prevention for January 1, 1994 through
December 31, 1996. Dean-Gaitor, H.D., and P.L. Fleming,
“Epidemiology of AIDS in Incarcerated Persons in the
United States, 1994–1996,” AIDS 13 (1999): 2429–2435.
4. Several qualifications to the syphilis estimates should
be noted. They are based on limited data, some of which
represent crude RDR test positivity rates that may include
false positives and do not reflect disease stage or infectiousness. Morever, the incidence of syphilis has dropped

substantially since 1996–97, the years for which these
estimates were made. Because syphilis is concentrated in
the South, a range of prevalence estimates excluding and
including Southern jurisdictions were calculated. The
details of the methodology are described in the background paper in volume 2 by Hammett, Harmon, and
Rhodes, “The Burden of Infectious Disease Among
Inmates and Releasees From Correctional Facilities.”
5. The U.S. Department of Justice, Bureau of Justice
Statistics, is preparing a report on the prevalence of hepatitis among correctional populations for release in 2002,
based on data from the 2001 census of State and Federal
correctional facilities.

28

6. This figure was derived by applying the prevalence of
TB disease among inmates in prisons (0.04%) and jails
(0.17%) to the estimated number of releasees from prisons and jails. The denominator (34,000) is an estimate of
the total number of persons with TB in the U.S. during
1996. The Centers for Disease Control and Prevention’s
TB Registry Reports, which reported the number of cases
in a given year, were discontinued in 1994. The only
report for subsequent years is CDC’s TB surveillance
report, which reports incident (new) cases each year. The
analysis calculated an average ratio of incident cases to
prevalent cases for the last 3 years in which the Registry
Reports were available (1992–94) and applied this ratio
(0.627) to the number of incident cases for 1996 (21,337)
to obtain the estimate of 34,000 prevalent cases in 1996.
7. These figures are supported and explained in more
detail in Hammett, Harmon, and Rhodes, “The Burden
of Infectious Disease Among Inmates and Releases From
Correctional Facilities,” in volume 2 of this report.
8. Centers for Disease Control and Prevention, HIV/AIDS
Surveillance Report, 1997, Atlanta, GA: U.S. Department
of Health and Human Services, 1997.
9. A more recent study concluded that the 1996 AIDS rate
for incarcerated persons was at least six times the national
rate. See Dean-Gaitor and Fleming, “Epidemiology of
AIDS” (see note 3).
10. McQuillan, G.M., M.J. Alter, L.A. Moyer, S.B.
Lambert, and H.S. Margolis, “A Population-Based
Serologic Survey of Hepatitis C Virus Infection in the
U.S.,” in M. Rizzetto, R.H. Purcell, G.L. Gerin, and G.
Verme (eds.), Viral Hepatitis and Liver Disease, Turin,
Italy: Edizioni Minerva Medica, 1997: 267–270.
11. Based on the prevalence estimate in McQuillan et al.,
“A Population Based Serologic Survey” (see note 10).
The 17.0–18.6 percent estimate is probably very low,
given that studies conducted in individual prison systems
have found prevalence rates of 30–40 percent. Hammett,
Harmon, and Rhodes, “The Burden of Infectious Disease
Among Inmates and Releasees” (see note 2).
12. A fourth chronic disease, heart disease, was excluded
from the report. Because the prevalence of heart disease
increases with age, rates of diagnosable heart disease
among inmates are low.
13. National Center for Health Statistics, National Health
and Nutrition Examination Survey III [NHANES–III],
Atlanta, GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention,
and the U.S. Department of Agriculture, 1997.

14. Ibid.
15. One study that interviewed admissions (conducted in
the Cook County [Chicago], Illinois, jail) found acute
symptoms of serious mental illnesses requiring treatment
in about 6 percent of males and 15 percent of females at
booking. See Teplin, L.A., “Psychiatric and Substance
Abuse Disorders Among Male Urban Jail Detainees,”
American Journal of Public Health 84 (1994): 290–293;
and Teplin, L.A., E.M. Abram, and G.M. McClelland,
“Prevalence of Psychiatric Disorders Among Incarcerated
Women,” Archives of General Psychiatry 53 (1996):
505–512.
16. Ditton, P.M., Mental Health and Treatment of
Inmates and Probationers, Special Report, Washington,
DC: U.S. Department of Justice, Bureau of Justice
Statistics, July 1999, NCJ 174463, found that about
16 percent of prison and jail inmates, or an estimated
283,800 inmates, reported either a mental or emotional
condition or an overnight stay in a mental hospital or
program in 1998.
17. Kessler, R.C., “The National Comorbidity Survey,”
International Review of Psychiatry 6 (1994): 365–376.
18. The National Comorbidity Study included information about antisocial personality, a character disorder
involving a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or
early adolescence and continues into adulthood. Although
antisocial personality disorder is a management problem
for correctional health care professionals and security
staff, it was excluded from this analysis because there is
no effective medical intervention for the condition. “In
general, adult antisocial behavior provokes therapeutic
pessimism. That is, therapists have little hope of changing a pattern of behavior that has been present almost
continuously throughout the patient’s life. Psychotherapy
has not been effective, and there have been no major
breakthroughs with biological treatments, including the
use of medications.” Kaplan, H.I., B.J. Sadock, and J.A.
Grebb, Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences, Clinical Psychiatry, 7th ed.,
Baltimore, MD: Williams & Wilkins, 1994: 799.
19. Dysthymia and anxiety range from completely disabling (e.g., agoraphobia) to not even mildly incapacitating (e.g., generalized anxiety disorder). Depending on the
severity of their condition, many individuals with dysthymia and anxiety do not require medical treatment.

29

Chapter 4. Improving Correctional Health
Care: A Unique Opportunity to Protect
Public Health
This chapter reviews the extent to which prisons
and jails provide prevention, screening, and treatment programs for communicable disease, chronic
disease, and mental illness. The chapter then examines whether current correctional prevention and
treatment efforts for selected communicable diseases and for mental illness meet accepted national
standards for correctional health care. The findings
suggest that there is a tremendous opportunity—as
yet, largely unexploited—to protect public health by
improving current correctional prevention, screening, and treatment programs.

Current State of Correctional
Prevention, Screening, and
Treatment Programs
Chapter 3, “Prevalence of Communicable Disease,
Chronic Disease, and Mental Illness Among the
Inmate Population,” documented that communicable
disease, chronic disease, and mental illness are prevalent in prisons and jails. Many specific conditions
are more prevalent among inmates than among the
general population. The discussion below suggests
that many correctional agencies are not doing enough
to address most of these medical conditions.

Communicable disease
Data suggest that many prisons and jails are not
adequately addressing three communicable diseases—human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS), syphilis,
and tuberculosis (TB).1
HIV/AIDS. Although rudimentary HIV education
programs are becoming more widespread in correctional facilities, few prison or jail systems have
implemented comprehensive HIV-prevention programs in all of their facilities.2 Most correctional
systems provide HIV antibody testing only when

inmates ask to be tested or have signs and symptoms of HIV disease. Testing is not aggressively
“marketed” in most correctional systems. Some correctional systems, however, are beginning to implement an integrated continuum of care for inmates
with HIV and AIDS.
Syphilis. Very few correctional systems routinely
screen inmates for syphilis. Despite the availability
of fairly inexpensive diagnostic and treatment
modalities for syphilis, a national survey conducted
by the Centers for Disease Control and Prevention
(CDC) found that fewer than one-half of all jails
(46–47 percent) offer routine laboratory testing for
the disease as a matter of policy. Even jails that
report aggressive screening policies actually screen
fewer than one-half of inmates (48 percent). As a
result, on average fewer than one-quarter of jail
inmates undergo laboratory testing for syphilis
while incarcerated. In jails that offer testing only to
patients with suggestive symptoms or signs, only
2–7 percent of inmates are tested. Continuity of care
for inmates released with syphilis and other sexually transmitted diseases (STDs) is also inadequate.
Tuberculosis. Although more prisons and jails
screen for TB than for STDs, too few conduct TB
screening. According to a 1997 survey conducted
for the National Institute of Justice (NIJ) and CDC,
more than 90 percent of State and Federal prisons,
and about one-half of jails, routinely screen at
intake for TB. In part, however, because of short
inmate stays in jail, TB skin test results—which
require 48–72 hours before they indicate infection—may not be read.3 Ninety-eight percent of
State and Federal prison systems and 85 percent of
jails report that they isolate inmates with suspected
or confirmed TB disease in negative pressure rooms.
Some facilities, however, do not test the rooms to
ensure that they are working properly, or they use the
rooms even when they are known to be out of order.

30

Directly observed therapy for latent TB infection
(watching patients swallow each dose of medication)
is the reported policy for all patients in 91 percent of
State and Federal prisons and in 85 percent of jails.
Correctional systems may have appropriate policies
in place related to TB, but implementation of those
policies may be inadequate.4

Chronic disease
As part of The Health Status of Soon-To-Be-Released
Inmates project, a survey was conducted examining
prevention, screening, and treatment services for
chronic disease offered by State departments of corrections (see chapter 2, “History of the Project”).5
Treatment protocols for chronic diseases in corrections systems. As shown in table 4–1, only 24
to 26 of the 41 States responding report they have
systemwide treatment protocols for diabetes, hypertension, and asthma. Departments of corrections
with systemwide protocols tended to be those with
the largest average daily population and the largest
number of annual releasees. Eighty-four percent of
inmates and 78 percent of annual releasees covered
by the 41 departments of corrections that responded
to the survey were in correctional systems that report
they have protocols for the treatment of asthma.
Seventy-three percent of inmates and annual
releasees from systems that responded to the survey
are from systems with protocols for the treatment
of diabetes. Seventy-seven percent of inmates and

annual releasees from systems that responded to
the survey were from systems with protocols for
treating hypertension. These figures may be overestimates, however; a content analysis found that
most of the clinical “guidelines” addressing chronic
disease that correctional systems submitted were
incomplete or out of date, making them useless for
screening or treating inmates or for measuring
quality of care. In addition, although the policies
and procedures in place may be acceptable, actual
services may be inadequate.
Status of discharge planning programs for
chronic diseases. Discharge planning is designed
to facilitate an inmate’s transition into the community. In the case of health care, discharge planning
means that, at a minimum, arrangements are made
for inmates to have a contact from whom they can
get needed services for any medical or mental condition they may have when they are released into
the community. Sixteen of the 41 responding States,
housing 61 percent of the total inmate population in
the responding States, had policies and procedures
for discharge planning for inmates with chronic diseases. Once again, however, the policies and procedures may not be followed, especially in jails; as a
result, services may be inadequate.
Twenty-nine of the 41 responding States, accounting for 84 percent of total annual releasees in these
States, indicated that inmates with chronic diseases

Table 4–1. States Reporting Systemwide Treatment Protocols for Chronic Disease* (n = 41)
Average Daily
Population
Chronic Disease

n

%**

Total Annual
Releasees
Mean

n

%***

Mean

Asthma (n = 26)

692,295

84.2

26,627

338,695

78.4

13,706

Diabetes (n = 24)

606,878

73.8

25,287

316,686

73.3

13,195

Hypertension (n = 25)

660,520

80.3

26,421

336,320

77.8

13,453

*As discussed in the text, the clinical guidelines from a large proportion of corrections systems that reported that their protocols were incomplete or
out of date.
**Percentage of all inmates housed in the prison systems covered by the protocols.
***Percentage of all releasees housed in the prison systems covered by the protocols.
Source: Hornung, C.A., B.J. Anno, R.B. Greifinger, and S. Gadre, “Health Care for Soon-To-Be-Released Inmates: A Survey of State Prison Systems,”
paper prepared for the National Commission on Correctional Health Care, Chicago, Illinois, 1998. (Copy in volume 2 of this report.)

31

were given a supply of medication when they were
released. Even when a discharge policy provides
for a supply of medication upon release, the policy
may not be followed because of logistical barriers.6
Security staff responsible for preparing an inmate’s
discharge may not inform health care staff that the
inmate is leaving, so the inmate does not receive
medication.

Communicable disease
A significant minority of prisons and jails do not
adhere to CDC standards with regard to screening
for and treating TB.11
●

About one-fourth of corrections systems do not
follow CDC recommendations regarding universal TB screening. About 10 percent of State and
Federal prisons and about one-half of jails do
not have mandatory TB screening for inmates at
intake and annually thereafter. CDC acknowledges that screening may be infeasible in shortterm facilities because most inmates are released
before the skin test can be read.

●

Nearly all (98 percent) of State and Federal
prison systems and 85 percent of jail systems
have a policy to isolate inmates with suspected
or confirmed TB disease in negative pressure
rooms. However, 16 percent of State and Federal
prison systems and 74 percent of jails report they
do not conform to the CDC guideline that respiratory isolation be maintained until patients have
tested negative for TB on three consecutive sputum smears.

●

Ten percent of State and Federal prison systems
and 15 percent of jails do not have policies for
directly observed therapy for treatment of latent
TB infection. (Only 2 percent of prisons and 5
percent of jails do not have policies for directly
observed therapy for TB disease.)

Mental illness
Surveys have documented that jails and prisons
provide inadequate services to inmates with mental
illness.
Jails. A study of mental health services in U.S. jails
having rated capacities for 50 or more detainees
found that few jails provide a comprehensive range
of services.7 Approximately 83 percent of all U.S.
jails provide intake screening, but only 60 percent
provide full mental health evaluations. Forty-two
percent provide psychiatric medications. In response
to emergencies, 43 percent of jails provide crisis
intervention services and 72 percent offer access to
inpatient hospitalization. Although 73 percent of
jails report they have suicide prevention programs,
the content of the programs is not known.8 Release
planning may be the most important service a jail
can provide to reduce the probability of mentally
ill releasees returning to jail. Only 21 percent of
jails, however, provide case management or discharge planning.9
Prisons. Among State adult prisons, 83 percent provide screening and assessment for mental illness,
80 percent provide medication and medication monitoring, 87 percent offer some form of counseling
or verbal therapy, and 77 percent have access to
inpatient care. Only 36 percent of prisons have specialized housing for individuals with stable mental
health conditions.10

Corrections’ Mixed Record of
Compliance With National Guidelines
The information above suggests that many prisons
and jails fail at least in part to conform to nationally
accepted health care guidelines. Illustrations of this
mixed record follow.

Chronic disease
A significant number of prisons and jails do not
appear to adhere to national standards for screening
for and treating chronic disease.
As discussed above, the survey of State departments
of corrections conducted as part of The Health Status
of Soon-To-Be-Released Inmates project found that
many departments report that they lack systemwide
protocols for screening for and treating diabetes,
hypertension, and asthma. Analysis of the existing
protocols found that most do not meet American
Diabetes Association and National Institutes of Health
standards for treating these diseases.12 Correctional
health care experts who have visited many prisons

32

conclude that, although it is relatively easy to provide services that meet national standards, it is
rarely done in the absence of any or appropriate
treatment protocols.

do not require inpatient treatment, but cannot
function adequately in the general population
housing.
●

Outpatient treatment services.

Mental illness

●

Consultation services.

Most prisons and jails do not conform to nationally
accepted health care guidelines for mental health
screening and treatment.

●

Transfer and discharge planning.

Screening. The American Psychiatric Association,13
the American Public Health Association,14 and the
National Commission on Correctional Health Care15
have established principles for the delivery of mental
health care services in prisons. All of these organizations’ standards emphasize that mental health screening and evaluation should be provided by qualified
personnel for all inmates as part of the admission
process to jail or prison.
The American Psychiatric Association describes the
following procedures for identifying inmates requiring mental health treatment:
●

Screening newly arriving inmates at the correctional facility immediately following admission.

●

Comprehensive evaluation in response to referrals from a screening examination or from other
staff, or in response to a self-referral.16

As noted in the previous section, 17 percent of jails
and prisons do not screen for mental illness at intake,
and 40 percent of jails and 17 percent of prisons do
not provide mental health evaluations.
Treatment. Professional standards also call for
comprehensive mental health treatment. According
to the American Psychiatric Association,17 the essential components of a comprehensive mental health
care system include:
●

An acute care program.

●

A crisis intervention program with infirmary beds
for short-term treatment and 24-hour availability
of a psychiatrist for clinical evaluations and
emergency medications.

●

A chronic care program or special needs unit
within the correctional setting that can house
30–50 inmates with chronic mental illness who

The fundamental policy goal of the American
Psychiatric Association guidelines is to provide the
same level of mental health care to patients in the
criminal justice system as is available in the average
community.18 As noted above, a significant proportion of correctional systems do not provide all the
called-for services. In particular, few jails provide
comprehensive services. The mental health treatment available to inmates in jails is often limited
by inmates’ short stays and the small size of most
facilities. The Center for Mental Health Services
argues that it is impractical for jails to provide
therapy and that—
only four services should reasonably fall within
the purview of the jail. . . . Realistically, [jail
inmates] . . . should be assessed, provided with
emergency treatment, and linked to the [community] mental health care system. Thus, the
essential jail services are intake screening,
evaluation, crisis intervention, and discharge/
transfer planning.19
As noted above, few jails provide the “essential”
service of discharge planning.

Implications: A Significant Opportunity
to Intervene
The previous chapter documented the high prevalence rates—disproportionately high, in some
cases—of communicable diseases, chronic diseases,
and mental illnesses among inmates. This chapter
establishes that many prisons and jails are doing too
little to address these conditions. Failure to prevent
or treat these conditions is likely to have significant
adverse effects on society.
●

Released inmates who are not treated for communicable diseases may transmit these diseases
to members of the general community.

33

●

Many inmates who are released with untreated
communicable or chronic diseases, or with
mental illness, are likely to become a much
greater financial burden on their local health care
system or, if indigent or elderly, a much greater
burden on State and national health care insurance systems (Medicaid, Medicare) than if they
had been treated while still incarcerated and in
an earlier stage of their disease.

By providing comprehensive prevention, screening,
and treatment services in prisons and jails, communities can take advantage of a tremendous opportunity
to improve public health by reducing the problems
associated with untreated inmates returning to the
community. The following chapter documents that
preventing, screening, and treating communicable
disease, chronic disease, and mental illness in prisons
and jails would be cost effective. The benefits of prevention and treatment would outweigh the expense.

Notes
1. Hammett, T.M., P. Harmon, and L.M. Maruschak
1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities, Issues and Practices, Washington,
DC: U.S. Department of Justice, National Institute of
Justice, July 1999, NCJ 176344.
2. A comprehensive HIV-prevention program provides
HIV counseling and testing, instructor-led education,
peer-based programs, and multisession HIV-prevention
counseling in each correctional facility.
3. Valway, S.E., R.B. Greifinger, M. Papania, J.O.
Kilburn, C. Woodley, G.T. DiFerdinando, and S.W.
Dooley, “Multidrug Resistant Tuberculosis in the New
York State Prison System, 1990–1991,” Journal of
Infectious Disease 170 (1994): 151–156.
4. Ibid.
5. Hornung, C.A., B.J. Anno, R.B. Greifinger, and S.
Gadre, “Health Care for Soon-To-Be-Released Inmates:
A Survey of State Prison Systems,” paper prepared for
the National Commission on Correctional Health Care,
Chicago, IL, 1998. (Copy in volume 2 of this report.)
6. This was the consensus of The Health Status of SoonTo-Be-Released Inmates project expert panels. (See
chapter 2, “History of the Project,” for a discussion of
the composition and role of the panels.)

7. Steadman, H.J., and B.M. Veysey, Providing Services
for Jail Inmates With Mental Disorders, Research in
Brief, Washington, DC: U.S. Department of Justice,
National Institute of Justice, 1997, NCJ 162207.
8. NCCHC Jail Standard on Suicide Prevention (J–51)
requires jails to have a program for identifying and
responding to suicidal individuals. Program components
include identification, training, assessment, monitoring,
housing, referral, communication, intervention, notification, reporting, review, and critical incident debriefing.
National Commission on Correctional Health Care,
Standards for Health Services in Jails, Chicago, IL:
Author, 1996.
9. Steadman and Veysey, Providing Services (see note 7).
10. Manderscheid, R.W., and M.A. Sonnenschein (eds.),
Mental Health, United States, 1998, Rockville, MD:
United States Department of Health and Human Services,
1999.
11. Hammett, Harmon, and Maruschak, 1996–1997
Update (see note 1). The CDC guidelines at the time
this report was written may be found in “Prevention
and Control of Tuberculosis in Correctional Facilities:
Recommendations of the Advisory Council for the
Elimination of Tuberculosis,” Morbidity and Mortality
Weekly Report 45 (RR–8) (June 7, 1996): 1–27.
12. American Diabetes Association, “Standards for
Medical Care for Patients With Diabetes Mellitus,”
Clinical Practice Recommendations 2000, Diabetes
Care 23 (supp. 1) (2000): 1–23; American Diabetes
Association, “Management of Diabetes in Correctional
Institutions,” Clinical Practice Recommendations 2000,
Diabetes Care 21 (supp. 1) (2000): 1–3; National
Institutes of Health, National Asthma Education and
Prevention Program, Expert Panel Report 2: Guidelines
for the Diagnosis and Management of Asthma, Bethesda,
MD: National Heart, Blood, and Lung Institute, February
1997; National Institutes of Health, Sixth Report of the
Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure,
Bethesda, MD: National Heart, Lung, and Blood
Institute, November 1997.
13. American Psychiatric Association, Task Force Report
No. 29: Psychiatric Services in Jails and Prisons,
Washington, DC: Author, 1989.
14. American Public Health Association, Standards for
Health Services in Correctional Institutions. Washington,
DC: Author, 1976.

34

15. National Commission on Correctional Health Care,
Correctional Mental Health Care: Standards and Guidelines for Delivering Services, Chicago, IL: Author, 1999.
16. Screening is a form of assessment that seeks to identify risks for various diseases, conditions, or behaviors in
ways that are quick, inexpensive, and relatively accurate.
Essentially, a screen is a form of probability estimate.
Diagnostic assessments (or evaluations) need to be thorough and definitive. An example of the distinction between
screening and assessment taken from the detection of
breast cancer would be the difference between a mammogram and a biopsy.
17. In 1982 the American Psychiatric Association (APA)
created a Task Force on Psychiatric Services in Correctional
Facilities, and in 1983 APA became officially represented
on the board of directors of the National Commission on
Correctional Health Care (NCCHC). Henry Weinstein, a
board member of both organizations, chaired APA’s most
recent revision of its guidelines, Psychiatric Services in
Jails and Prisons (1998), and NCCHC’s comprehensive

Correctional Mental Health Care: Standards and
Guidelines for Delivering Services (1999). Jails also
have a constitutional obligation to provide minimum
care. Custodial facilities have both the duty to protect
and the duty to treat serious medical and psychiatric conditions. See Cohen, F., and J. Dvoskin, “Inmates With
Mental Disorders: A Guide to Law and Practice,” Mental
and Physical Disability Law Reporter 16 (3–4) (1992):
39–46, 462–470; and Metzner, J.L., “An Introduction to
Correctional Psychiatry: Part III,” Journal of the American
Academy of Psychiatry and the Law 26 (1) (1998): 107–115.
18. American Psychiatric Association, Psychiatric
Services in Jail and Prisons. (see note 13).
19. Goldstrom, I., M. Henderson, A. Male, and R.W.
Manderscheid, “Jail Mental Health Services: A National
Survey,” in R.W. Manderscheid and M.J. Henderson
(eds.), Mental Health, United States, 1998, Rockville,
MD: U.S. Department of Health and Human Services,
Center for Mental Health Services, 1999, p. 182.

35

Chapter 5. Cost-Effectiveness of Prevention,
Screening, and Treatment of Disease
Among Inmates
This chapter assesses whether it would be cost
effective for correctional systems to implement
interventions for preventing, screening for, and
treating selected communicable and chronic diseases. The chapter concludes that a number of interventions would be cost effective and, in several
cases, save money. Although clinical guidelines are
available for certain mental illnesses, such as major
affective disorder (depression and bipolar disorder)
and schizophrenia,1 insufficient data are available to
analyze the cost implications of following these
guidelines for corrections.2

Cost-Effectiveness of Prevention,
Screening, and Treatment
The project considered whether it would be cost
effective or a cost saving to prevent, screen for,
and treat selected diseases. (See “The Differences
Between Cost Effective and a Cost Saving”.) For
each disease, the discussion below (1) summarizes
the results of the cost-effectiveness and cost-saving
analysis, (2) describes briefly the analytic methodology used, and (3) reviews the findings. “Summary of
Cost-Effectiveness and Cost-Savings Estimates”

provides an overview of the project’s conclusions
regarding the cost-effectiveness and the cost saving
of the interventions.

Communicable Disease
The discussion below examines whether it would be
cost effective and a cost saving to screen for and treat
three sexually transmitted diseases (STDs) (syphilis,
gonorrhea, and chlamydia), tuberculosis (TB), and
human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). The analysis frequently makes the case for cost-effectiveness or a
cost saving, assuming that a minimum level of infection is present among the inmates in a correctional
system. Whether and to what extent an intervention
for a specific disease is cost effective or a cost saving
depends on each correctional system’s prevalence
infection rate for the disease. The higher the rate,
the greater the intervention’s cost-effectiveness and
cost savings will be.

Syphilis, gonorrhea, and chlamydia
Summary. It would be cost effective to screen routinely for syphilis, gonorrhea, and chlamydia in

The Differences Between Cost Effective and a Cost Saving
A cost-saving intervention saves more money in averted medical costs than is needed to implement the intervention. A program does not have to save costs to be a worthwhile investment. If the reduction in adverse
health consequences is judged to be worth the cost of the program, the program is still cost effective. A costeffective intervention means that the benefits the intervention will achieve are worth the costs even if the
intervention costs more than the money that is saved as a result of averted illness or death. Clearly, any
intervention that is cost saving is also cost effective, but not all cost-effective interventions save money.*
*A cost-effectiveness analysis compares the cost of incremental interventions with the financial value of the effect or intended outcome.
The outcome may be expressed in terms of dollars expended per case (or complication avoided), as it is for sexually transmitted diseases
in this report. Cost-effectiveness ratios can be calculated for the incremental prices (as in dollars per year or dollars per quality-adjusted
year of life expectancy [QALY]). In this report, ratios of this type are used to evaluate chronic disease interventions. See M.R. Gold, J.E.
Siegel, L.B. Russell, and M.C. Weinstein, Cost-Effectiveness in Health and Medicine, New York, New York: Oxford University Press,
1996; and A.C. Haddix, S.M. Teutsch, P.A. Shaffer, and D.O. Dunet, Prevention Effectiveness: A Guide to Decision Analysis and
Economic Evaluation, New York, New York: Oxford University Press, 1996.

36

prisons and jails. It would be a cost saving to screen
routinely for syphilis in prisons and jails. The
methodology and findings presented below are
based on the paper “Cost-Effectiveness of Routine
Screening for Sexually Transmitted Disease in
Inmates of U.S. Correctional Facilities,” by Julie R.
Kraut, Anne Haddix, Vilma Carande-Kulis, and
Robert B. Greifinger, in volume 2 of this report.
Methodology. The method of estimating the costeffectiveness of preventing and treating these three
STDs considers the number of new individuals
whom inmates leaving prison or jail with these diseases are likely to infect and the averted costs of
treating these new cases. To make this calculation,
the analysis makes assumptions regarding the prevalence of infection among inmates. The analysis for
syphilis makes the following additional assumptions:
●

The average number of people an infected person
further infects in a susceptible population.

●

The probability of transmitting the disease from
an infected person to someone else.

●

The length of time during which the person with
the disease remains infectious.

●

The average number of new people with whom
the infected person will have sexual contact over
a given period of time.

Findings. The findings are largely similar for the
three sexually transmitted diseases but at different
levels of prevalence.
●

Syphilis. Routine syphilis screening on intake to
prisons or jails would be a cost saving (and therefore cost effective) if at least 1 percent of inmates
were infected. In a hypothetical cohort of 10,000
inmates, screening would identify and make it
possible to treat 234 individuals before they could
transmit the disease to others. By interrupting

Summary of Cost-Effectiveness and Cost-Savings Estimates
Condition

Syphilis
Gonorrhea

Intervention

Cost Effective

Where

Cost Saving

Where

universal
screening
universal
screening

yes, if >1%

prisons
and jails
prisons
and jails

yes, if >1%

prisons
and jails
prisons
and jails*

yes

Chlamydia

universal
screening

yes

prisons
and jails

HIV Infection

counseling
and testing
universal
screening

yes

prisons

yes

prisons

yes

prisons
and jails
prisons
and jails

Tuberculosis
Infection

Hypertension
Diabetes

universal
screening
universal
screening

yes

*For jail inmates, to be a cost saving, at least 85 percent of diagnosed women would need to be treated.

no (men), yes,
if prevalence
is >8%
(women)
no (men), yes,
if prevalence
is >9%
(women)
yes
yes, if >3%
of HIV-infected
inmates have
TB infection
no
no

prisons
and jails*

prisons
prisons

N/A
N/A

37

transmission of the disease, this would prevent at
least 186 new cases of syphilis in sexual partners
of inmates. The public health benefits would
probably be even greater, as the analysis could
not estimate the total number of cases detected
resulting from interrupting transmission in the
community. Routine screening for syphilis would
also prevent 10 new cases of HIV infection
because the risk of HIV transmission is increased
in persons with both HIV and syphilis infection.
Routine screening for syphilis would save almost
$1.6 million in future treatment costs for every
10,000 inmates screened, excluding any savings
associated with HIV prevention.
●

Gonorrhea. Routine screening for gonorrhea for
men in prisons and jails would be cost effective
but not a cost saving. Because women face more
and costlier complications related to the disease,
the concern is that undiagnosed men may transmit the disease to women. Screening men would
prevent a substantial number of undiagnosed
cases of gonorrhea, decreasing transmission rates.
For a hypothetical cohort of 10,000 male prison
inmates, at least 6 percent of whom were infected,
routine screening would prevent 296 cases of
untreated or undiagnosed gonorrhea. It would cost
only $267 to prevent a case of undiagnosed gonorrhea, an acceptable cost-effectiveness ratio. This
probably underestimates the cost-effectiveness
of screening because some averted HIV treatment
costs were excluded from the analysis.
As with men, routine screening for gonorrhea for
women in prisons and jails would be cost effective
because it would prevent many cases of gonorrhea
and avert the development of complications associated with the disease. Routine screening may
also be considered cost effective because it would
cost the health care system only $585 to $3,638,
depending on the setting, to avert a single case
of pelvic inflammatory disease (PID).3 Routine
screening for women would be a cost saving in
prisons if at least 8 percent of female inmates
had gonorrhea. To be a cost saving for a cohort
of the same size in a jail, the prevalence of gonorrhea would also have to be at least 8 percent,
and at least 85 percent of diagnosed women
would have to be available to be treated.

●

Chlamydia. Routine screening at intake for
chlamydia for men in prisons and jails would be
cost effective. Screening would detect a substantial number of undiagnosed cases and decrease
transmission from men to women. It would cost
only $198 in prisons and about $1,100 in jails
to prevent one case of chlamydia, an acceptable
cost-effectiveness ratio. Screening would not be
a cost saving for men in prisons and jails.

Routine screening of female inmates for chlamydia
in prisons and jails would be cost effective. Screening
would substantially reduce the number of PID cases
and untreated or undiagnosed cases of chlamydia
in prisons. It would cost only $198 to prevent each
case of PID in prisons, and the cost per case of PID
averted would be about $2,450. These are acceptable cost-effectiveness ratios. The results probably
underestimate the cost-effectiveness of screening
because, as with gonorrhea, some averted treatment
costs were excluded from the analysis. Screening
for chlamydia would be a cost saving for female
prison inmates only if at least 9 percent of women
were infected. To be a cost saving for a cohort of
the same size in a jail, the prevalence of chlamydia
would also have to be at least 9 percent, and at
least 85 percent of diagnosed women would have
to be treated.

HIV
Summary. HIV counseling and testing in prisons
would be cost effective and a cost saving. The
methodology and findings presented below are
based on the paper, “Cost-Effectiveness of HIV
Counseling and Testing in U.S. Prisons,” by
Beena Varghese, in volume 2 of this report.
Methodology. This analysis examined the costeffectiveness of HIV counseling and testing (not
treatment) of prison inmates in preventing future
HIV infection. The analysis included all societal
costs and benefits of a prevention program, including personnel and laboratory costs for counseling
and testing, and averted lifetime treatment costs of
HIV (excluding the costs and benefits of identifying
and treating HIV-infected inmates).4
Findings. As an HIV-prevention program, voluntary
counseling and testing in prisons would be cost

38

effective and a cost saving. Offering counseling
and testing to 10,000 prison inmates would prevent
three future cases of HIV if 60 percent of the inmates
agreed to be counseled and tested. Preventing
these future cases would save $410,000—almost
$137,000 per future case of HIV prevented.5 For
correctional systems with HIV prevalence rates as
low as 1.5 percent, offering counseling and testing
to 10,000 inmates would cost the prison system
about $117,000, or approximately $39,000 per case
of HIV prevented. As the prevalence of HIV, transmission rate, and effectiveness of counseling
increased, counseling and testing would become
more cost effective. The cost drops to $28,000 per
case of HIV prevented when HIV prevalence among
inmates increases to 3 percent or more—the current
percentage in most State prisons in the Northeast
and some in the South.6

5 percent and to 1,704 cases prevented for prisons
with an HIV infection rate of 7.85 percent.

Tuberculosis

Chronic Disease

Summary. Screening all prison inmates for TB at
intake would be cost effective and, in certain circumstances, cost saving. The methodology and findings presented below are based on the presentation,
“The Cost-Effectiveness of Preventing Tuberculosis
in Prison Populations,” by Zachary Taylor and
Cristy Nguyen, in volume 2 of this report.

Summary. Universal screening and treatment in
prisons and jails for hypertension and diabetes
would be cost effective but not cost saving. The
methodology and findings presented below are
based on “Cost-Effectiveness Analysis of Annual
Screening and Intensive Treatment for Hypertension
and Diabetes Mellitus Among Prisoners in the
United States,” by Donna M. Tomlinson and Clyde
B. Schechter, in volume 2 of this report.

Methodology. This analysis takes into consideration
a range of prevalence estimates for latent TB infection, screening costs, the health effects of latent TB
infection and active TB disease, the effectiveness of
screening for prison inmates, and the effectiveness
of preventive therapy (90 percent in HIV-negative
patients, 73 percent in HIV-positive patients).
Findings. Screening for latent TB infection in prisons would be cost effective. For every 100,000
prison inmates tested and with treatment of those
who are found to have latent TB infection,7 989
cases of active TB would be prevented each year.
With a high-risk group, such as HIV-infected
inmates, the number of TB cases prevented would
increase according to the rate of HIV infection. The
estimate of 989 cases that would be prevented per
100,000 screened inmates assumes that 2.3 percent
of inmates are HIV positive—the percentage infected in the Nation’s prisons and jails as a whole. The
number of TB cases prevented would increase to
1,336 cases for prisons with HIV infection rates of

Screening for latent TB infection in prisons would
be cost saving if the prevalence were more than 3
percent among HIV-infected inmates. The 989 cases
of active TB that would be prevented per 100,000
screened inmates, assuming that 2.3 percent of
inmates are HIV positive, would save $7,174,509,
or $7,254 per case prevented.
This cost-effectiveness analysis is limited to prisons. Because the short stays and rapid turnover of
jail inmates present serious challenges to screening
for latent TB infection, jails are not included. In the
jail setting, the highest priority should be placed on
screening incoming inmates for active TB disease so
that any contagious individuals are properly isolated.

Methodology.8 A simulation was constructed that
projected the 20-year economic and health consequences of initiating annual screening and intensive
treatment for hypertension and diabetes. The occurrence of complications in a cohort of released
inmates was then predicted using the results of three
epidemiological studies of heart disease and diabetes.9 The average per-inmate annual cost of
screening and confirmatory tests for both diseases
was estimated at about $15. Assuming that the least
expensive generic brands of drugs were used, and
assuming five physician checkups per year, the
annual per-inmate cost of treating inmates with
hypertension would be approximately $388.10 The
average increased costs associated with aggressive
diabetic treatment were estimated to be $1,983 per
year per diabetic. The analysis factored in the number of years of less-than-ideal quality of life that
infected inmates would avoid if treated aggressively.

39

Findings. Universal screening for hypertension and
diabetes would be cost effective because of the
added years that inmates with these diseases could
expect to live and the reduced number of medical
complications they could be expected to experience.
Over 20 years of followup, in the absence of screening and treatment, the 1,599,409 individuals incarcerated in 1998 could be expected to live 7,616,668
years in prison and another 22,567,690 years outside prison. With aggressive screening and treatment, and assuming 100 percent compliance, they
could be expected to live another estimated 386,108
years, 3,768 years in prison and 382,340 years
(more than 99 percent of the total) outside prison.
The cost to achieve this improved survival would be
$131.71 per inmate per year, about 5 percent of current average correctional health care budgets.
There would be large public benefits to this investment. In addition to increased survival, investment
in screening and treatment would result in reductions of:
●

31,697 years of blindness (94.1 percent outside
prison).

●

61,021 episodes of coronary heart disease
(91.7 percent outside prison).

●

31,555 years of congestive heart failure
(89.25 percent outside prison).

●

44,400 strokes (more than 90 percent outside
prison).

●

15,395 years of terminal kidney disease
(94.6 percent outside prison).

Moving Beyond Cost-Effectiveness
The discussion above demonstrates that it would be
cost effective and, in some cases, save money for
prisons and jails to introduce or expand prevention,
screening, and treatment interventions targeting
communicable and chronic disease. There are issues
to consider beyond that of cost-effectiveness—in
particular, identifying specific interventions that
have been shown scientifically to prevent and
reduce these diseases among inmates. Only those
interventions that are known to work will be cost
effective. The discussion below examines scientifically tested interventions that correctional agencies
can introduce to target selected diseases and chronic

diseases. These interventions would address three
public health goals:
●

Decrease the likelihood of infection being transmitted from an infected person to an uninfected
person.

●

Reduce the time period during which the infected
person can transmit the disease to others.

●

Reduce the number of contacts the infected
person has with uninfected persons.

Scientifically tested interventions addressing
communicable disease
A complete discussion of most of the scientifically
tested interventions that prisons and jails can implement to reduce the prevalence of communicable
disease among inmates may be found in the paper,
“Communicable Diseases in Inmates: Public Health
Opportunities,” by Jonathan Shuter, in volume 2 of
this report. See “Summary of Scientifically Tested
Interventions Correctional Agencies Can Implement
to Reduce Communicable Disease” for a list of
these interventions.
Sexually transmitted diseases. Syphilis, gonorrhea,
and chlamydia are highly prevalent in correctional
populations. Correctional agencies can introduce a
variety of proven approaches to preventing, screening for, or treating these diseases.
Reducing the likelihood of transmission per contact.
In addition to screening and treating current infection, the ideal approach to reducing the likelihood
of transmission of all three STDs would include
multiple culturally appropriate educational sessions
led by peer counselors who would teach the dangers
of unsafe sexual practices, the importance and proper use of barrier protection, and techniques to
encourage safer sexual practices. These approaches
have demonstrated effectiveness.11
Reducing the duration of infectiousness. Reducing
the length of time during which an inmate is infectious depends on timely screening and prompt
treatment. The following screening and treatment
methods would reduce the period of infectiousness:
●

Syphilis. Rapid screening and treatment can be
done at little cost in jails and prisons.12 Rapid
screening techniques reduce the time lag from

40

Summary of Scientifically Tested Interventions Correctional Agencies
Can Implement to Reduce Communicable Disease
Sexually transmitted diseases
●

Offer educational interventions regarding the dangers of sexual contact with multiple partners.

●

Offer peer-led educational sessions addressing safer sexual practices.

●

Provide rapid screening and treatment of syphilis.

●

Screen for and treat gonorrhea and chlamydia in correctional systems with high rates of these infections.

HIV/AIDS
●

Aggressively market confidential counseling and testing so that all inmates with risk factors accept
these interventions.

●

Provide educational programs to help inmates reduce their risk of acquiring or transmitting HIV infection.

●

Offer treatment to all inmates with HIV disease who qualify under current guidelines.

Tuberculosis
●

Ventilate high-population areas adequately.

●

Train correctional staff to be alert for inmates with TB symptoms.

●

Screen all new admissions for latent TB infection and treat as appropriate; test current inmates and
all staff annually.

●

Provide access to negative pressure isolation rooms.

●

Provide prompt and effective treatment under direct observation.

●

Provide for followup in the community when release precedes completion of treatment.

●

Identify all contacts of inmates newly discovered to be infected.

●

Coordinate all TB control activities with local or State departments of health.

Hepatitis B and C
●

Routinely vaccinate all inmates, or susceptible inmates, against hepatitis B.

●

Consider screening before vaccinating in systems with high rates of hepatitis B.

●

Offer educational sessions to encourage steps to avoid acquiring or transmitting hepatitis B and C.

41

testing to start of treatment, increasing the likelihood that the infected patient will be treated
before being released. All new admissions to
jails and prisons should be tested, and infected
inmates should be treated on the same day.
●

Gonorrhea. Every correctional system should
screen new admissions for gonorrhea infection.
New screening methods for gonorrhea are very
accurate and less uncomfortable than traditional
methods. A urine screening test (Ligase Chain
Reaction) already in wide use is much less invasive and less uncomfortable for the patient, and
requires less staff time, than traditional culture
methods. Inmates diagnosed with gonorrhea
should receive medication that can be taken in a
single dose. Staff can observe inmates taking single doses, increasing the certainty of treatment
and reducing the chance that drug resistance may
develop from partial treatment.

●

Chlamydia. Every correctional system should
screen new admissions for chlamydia infection.
Urine screening is a viable alternative to the
traditional culture method, which requires an
uncomfortable vaginal examination for women.
Inmates testing positive for chlamydia infection
should receive a single dose of azithromycin,
even though other medications that require multiple administrations cost less. The single-dose
treatment is more reliable and therefore more
effective. Correctional systems in which more
than 20 percent of the entire inmate population—
or 20 percent of identifiable subgroups of
inmates—have chlamydia infection might
consider immediate treatment for every inmate
in the risk group without waiting for laboratory
confirmation.

Reducing the number of new contacts. Educational
interventions that heighten awareness of the dangers
of having sexual contact with numerous partners—
a form of “harm-reduction strategy”—appear to
be effective with inner-city patients with STDs.13
Culturally appropriate messages delivered by
respected personalities or peers are most likely to
be effective.14 Patients diagnosed with any STD
should be referred for immediate HIV testing.
HIV/AIDS. Three interventions hold promise for
preventing HIV and AIDS among inmates: testing,
education, and treatment.

HIV testing. Correctional systems should incorporate easy, convenient, and voluntary HIV testing
into the intake procedure for all inmates who are
not already known to be HIV infected. Because new
medications have reduced mortality in recent years,
correctional systems should encourage all incoming
inmates with HIV risk factors who have not knowingly tested positive for HIV to receive counseling
and testing. Alternatively, routine testing of incoming inmates with risk factors might be considered.
The United States military is already using testing
programs of this magnitude efficiently and affordably at a cost of approximately $2.50 per test.15
Because pretest counseling sessions and drawing
blood require many staff, larger correctional systems should consider innovative approaches to
enhance efficiency, such as showing videotaped
pretest counseling sessions (instead of using live
counselors) and using fingerstick blood or oral fluid
samples for testing purposes. Correctional systems
should maintain logs of inmates who choose not to
be tested at intake and recontact these individuals
periodically during their incarceration. Results of
HIV tests should be confidential and available in a
timely fashion. Correctional systems should coordinate with local health departments to ensure that
test results are communicated to inmates who have
been released from prison or jail before testing is
complete or before the test results are known.
Inmates must be informed of their test results in a
method that assures confidentiality. A few departments of corrections have systems of anonymous
testing in which, for example, inmates are given a
toll-free telephone number and a password to obtain
their test results.
Harm-reduction training. All correctional systems
should offer educational programs aimed at helping
inmates reduce their risk of acquiring or transmitting HIV, including discussions of condom usage
and safer injection practices. Correctional institutions might consider inviting respected members
of the community to talk with groups of inmates at
highest risk of acquiring HIV infection or transmitting it to others, such as inmates with active STDs,
sex workers, and active injection drug users.
Treatment of HIV disease. Prisons and jails should
offer comprehensive therapy to inmates with HIV
infection, including standard diagnostic testing and
antiretroviral medications as appropriate to each

42

patient. HIV treatment regimens require that medications be taken on a strict schedule. Therefore,
many correctional systems distribute a full day’s
medication each morning in “day packs” to improve
the inmate’s ability to take his or her medications at
the proper times. Systems might consider increasing
the flexibility in their medication or meal distribution
schedules to accommodate these and other requirements of treating HIV-infected inmates. Some regimens require that medications be taken on an empty
stomach or after a full meal, or that patients have
free access to fluids. Inmates in all systems housing
HIV-infected individuals should have access to consultation with an infectious-disease or HIV specialist.
Tuberculosis. In considering interventions for
tuberculosis, it is important to keep in mind the distinction between latent TB infection and active TB
disease explained in chapter 4: Active TB is a contagious and progressive disease, but individuals with
latent TB infection are free of symptoms and therefore cannot spread the disease. Individuals with latent
TB infection, however, have a 10 percent chance of
developing active TB disease in their lifetimes. Among
HIV-infected persons, the risk goes up to 10 percent
per year. Nevertheless, correctional systems can
implement clinically tested steps to reduce both
latent TB infection and active TB disease.
Reducing the likelihood of disease transmission.
Areas within prisons and jails that house large
numbers of inmates for substantial periods of time
should be well ventilated. Initial intake areas and
sick-call clinics with poor ventilation should be
evaluated for additional measures, such as highefficiency particulate air (HEPA) filtration and
ultraviolet radiation (which kills microbes).
Dormitories and infirmaries that house inmates with
weakened immune systems, such as AIDS patients,
should be particularly stringent in screening current
and prospective admissions for active TB because
TB can spread extremely rapidly through these populations.16 Correctional systems should train all staff
to be attuned to the prevalence and nature of TB
and to be alert for inmates with persistent coughs,
sputum production, chronic fever, or unexplained
weight loss. Staff should encourage inmates who
are coughing to cover their mouths with their hands
or with tissues until medical evaluation is complete.

Reducing the duration of infectiousness. Correctional
systems should take advantage of three approaches
to reducing the duration of infectiousness of active
TB cases.
●

Timely diagnosis. All correctional systems should
have formal programs to screen new admissions
for latent TB infection and active TB disease, and
to test all staff and inmates annually for latent TB
infection. These programs should include a history and physical examination by a qualified health
care provider and tuberculin skin testing. For
inmates with a history of old or recently active
TB, the facility should check with the local
health department for treatment information.
Each facility should, in cooperation with local
public health agencies, adjust the intensity of
these efforts to reflect the prevalence of TB in
the surrounding community.

●

Respiratory isolation. All correctional systems
should have access to appropriate negative pressure isolation rooms either onsite or at a local
hospital. Patients should remain in isolation until
there is no risk of transmitting TB to others.

●

Prompt and effective treatment. Patients without
drug-resistant tuberculosis rapidly become noncontagious with appropriate medical therapy.17
Correctional staff should directly observe all
inmates being treated for active TB to make sure
patients swallow their medication.18 Followup in
the community with local public health authorities should be arranged for inmates released
before their course of treatment has ended.

Reducing the number of new contacts. Many of the
measures outlined above will reduce the number of
new contacts as well as the likelihood that individuals infected with TB will transmit the disease to
others. The occasional inmate with TB who ends
up in the general inmate population despite existing
screening practices is least likely to infect other
inmates and staff in a facility that is not overcrowded and where staff are sensitive to the symptoms
and signs of disease.
Miscellaneous measures. At least two other components are required for an effective TB control program in correctional systems.

43

●

●

When an inmate housed in the general inmate
living area develops active TB, every correctional
facility should be able to conduct a thorough
investigation to identify all individuals with
whom the infected person has come in contact.
Because newly infected individuals are at high
risk of progression to active TB, health care staff
should screen and evaluate inmates with recent
close contact with a patient with active TB for
signs of new infection.19 Some groups, such as
HIV-infected patients, are at such high risk of
becoming infected through contact that TB preventive therapy should begin as soon as possible
after it becomes known that the individual has
had close contact with a contagious inmate.20
All TB control activities in jails and prisons
should be performed in concert with local or
State health departments. Access to county and
city department of health registries is invaluable
in identifying patients who may fail to report
their diagnosis at intake.21 These agencies may
also help ensure followup of inmates after release
and help track epidemiological trends pertaining
to TB both inside and outside the facility.

Hepatitis B and C. As explained in chapter 4, hepatitis B and C are both bloodborne infections affecting the liver. Hepatitis C, however, is responsible
for about five times as many deaths each year as
hepatitis B. A vaccine protects against hepatitis B
but not hepatitis C. Nevertheless, prisons and jails
can implement proven interventions that will reduce
the spread of both hepatitis B and C.
Reducing the likelihood of disease transmission.
Because inmates are such a high-risk group for
future hepatitis B infection, the Centers for Disease
Control and Prevention recommends one of two
options: (1) routine vaccination against hepatitis B
for all new prison and jail inmates or (2) screening
all new inmates for the infection. The rationale for
not routinely vaccinating all incoming inmates is
that up to 80 percent of some groups of inmates in
some facilities (e.g., injection drug users) may show
evidence upon screening of prior hepatitis B infection.22 Inmates with prior infection would not
benefit from vaccination. In these high-prevalence
populations it may be more cost effective to screen

prior to vaccination than to immunize every inmate.
This will avoid the expense of immunizing large
numbers of inmates for whom the vaccine will be
of no benefit. Health care staff can vaccinate only
those inmates who screening shows are not yet
infected with hepatitis B because these individuals
are highly susceptible to the infection.
A complete hepatitis B vaccination series requires
three injections administered over 6 months.
Although inmates who will be incarcerated for less
than 6 months are unlikely to complete the series
after release, an incomplete series of injections can
still be beneficial. The first dose of vaccine confers
immunity in up to 50 percent of patients, and the
second dose yields an immunity rate of up to 85
percent.23 Although the three-dose series, which
immunizes 95 percent of patients, is best, the rates
of immunity conferred with fewer doses remain
high enough to merit recommendation.
Other methods to reduce the likelihood that infected
inmates will acquire or transmit hepatitis B or C
include harm reduction messages identical to those
recommended for HIV. It is important to inform
inmates that hepatitis B and C are both serious
threats separate from the risk of HIV and that safer
drug injection and sexual practices are necessary
even when individuals have tested negative for HIV.
Hepatitis B is generally more easily transmitted
than HIV, and hepatitis C is more easily spread
through needle use than HIV.
Improved and early diagnosis may reduce the transmission of hepatitis B and C by making it possible
to treat selected infected inmates with antiviral
agents. Although antiviral treatment is currently
controversial because it is not always effective,
it cures 35–45 percent of patients.24 Even among
patients it does not cure, antiviral treatment may
reduce the amount of the virus in the body and
therefore reduce transmissibility.25
Reducing the number of new contacts. As with HIV
prevention, harm-reduction counseling and behavior
modification techniques may decrease the number
of contacts that infected individuals have with susceptible other people.

44

Minimum Standards for Care of Chronic Disease in Prison (evidence based
on current, nationally accepted guidelines—January 25, 2000)
Parameter
Definition
Applies
Initial
history

Admission
physical
examination
Physician, NP
or PA visits
(controlled
disease)
Office
procedure
each visit
Laboratory, initial
every 3 months,
until controlled,
then at least
every 6 mos.
Laboratory, initial
and annual for
controlled disease
Vaccine
Medication as
appropriate
Routine referral
Special needs

Diabetes Types
1 & 21,2

Asthma3

Hypertension4

untreated preprandial
blood glucose
>125 mg/dL
all diabetics, both
insulin- & non-insulindependent
complete, including
nutrition, medications,
monitoring, known
complications

on or should be on
medication; ≥1 ß-agonist
inhaler/month
limited to moderate,
persistent, and severe
persistent
complete, including
triggers, medications,
use of PEFR

complete, including BP,
EKG, cardiovascular,
dilated retinal referral
and foot
at least quarterly until
controlled, then at least
every 6 months

complete, including
peak flow measure

complete, including
nutrition, medications,
TB infection status,
STD status, known
complications
complete, including BP,
complete, all
weight, EKG fundoscopy systems

at least quarterly until
controlled, then at least
every 6 months

at least quarterly until
controlled, then at least
every 6 months

3 mos CD4+ <500
6 mos CD4+ >500

foot exam including
monofilament testing,
weight, annual EKG
glycated hemoglobin,
fasting glucose

peak flow measure
(PEFR)

blood pressure, weight,
annual EKG

system review,
weight

annual dilated retinal
exam by eye care
specialist
daily access to
glucose monitor,
exercise, diet, insulin
timed with meals

all; asymptomatic
and symptomatic

CD4+ & RNA
viral load

fasting lipid,
urine protein
annual influenza,
1 pneumococcal
inhaled steroid if
on ≥1 ß-agonist
inhaler/month

known infection

complete, including
nutrition, medications,
known complications,
smoking, alcohol

theophylline level (if on)

fasting lipid,
urinary microalbumin
annual influenza,
1 pneumococcal
insulin, oral
hypoglycemics, aspirin

systolic >140 or diastolic
>90 mm Hg or on Rx
(130/85 for diabetics)
all risk groups

HIV 5,6

ß-blocker, diuretic,
add appropriate
ACE inhibitor, Ca+
blocker, etc., aspirin

RPR & GC &
Chlamydia screen,
Pap (6 months)
annual influenza,
1 pneumococcal
as appropriate for
viral load & trend; OI
prophy <500 CD4+
HIV knowledgeable
physician

daily access to peak
flow monitoring,
environmental
control

exercise, diet

diet, exercise,
appropriately timed
medications

Note: Clinical guidelines are time sensitive; they may be outdated by the time they are published. Guidelines should be updated at least every
2 years and as often as every 6 months for diseases such as HIV infection for which therapies change rapidly.
1. American Diabetes Association, “Clinical Practice Recommendations 2000: Standards of Medical Care for Patients With Diabetes Mellitus,”
Diabetes Care 23 (supp. 1) (2000): 1–23.
2. American Diabetes Association, “Clinical Practice Recommendations 1998: Management of Diabetes in Correctional Institutions,” Diabetes
Care 21 (supp. 1) (1998): S80–S81.
3. “National Asthma Education and Prevention Program, Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma,”
Washington, D.C.: National Institutes of Health, National Heart, Blood, and Lung Institute, February 1997.
4. “The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,” Washington,
D.C.: National Institutes of Health, National Heart, Blood, and Lung Institute, November 1997.
5. “Report of the NIH Panel to Define Principles of Therapy of HIV Infection and Guidelines for the Use of Antiretroviral Agents in HIV-Infected
Adults and Adolescents” (updated May 5, 1999).
6. Centers for Disease Control and Prevention, “1999 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected
With Human Immunodeficiency Virus,” Morbidity and Mortality Weekly Report 48 (RR–10) (August 20, 1999): 1–59.
Source: Robert B. Greifinger, Principal Investigator

45

Scientifically tested interventions addressing
chronic disease

patient, especially as these needs are unique to
corrections.

There is sound clinical evidence that certain interventions are effective in interrupting the progression
of certain common chronic diseases or in reducing
or delaying their complications or symptoms.
Appendix D, “Sample Draft Clinical Guidelines,”
illustrates clinical guidelines for the screening and
treatment of four diseases—asthma, diabetes, hypertension, and HIV. The guidelines are examples of
empirically based interventions that, if applied by
correctional systems, are known to reduce illness
and death associated with the four chronic diseases.

Conclusion

“Minimum Standards for Care of Chronic Disease
in Prison,” abstracts various aspects of four clinical
guidelines discussed in detail in appendix D. Each
of the recommendations (elaborated fully in the
appendix) is based on the nationally accepted guidelines that are referenced to the text. The recommendations are designed to guide the clinician in areas
where scientific evidence of the value of selected
interventions exists. The recommendations constitute a set of definitions and abbreviated “decision
trees” for the diagnosis and management of various
chronic diseases and conditions.
The definition specifies the point at which a person
has a diagnosis assigned for the purposes of the
guideline. The guideline may apply to all patients
with the diagnosis (e.g., diabetes, hypertension,
HIV), or only to some of those with the diagnosis
(e.g., asthma).
The sections on initial history and admission physical examination present the specific areas of clinical
inquiry that should be pursued and documented.
This is the area where risk factors are identified and
physiologic baselines are established. The next rows
describe the expected frequency of visits, depending
on how well the patient’s condition is controlled.
The rows describe the expectations for physical
examination and laboratory examination. The guidelines present the expected preventive interventions,
such as vaccinations to prevent diseases for which
the patient is at especially high risk, medications to
treat the illness, and the threshold for referral by the
primary care practitioner to the specialist. Finally,
the guidelines describe the special needs of the

This chapter has demonstrated that a number of
interventions for preventing, screening for, and
treating several communicable and chronic diseases
can be cost effective and, in some cases, can even
save the community money. The chapter has also
presented a number of prevention, screening, and
treatment interventions that correctional systems
can introduce that have been shown scientifically to
be effective in preventing or reducing these diseases.
The recommendations for addressing communicable
and chronic diseases discussed above illustrate some
of the empirically proven interventions that provide
the scientific basis for the more general policy recommendations presented in chapter 7.
Introducing or expanding these interventions will
be difficult for many correctional administrators.
The following chapter identifies some of the barriers correctional systems may encounter—and, in
many cases, have already encountered—in trying to
expand or improve health care services to inmates.
The chapter also suggests how some prisons and
jails have overcome these barriers.

Notes
1. See Agency for Health Care Policy Research,
“Depression in Primary Care,” Clinical Practice
Guideline, vols. 1 and 2, Washington, DC: U.S.
Government Printing Office, April 1993.
2. The literature reports a wide range of direct cost estimates for mental illness, in large part because of differences in the types of costs that have been measured and
in the types of mental illness on which the cost estimates
have been based. The even larger range of estimates for
the indirect costs of mental illness in the available studies
makes them impossible to use in a cost-effectiveness
analysis. The difficulties involved in estimating the costeffectiveness of screening for and treating mental disorders are elaborated in White, A., L. Hatt, K. Reszek, and
T. M. Hammett, “The Feasibility of Using Published
Estimates of the Costs of Chronic Diseases and Mental
Illness to Conduct Cost-Benefit Analyses of Prevention
and Early Intervention,” paper prepared for the National
Commission on Correctional Health Care, Chicago, IL,
February 1999.

46

3. Pelvic inflammatory disease (PID) is a bacterial infection of the female upper genital tract, including the
uterus, fallopian tubes, and ovaries. Complications of
PID can include abscesses, chronic pelvic pain, infertility, and, occasionally, death.
4. The cost estimates for counseling and testing services
are based on estimates collected from HIV/STD clinics at
the Michigan Department of Community Health, with
time estimates and lifetime treatment costs from the literature. All cost figures are expressed in 1997 dollars.
5. The estimate assumes that, without HIV counseling
and testing, 7 percent of infected inmates would transmit HIV to an uninfected partner (De Vincenci, I., “A
Longitudinal Study of Human Immunodeficiency Virus
Transmission by Heterosexual Partners,” New England
Journal of Medicine 331 (6) (1994): 341–346) and 0.35
percent of uninfected inmates would acquire HIV infection within 12 months (Kamb, M.L., M. Fishbein, J.M.
Douglas, F. Rhodes, J. Rogers, G. Bolan, J. Zenilman, T.
Hoxworth, C.K. Malotte, M. Iatesta, C. Kent, A. Lentz,
S. Graziano, R.H. Byers, and T.A. Peterman, “Efficacy
of Risk-Reduction Counseling to Prevent Human
Immunodeficiency Virus and Sexually Transmitted
Diseases: A Randomized Controlled Trial,” Journal
of the American Medical Association 280 (1998):
1161–1167). The analysis assumes that HIV counseling
and testing reduces the risk of transmission from infected
inmates to uninfected partners by 25 percent (from 7 percent to 5.2 percent) and the risk of acquiring infection
from uninfected inmates by 10 percent (from 0.35 percent to 0.31 percent) (Kamb et al., “Efficacy of RiskReduction Counseling”; McKay, N.L., and K.M. Phillips,
“An Economic Evaluation of Mandatory Premarital
Testing for HIV,” Inquiry 28 (1991): 236–248; Holtgrave,
D.R., R.O. Valdiserri, A.R. Gerber, and A.R. Hinman,
“Human Immunodeficiency Virus Counseling, Testing,
Referral, and Partner Notification Services: A CostBenefit Analysis,” Archives of Internal Medicine 153
(1993): 1225–1230). The study estimated that offering
HIV counseling and testing to 10,000 inmates would have
averted more than three future infections. Each averted
infection saves almost $175,000, while the counseling
and testing program would cost only $117,000. Offering
HIV counseling and testing programs to 10,000 inmates
would result in societal savings of almost $410,000
($175,000 x 3 - $117,000).
6. Hammett, T.M., P. Harmon, and W. Rhodes, “The
Burden of Infectious Disease Among Inmates and
Releasees From Correctional Facilities,” paper prepared
for the National Commission on Correctional Health
Care, Chicago, IL, October 1999. (Copy in volume 2 of

this report.) A case for the cost-effectiveness of providing
treatment to inmates with HIV can be based on the speculation that, if HIV virus circulating in the blood is
reduced to undetectable levels, an HIV-positive individual’s chances of transmitting the disease to others may be
reduced. R.B. Greifinger, personal communication,
January 26, 2000.
7. American Thoracic Society and the Centers for
Disease Control and Prevention, “Targeted Tuberculin
Testing and Treatment of Latent Tuberculosis Infection,”
American Journal of Respiratory and Critical Care
Medicine 161 (2000): 221S–247S; American Thoracic
Society and the Centers for Disease Control and
Prevention, “Diagnostic Standards and Classification of
Tuberculosis in Adults and Children,” American Journal
of Respiratory and Critical Care Medicine 161 (2000):
1376–1395.
8. The economic calculations for communicable disease
and chronic disease were estimated in different ways.
Rates of communicable disease vary widely across
regions of the Nation. TB is more prevalent in urban
areas in the Northeast and along the coasts than in the
rest of the Nation. Sexually transmitted diseases are most
prevalent in the Southeast. Both TB and STDs are more
prevalent in areas where there are high rates of HIV
infection. Because of these variations, the economists
who modeled communicable diseases (see the papers in
volume 2) used sensitivity analysis. This model assumes
a variety of underlying prevalence rates and reports
quantitatively on the cost-effectiveness or cost-saving
potential at varying prevalence rates. Areas with high
prevalence of the underlying condition would demonstrate more favorable ratios than areas with low prevalence. Modeling that uses sensitivity analysis is a useful
tool for local decisionmaking where the underlying rates
of disease vary considerably. Cost-effectiveness analyses
were also done for hypertension and diabetes. Although
the rates of these diseases vary with gender, race, and
age, they have little geographic variation, so there is less
value in performing a sensitivity analysis in the modeling. Consequently, the cost-effectiveness study used the
National Commission on Correctional Health Care data
set for the correction population (see Hornung, C.A.
R.B. Greifinger, and S. Gadre, “A Projection Model of
the Prevalence of Selected Chronic Diseases in the
Inmate Population,” in volume 2 of this report ). This
data set is based on the National Health and Nutrition
Examination Study (NHANES–III), adjusted to reflect
the gender, race, and age mix of the correctional population in 1996. The question for this simulation was, given
this sample population, “Would it be cost effective to
provide diagnosis and treatment?”

47

9. The three studies used are the Diabetes Control and
Complications Trial, the Wisconsin Epidemiologic Study
of Diabetic Retinopathy, and the Framingham Heart Study.
10. Pearce, K.A., C. Furberg, B.M. Psaty, and J. Kirk,
“Cost-Minimization and the Number Needed to Treat
in Uncomplicated Hypertension,” American Journal of
Hypertension 11 (1998): 618–629.
11. Ngugi, E.N., D. Wilson, J. Sebstad, F.A. Plummer,
and S. Moses, “Focused Peer-Mediated Educational
Programs Among Female Sex Workers to Reduce Sexually
Transmitted Disease and Human Immunodeficiency
Virus Transmission in Kenya and Zimbabwe,” Journal
of Infectious Disease (174) (1996): S240–247; DiClemente,
R.J. and G.M. Wingood, “A Randomized Controlled
Trial of an HIV Sexual Risk-Reduction Intervention
for Young African-American Women,” Journal of the
American Medical Association 274 (1995): 1271–1276.
12. Centers for Disease Control and Prevention, “Syphilis
Screening Among Women Arrestees at the Cook County
Jail—Chicago, 1996,” Morbidity and Mortality Weekly
Report 147 (1998): 432–433; Blank, S., D.D. McDonnell,
S.R. Rubin, J.J. Neal, M.W. Brome, M.B. Masterson,
and J.R. Greenspan, “New Approaches to Syphilis
Control: Finding Opportunities for Syphilis Treatment
and Congenital Syphilis Prevention in a Women’s
Correctional Setting,” Sexually Transmitted Diseases 24
(1997): 218–228.
13. “Community-Level Prevention of Human
Immunodeficiency Virus Infection Among High-Risk
Populations: The AIDS Community Demonstration
Projects,” Morbidity and Mortality Weekly Report 45
(RR–6) (1996): 1–24; Wiebel, W.W., A. Jimenez, W.
Johnson, L. Ouellet, B. Jovanovic, T. Lampinen, J.
Murray, and M.U. O’Brien, “Risk Behavior and HIV
Seroincidence Among Out-of-Treatment Injection Drug
Users: A Four-Year Prospective Study,” Journal of AIDS
12 (1996): 282–289.
14. Hammett, T.M., P. Harmon, and L. Maruschak,
1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities, Washington, DC: U.S. Department
of Justice, National Institute of Justice, Centers for
Disease Control and Prevention, and Bureau of Justice
Statistics, 1999, NCJ 176344: 33–44; Grinstead, O., B.
Faigeles, and B. Zack, “The Effectiveness of Peer HIV
Education for Male Inmates Entering State Prison,”
Journal of Health Education 28 (November–December,
1997, Supplement): S31–S37; Kelly, J.A., J.S. St.
Lawrence, Y.E. Diaz, L.Y. Stevenson, A.C. Hauth., T.L.

Brasfield, S.C. Kalichman, J.E. Smith, and M.E. Andrew,
“HIV Risk Behavior Reduction Following Intervention
With Key Opinion Leaders of Population: An Experimental
Analysis,” American Journal of Public Health 81 (1991):
168–171; DiClemente and Wingood, “A Randomized
Controlled Trial” (see note 11); Wiebel, Jimenez,
Johnson, et al., “Risk Behavior and HIV Seroincidence”
(see note 13); “Sexual Risk Behaviors of STD Clinic
Patients Before and After Earvin ‘Magic’ Johnson’s HIVInfection Announcement—Maryland,” Morbidity and
Mortality Weekly Report 42 (1993): 45–48.
15. Brown, A.E., and D.S. Burke, “Cost of HIV Testing
in the U.S. Army,” New England Journal of Medicine
332 (1995): 963.
16. Daley, C.L., P.M. Small, G.F. Schecter, G.K.
Schoolnik, R.A. McAdam, W.R. Jacobs, and P.C.
Hopewell, “An Outbreak of Tuberculosis With
Accelerated Progression Among Persons Infected With
the Human Immunodeficiency Virus,” New England
Journal of Medicine 326 (1992): 231–235.
17. Riley, R.L., and A.S. Moodie, “Infectivity of Patients
With Pulmonary Tuberculosis in Inner City Homes,”
American Review of Respiratory Disease 110 (1974):
299–308.
18. “Controlling TB in Correctional Facilities,”
Rockville, MD: U.S. Department of Health and Human
Services, 1995, 1–58; “Prevention and Control of Tuberculosis in Correctional Facilities,” Morbidity and Mortality
Weekly Report 45 (RR–8) (1996): 1–27.
19. “Prevention and Control of TB,” Morbidity and
Mortality Report (see note 18).
20. Alcabes, P., P. Vossenas, R. Cohen, C. Braslow, D.
Michaels, and S. Zoloth, “Compliance With Isoniazid
Prophylaxis in Jail,” American Review of Respiratory
Disease 140 (1980): 1194–1197.
21. Layton, M., T. Frieden, and K. Henning, “Screening
of Inmates for Tuberculosis by Chest X-Rays,” presentation to the 34th Interscience Conference on Antimicrobial
Agents and Chemotherapy, Orlando, FL, October 4–7,
1994.
22. American College of Physicians, Task Force on
Adult Immunization, and Infectious Diseases Society of
America, “Guide for Adult Immunization,” Philadelphia,
PA: Author, 1994: 32.

48

23. R. Lyerla, “What Is the Value of Immunizing Prison
Inmates Against Hepatitis B?” presentation prepared for
the National Commission on Correctional Health Care,
Chicago, IL, 1998. (Copy in volume 2 of this report.)
24. McHutchison, J.G., S.C. Gordon, E.R. Schiff, M.L.
Schiffman, W.M. Lee, V.K. Rustgi, Z.D. Goodman, M.H.
Ling, S. Cort, and J.K. Albrecht, “Interferon Alfa-2b
Alone or in Combination With Ribavirin as Initial

Treatment for Chronic Hepatitis C,” New England
Journal of Medicine 339 (1998): 1493–1499.
25. “Recommendations for Prevention and Control of
Hepatitis C Virus (HCV) Infection and HCV-Related
Chronic Disease,” Morbidity and Mortality Weekly
Report 47 (RR–19) (1998): 1–39; Omata, M., “Treatment
of Chronic Hepatitis B Infection,” New England Journal
of Medicine 339 (1998): 114–115.

49

Chapter 6. Barriers to Prevention, Screening,
and Treatment—and Overcoming Them
The previous chapter demonstrated that it would be
cost effective and, in some cases, save money to initiate or expand programs to prevent, screen for, and
treat a number of communicable and chronic diseases among inmates. Even when it is not possible
to demonstrate that prevention or treatment would
be cost effective—as with mental illness—prisons
and jails should improve their efforts to address
these conditions because of the large number of
inmates who suffer from them and because of constitutional obligations of correctional systems to
provide adequate health care.1
Despite the compelling reasons for improving the
prevention, screening, and treatment of disease
among inmates, significant barriers make it difficult
for prisons and jails to improve these services. This
chapter identifies some of these barriers and discusses how they can be overcome, using examples
of successful correctional health care programs.

Similarly, some public health officials may not
believe that it is their mission to advocate and work
with prison and jail administrators to improve correctional health care, may not understand that such
improvements can more effectively protect public
health in their communities, or may feel they do not
have the resources to provide assistance.

Logistical barriers
Very short periods of incarceration are a serious
barrier to identifying jail inmates with health problems, particularly communicable diseases. Many jail
inmates are held for no more than 48 hours pending
a probable cause hearing. Others are jailed a few
days until they can post bond.2 Short stays create
three impediments to effective disease screening
and treatment in jails:
●

Even in facilities with routine screening policies,
screening may be delayed for up to 14 days after
intake. Correctional health care staff lose the
opportunity to treat inmates who are released
before they can be tested.

As summarized in “Selected Barriers to Improved
Prevention, Screening, and Treatment of Inmates”
and discussed below, the four principal barriers to
improved correctional health care for inmates are
the following: obstacles related to lack of leadership, the logistics of operating a prison or jail, limited resources, and correctional policies regarding
treatment and security.

●

Because certain tests, such as TB skin tests, take
time to show results, inmates may return to the
community without ever learning the results—
and may therefore be unaware that they are
infected and need treatment.

●

Inmates who are screened and diagnosed may be
released before a course of treatment can be initiated or completed.

Lack of leadership

A concrete example illustrates the potential seriousness of these problems. A study found that of 93
inmates with latent tuberculosis (TB) infection who
were released from the San Francisco County Jail in
1994 before their prescribed isoniazid therapy was
completed, only 3 went to the public health TB
clinic for more medication in the month after their
release.3 The public health implications of this lack
of followup are serious. Incomplete TB treatment
may result in increased transmission of latent TB

Barriers to Improved Prevention,
Screening, and Treatment

Some corrections administrators may not believe
that inmates are entitled to the level of health care
that this report suggests is needed. Other administrators are unaware of the need for improved care
or of how it could save them or their communities
money in the long run. Many administrators may
still be reluctant to consider that protecting public
health through comprehensive medical and mental
health care is a correctional responsibility.

50

Selected Barriers to Improved Prevention, Screening, and Treatment of Inmates
Lack of leadership
●

Lack of awareness of need for improved health care services.

●

Reluctance to consider improving public health as a correctional responsibility.

●

Unwillingness of public health agencies to collaborate or become advocates for improved
corrections health care.

Logistical barriers
●

Short periods of incarceration.

●

Safety-encumbered administration procedures for distributing medications.

●

Difficulty coordinating discharge planning.

●

Inmate difficulties attending to health problems after release.

Limited resources
●

High cost of health care services.

●

High cost of some medications.

●

Lack of sufficient space.

Correctional policies
●

Failure to specify minimum levels of required care in contracts with private health care vendors.

●

Requirements that inmates be escorted to medical treatment.

●

Poor communication between public health agencies and prisons and jails.

●

Lack of adequate clinical guidelines.

infection and active disease, and the development of
drug-resistant strains. The cost to the Nation of failure to control the spread of TB can be high. Efforts
to control the resurgence of TB in the early 1990s
cost New York City alone more than $1 billion.4
There are logistical barriers to the efficient distribution of medications in prisons and jails. Medication
administration schedules and inmates’ inability to
go to a pharmacy or telephone a physician can
impose extra steps in securing approval for a medication.5 “Pill lines”—prescribed times during the
day when inmates pick up their medicines—can
prevent proper administration of medications that
must be taken at specific times (e.g., with meals).

The rapid and unpredictable manner in which jail
inmates are typically processed limits a jail’s ability
to provide meaningful discharge planning that would
help ensure a continuum of care for inmates after
release into the community. In many instances, jail
health care personnel do not know when an inmate
will be released. By the time they find out, it may
be too late to develop effective linkages with community providers.
Providing case management and discharge planning
in prisons can also be difficult to coordinate. Because
prisons are often located in rural areas far from the
cities that are home to many inmates, prison health
care staff may have difficulty establishing close ties

51

with health care providers in inmates’ home communities, and these providers may be unable to visit the
prison to establish relationships with inmates who
are nearing release. Of all the potential problems
that prisons and jails may encounter in discharge
planning, one of the most difficult to negotiate is
continuity of mental health treatment, particularly
providing uninterrupted medication.
Many inmates require not only ongoing medical and
mental health treatment after release but also other
community-based services, including substance
abuse treatment and assistance with housing, child
care, and public assistance programs. Ex-offenders
often find it very difficult to obtain these services.
Problems in these other areas of their lives can hamper releasees’ motivation and ability to attend to
their health problems after release. Compounding
these personal problems, inmates released from
prisons and jails—even with help from corrections
staff—often encounter serious bureaucratic obstacles to becoming eligible for Medicaid after release,
delaying their access to immediate and ongoing
treatment.

Limited resources
Correctional systems often face serious resource
limitations in providing inmate health care services.
Meeting inmate health care needs can be expensive.
Inmates have high rates of many diseases that require
medical attention. In part, this is due to the lack
of health care they have typically received before
incarceration. Changes in inmate demographics—
an aging population and increasing numbers of
substance abusers—also create greater demands
for correctional health care services (see chapter 1,
“Introduction”).
Current correctional budgets are often too small to
pay for the staff, equipment, medicines, or space
needed to provide all the prevention, screening, and
treatment services that should be made available or
to provide all these services in the recommended
manner. Among the problems encountered are the
following:
●

The Centers for Disease Control and Prevention
(CDC) recommends that staff directly watch

inmates with tuberculosis disease or latent TB
infection swallow each dose of medication.6
Given that up to 9 percent of inmates may be
infected with TB, thousands of inmates per year
would be candidates for directly observed therapy. In part because of the cost of this approach,
compliance with this CDC recommendation has
been inconsistent.
●

Many correctional systems may find it expensive
to provide all eligible inmates all the medications
that current U.S. Public Health Service guidelines recommend for treating HIV,7 and must
therefore make difficult budgeting choices.

●

The current standard of treatment for hepatitis
C (combination therapy with interferon and ribavirin) costs about $12,000 per patient per year.
As a result, potential treatment costs for correctional systems with large numbers of eligible
patients may be extremely high. Given the uncertainties regarding the treatment’s efficacy, few
correctional systems have instituted widespread
treatment for hepatitis C.

●

A relatively new class of medications known as
selective serotonin reuptake inhibitors (SSRIs),
such as sertraline, paroxetine, and fluoxetine, has
been shown to be more effective than older medications in treating some mentally ill patients.
Some correctional systems cannot afford the
higher cost of these newer medicines, resulting in
inferior treatment for many mentally ill inmates.

Because of the high cost of treating every inmate
who is found to have a treatable medical condition,
correctional administrators (including some health
care managers) may prefer to avoid screening
inmates for some medical and mental conditions.
Administrators know that, once an inmate has been
found to have a disease, case law and professional
ethics require them to provide treatment that meets
community standards.
Because of limited resources, some correctional
facility medical departments are cramped. With
insufficient space, maintaining confidentiality is difficult, and the environment may not be conducive to
adequate care.

52

Policy barriers
Some correctional systems have rules or policies
that interfere with providing proper health care to
inmates.
Many correctional systems prohibit inmates dually
diagnosed with both a substance abuse problem and
a mental illness from participating in drug treatment
programs. These programs frequently require complete abstinence from all drugs, including prescription medications these inmates may be taking for
their mental illness. As a result, these inmates are
precluded from participating.
An increasing number of correctional systems are
contracting with private vendors for inmate medical
care. Some systems do not explicitly include in their
request for proposals all the minimal requirements
for services that every bidder must agree to provide.
As a result, the successful bidder may cut costs by
reducing inmate access to medical staff, minimizing disease screening, or excluding newer, more
expensive medications from their formularies of
approved drugs.
Understandably, correctional agencies’ first priorities are facility security and staff safety. Some systems require two correctional officers to accompany
every inmate on every visit to an outside hospital or
clinic for special testing or treatment. Other departments require that inmates be transported individually in agency vans. Typically, correctional officers
must escort inmates moving within a facility. Some
correctional systems require that two or three officers accompany high-risk inmates for medical
screening or treatment within a prison or jail. The
limited number of available correctional officers or
vehicles may create long delays if more than one or
two inmates need to be transported for medical care
at the same time.
Some correctional systems have policies that
impose unpleasant requirements on inmates with
certain conditions, making them reluctant to disclose that they have the diseases. Courts have
upheld the right of correctional systems to segregate inmates with AIDS in separate housing.8

Correctional systems’ lack of appropriate policy or
practice protecting the confidentiality of inmates’
medical status also discourage disclosure and
acceptance of testing.
Correctional systems’ lack of clinical guidelines or
inadequate guidelines for prevention, screening, and
treatment practices can result in inadequate medical
care. Few of the 41 State departments of corrections
surveyed as part of The Health Status of Soon-ToBe-Released Inmates project (see chapter 2, “History
of the Project”) submitted complete and up-to-date
clinical guidelines for HIV, hypertension, diabetes,
asthma, or mood-altering medications for treating
mental illness. Only five States returned guidelines
for treating HIV, none of which had been updated to
reflect current standards for combination therapies.
Four of the thirteen States that submitted guidelines
for diabetes did not require annual eye examinations, which are well known to help prevent blindness in diabetics. Only one State submitted clinical
guidelines for prescribing mood-altering medications for mental illness.
Public health agency policies may also hamper
effective treatment. When county health departments test or screen inmates for communicable diseases, poor interagency communication may prevent
inmates from learning their test results. Jail inmates
may have left the facility by the time the public health
department communicates the test results, and correctional health care staff may be unable or may not
try to locate releasees to provide the results.
Ethical dilemmas related to providing correctional
health care can present correctional and public health
administrators with difficult choices in attempting
to provide inmates with adequate services. Issues
in correctional health care that may present ethical
dilemmas include mandatory clinical testing and
forced treatment of inmates; cost-based formulary
decision making; pharmaceutical company sponsorships; recruitment of inmates in clinical research;
use of health care professionals whose credentials
may not meet community standards; and the role of
correctional clinicians in decisionmaking by reentry
courts and parole boards.

53

Solutions
Most of these barriers to improved health care for
inmates can be overcome. As discussed below:
●

Position statements on appropriate health care for
inmates developed by professional organizations
can encourage correctional administrators to
eliminate barriers to proper care.

●

Correctional systems should not have to shoulder
the burden alone for filling gaps in inmate health
care, but should collaborate with public health
agencies and community-based organizations to
improve the prevention, screening, and treatment
of diseases among inmates.

●

“Success stories” provide models for how communities can overcome barriers to improving
inmate health care services.

Correctional health care position statements
A number of professional groups have developed
guidelines describing appropriate health care for
inmates. These position statements can be used as
leverage to encourage correctional administrators
to find ways of resolving barriers to providing
adequate care. The National Commission for Correctional Health Care has prepared guidelines for
the administrative management of HIV-positive
individuals in correctional facilities.9 The American
Correctional Association Delegate Assembly passed
a resolution in 1999 supporting nonsmoking facilities and smoking cessation classes for both inmates
and correctional staff. The American Psychiatric
Association and the American Public Health
Association have also developed guidelines for
inmate health care (see chapter 4, “Improving
Correctional Health Care: A Unique Opportunity
to Protect Public Health”).

Linkages among corrections, public health
care agencies, and community-based
organizations
Collaboration between correctional agencies and
public health agencies can help overcome the lack
of funds and staff that make it difficult for many
prisons and jails to address adequately the health
care needs of all inmates. Public health departments
may be willing to contribute funds, staff, and

expertise if they understand that this use of their
resources can advance the cause of public health in
their communities. Correctional agencies have a
stake in convincing public health officials and other
government decisionmakers of the public health
importance of improving the prevention, screening,
and treatment of diseases among inmates.
Community-based organizations and community
providers may be qualified and interested in working with inmates and releasees.
Public health and correctional agencies are already
working together to improve the health care of
inmates and, at the same time, the health of the
larger community. This was the finding of a 1997
survey conducted jointly by the U.S. Department of
Justice’s National Institute of Justice and the Centers
for Disease Control and Prevention to learn about
the extent and nature of public health/corrections
collaborations in the prevention and treatment of
HIV/AIDS, sexually transmitted diseases, and TB.10
According to the study, almost all correctional systems collaborate to some extent with public health
agencies. Some jurisdictions have established extensive collaborations to help fill gaps in the prevention
and treatment of these diseases.
The collaborations have found ways to overcome
many of the barriers that make it difficult for prisons
and jails to provide these services by themselves. In
particular, the partnerships helped to overcome correctional departments’ lack of resources by involving
public health departments
in initiating or expanding the following:
●

Testing and screening of inmates.

●

Prevention and treatment programs in prisons
and jails.

●

Following up inmates after release to ensure a
continuum of care.

Researchers visited six States and five cities or
counties with promising approaches to collaboration. The researchers found that several factors
facilitated collaboration:
●

The availability of data on the prevalence of diseases among inmates and in the community, or
dramatic events, such as outbreaks of disease that
demonstrated the need for collaboration.

54

●

Legislation or regulatory requirements that make
public health departments responsible for providing health care services in corrections facilities or
for reporting disease among inmates.

●

Correctional system willingness to open its facilities to outside organizations.

●

Sensitivity on the part of correctional administrators and public health staff to each other’s missions, challenges, priorities, and perspectives.

●

Health department funding of programs in
correctional facilities.

●

The presence of health department personnel in
correctional facilities and liaison staff in correctional and public health agencies, formal agreements for collaboration, and the development of
interagency relationships over time.

●

Frequent communication and information
exchanges, such as serving on joint committees,
holding meetings at leadership and operating
levels, and exchanging important databases and
information about patients.

State and local public health agencies and service
providers are the most appropriate and likely collaborators in any effort designed to improve inmate
health care. Barriers to inmate health care can be
addressed still more effectively if collaborative
efforts include other organizations, such as probation and parole agencies, community-based organizations, academic medical centers and universities,
and substance abuse treatment programs and other
service providers. As the following section suggests,
some communities have established broader based
collaborations.

Two collaborations that have overcome
barriers
The State of Rhode Island and Hampden County,
Massachusetts, have established partnerships that
illustrate how joint endeavors can overcome many
of the barriers to improving correctional health care
services for inmates.
Collaboration in Rhode Island.11 Rhode Island
has developed a collaboration among the State
Department of Health, the State Department of
Corrections, an academic medical center (Miriam

Hospital, affiliated with Brown University), and
approximately 40 community-based organizations
and service agencies. In addition to regular meetings, the partners work together on disease surveillance; inmate disease prevention services; discharge
planning; and policies, legislative proposals, and
union issues related to health care issues.
The Department of Health provided much of the
initial funding for staffing the program. Over time,
however, the Department of Corrections has picked
up an increasing share of the personnel costs, funding two public health educator positions from its
regular budget.
The collaboration initially focused on treatment and
support services for inmates with HIV and on continuity of care between providers in prison and in the
community. Pretest and posttest counseling, discharge planning, transitional services, and community linkages for HIV-infected inmates were added
later. The collaboration has added sexually transmitted diseases and tuberculosis to its purview.
The collaboration’s focus on prerelease planning
and followup is especially important in light of the
failure of most prisons and jails to provide continuity
of care. The following steps have been established:
●

Inmates with HIV are treated in prison by the
same physician who will treat them after they
return to the community.

●

The Rhode Island Department of Corrections
notifies the State health department’s TB unit
when an inmate with active or suspected TB,
or an inmate receiving TB therapy, is being
released, so that continuity of care can be
arranged.

●

Postrelease services for inmates with HIV infection and inmates at risk for HIV infection include
housing, substance abuse treatment, job development, psychosocial support, and long-term case
management.

●

At a weekly case assignment meeting, program
staff involved in the collaboration meeting discuss community linkages and placements for
inmates nearing release. The four communitybased organizations that participate in these
meetings are mentors to employable women

55

who are being released and arrange services
for cocaine- and alcohol-involved releasees,
long-term sex workers, injection drug users,
and HIV-infected releasees.
●

A disease investigation specialist, funded by the
Department of Health and based in the prison,
locates HIV-positive individuals who have been
released to the community before they received
their test results to link them to services at
Miriam Hospital or another equally qualified
provider of HIV services.

Compliance with postrelease medical and other
appointments for services increased dramatically
as a result of the collaboration. Evaluation results
suggested that recidivism among female inmates
who participated in these postrelease programs
was lower than in a comparison group who did
not participate.12
Collaboration in Hampden County, Massachusetts.13
The Hampden County Correctional Center, which
serves Massachusetts’ second largest metropolitan
area, has developed a public health model of correctional health care that focuses on disease screening,
patient health education, prevention, treatment, discharge planning, and continuity of care for releasees.
The program costs about $6 per inmate day, or 9 percent of the facility’s budget.
Significant features of the program include the
following:
●

●

Based on ZIP Code of residence, inmates with
HIV/AIDS and other serious medical and mental
health conditions are assigned to one of four
health teams that work jointly in the correctional
center and in four community health centers.
(Eighty percent of the inmates come from the
catchment areas of these four community health
centers.) In 1997 more than 70 percent of releasees
with HIV/AIDS kept their first appointments with
their assigned community health center.
Case managers who work in both agencies provide case management and discharge planning
services for all inmates with HIV/AIDS and serious mental health problems. A discharge planning
nurse at the facility provides similar services for
inmates with chronic diseases.

●

Releasees are linked with community-based
agencies that address issues of family reintegration, housing, employment training and readiness, and benefit programs.

The Hampden County program serves a metropolitan area of 500,000. Because 80 percent of metropolitan areas in the United States have populations
of between 100,000 and 1 million, the Hampden
County model should be replicable in many other
communities. The Massachusetts Department of
Public Health is using a CDC grant to establish case
management, discharge planning, and community
linkage programs in other Massachusetts county
jails. These programs will also serve HIV-positive
inmates being released from State prisons.
The success of the Rhode Island and Hampden
County models depended on the political will, commitment, and leadership of correctional and public
health officials in these jurisdictions.

Promising practices in jails for treating
mental illness
A number of programs in jails provide comprehensive mental health services.14 Erie County,
Pennsylvania, has developed an integrated network
of criminal justice and mental health professionals
to create a community-based forensic program. The
program provides a continuum of care that begins
during incarceration in the county prison and
extends to the community upon discharge or
parole.15 Some jails appear to have incorporated
innovative features of a comprehensive mental
health care system:
●

Two jails contract for psychiatric services with
the community psychiatry program at their local
medical school. The medical college’s community psychiatry rotation includes assignments at the
local jail. This arrangement ensures that trained
medical personnel are in the jail on a regular
basis.16

●

A number of jails employ crisis intervention
specialists or teams. The primary responsibilities
of these specialists and teams are to stabilize
inmates experiencing mental health crises as
quickly as possible, house them appropriately,

56

and provide them with direct mental health services. Providing crisis intervention specialists in
the jail frees correctional officers from having to
handle difficult situations and allows for timely
and appropriate solutions.17
Local policymakers have worked with officials in
the Maryland Department of Health and Mental
Hygiene and other State officials to establish the
Maryland Community Criminal Justice Treatment
Program, a multiagency collaboration that provides
shelter and treatment services to mentally ill jail
offenders in their communities.18 Operating in 18
of the State’s 24 jurisdictions, the program includes
the following features:
●

Case management services, such as crisis intervention, screening, counseling, discharge planning, and followup in the community.

●

Services for mentally ill offenders who are
homeless or have a substance abuse problem.

●

Routine training for criminal justice and treatment professionals.

●

Diversion after booking for qualified mentally
ill defendants.

Criminal justice and treatment professionals credit
the program with improving the identification and
treatment of jailed mentally ill individuals, increasing communication between mental health and corrections professionals, improving coordination of
in-jail and community-based services, and reducing
disruption in local jails.
The Fairfax County (Virginia) Jail has also overcome the pervasive barriers to discharge planning
for mentally ill inmates.19 The jail uses a private
nonprofit organization to link detainees with mental
health-related services upon release and to maintain
the detainee’s family ties while the inmate is incarcerated. This affords the inmate a source of additional support after release. The organization’s eight
staff also:
●

Provide transportation and housing assistance to
mentally ill releasees upon release.

●

Provide emergency services for releasees without
plans at release.

●

Teach, mentor, and tutor classes in the facilities.

●

Teach life skills that inmates will need after
release.

●

Provide group therapy for inmates and their
families.

●

Arrange support groups for families and close
friends of inmates.

●

Offer families emergency funds for food and
clothing while their providers are in jail.

The jail provides discharge planning for every
inmate, but detainees with mental illnesses work
with the same staff person from intake through
discharge.
A review of seven programs developed in State and
Federal prisons for mentally ill inmates who also
have a substance abuse problem (the “dually
diagnosed”) found that the programs’ key components included an extended assessment period,
motivational activities, psychoeducational groups,
cognitive-behavioral interventions (such as restructuring of criminal thinking errors), self-help groups,
medication monitoring, relapse prevention, and
transition into institution or community-based aftercare facilities.20 Many programs used therapeutic
community approaches that had been modified to
provide greater individual counseling and support,
less confrontation, smaller staff caseloads, and staff
cross-training. Capsule descriptions of two of these
programs follow.
●

The Alabama Department of Corrections, with
funding from the U.S. Department of Health and
Human Services’ Center for Substance Abuse
Treatment, established a separate dormitory for
the dually diagnosed in the Venteress Correctional
Facility. Treatment includes group therapy, psychoeducational groups, 12-step groups, AIDS
prevention and education activities, psychiatric
medications, relapse prevention training, and
community reentry services including development of an aftercare treatment plan. The program’s highly regimented schedule of activities
includes several core modules drawn from the
facility’s 8-week treatment program combined
with 10 weeks of additional treatment services
to address management of emotional problems.

57

●

The Delaware Department of Corrections’ Chronic
Care Program, located in the State’s maximum
security facility, houses 25 dually diagnosed
inmates. A private vendor provides treatment
services 7 days a week. Treatment includes individual and group therapy, drug education, medications, psychoeducational groups, AIDS prevention
education, relapse prevention, and individual case
management and planning for community reentry.
Inmates participate for 8 weeks in a “Medication/
Mental Illness” group designed to help them to
understand their mental illness and their psychotropic medications. Behavioral reinforcement
is provided through a system in which inmates
progress to higher levels of responsibility and
privilege based on compliance with treatment
goals and community rules.

Conclusion
This chapter has identified several barriers to
improving health care for inmates in prisons and
jails. With political will and commitment from corrections and public health administrators, most of
these obstacles can be overcome. The policy recommendations for improving correctional health care
provided in the following and final chapter recognize that improving prevention, screening, and
treatment in prisons and jails will not be easy. The
recommendations represent feasible steps correctional systems can take and that, as described
above, at least some prisons and jails have already
implemented.

Notes
1. Estelle v. Gamble, 429 U.S. 97 (1976), held that
“deliberate indifference” (not mere medical malpractice)
to “serious medical needs” of inmates violates the eighth
amendment’s prohibition against cruel and unusual
punishment.
2. The U.S. Department of Justice, Bureau of Justice
Statistics (BJS), does not collect information regarding
length of stay of presentenced inmates. A BJS survey of
more than 6,000 sentenced inmates from 431 jails found
that the median length of stay for sentenced inmates
was 5.7 months. Because the data on time served were
restricted to persons in jail, the data overstates the median time served. Persons with shorter sentences leave jail
more quickly, resulting in a longer average sentence

among persons in the inmate sample. Harlow, C.W.,
Profile of Jail Inmates 1996, Special Report, Washington,
DC: U.S. Department of Justice, Bureau of Justice
Statistics, April 1998, NCJ 164620.
3. Tusky, J.P., M.C. White, C. Dawson, T.M. Hoynes, J.
Goldenson, and G. Schecter, “Screening for Tuberculosis
in Jail and Clinic Followup After Release,” American
Journal of Public Health 88 (1998): 223–226.
4. Satcher, D., “Tuberculosis—Battling an Ancient
Scourge,” Journal of the American Medical Association
282 (1999): 1996.
5. Greifinger, R.B., and M. Horn, “Quality Improvement
Through Care Management,” in M. Puisis, (ed.), Clinical
Practice in Correctional Medicine, St. Louis, MO:
Mosby, 1998.
6. Centers for Disease Control and Prevention,
“Prevention and Control of Tuberculosis in Correctional
Facilities,” Morbidity and Mortality Weekly Report 45
(RR–8) (1996): 1–27.
7. U.S. Department of Health and Human Services,
Guidelines for the Use of Antiretroviral Agents in HIVInfected Adults and Adolescents, Washington, DC: Public
Health Service, January 28, 2000.
8. See, for example, Onishea v. Hopper, 126 F.3d 1323
(11th Cir. 1997).
9. See appendix E, “Information About NCCHC and Its
Position Statements.” The current copy of the position
statement on the Management of HIV in Correctional
Facilities can be accessed at: http://www.ncchc.org.
10. Hammett, T.M., Public Health/Corrections Collaborations: Prevention and Treatment of HIV/AIDS, STDs,
and TB, Research in Brief, Washington, DC: U.S.
Department of Justice, National Institute of Justice, and
U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, July 1998, NCJ 169590.
11. Ibid.
12. Vigilante, K.C., M.M. Flynn, P.C. Affleck, J.C.
Stunkle, N.A. Merriman, T.P. Flanigan, J.A. Mitty, and
J.D. Rich, “Reduction in Recidivism of Incarcerated
Women through Primary Care, Peer Counseling, and
Discharge Planning,” Journal of Women’s Health 8
(1999): 409–415.

58

13. Hammett, T.M., P. Harmon, and L.M. Maruschak,
1996–1997 Update: HIV/AIDS, STDs, and TB in
Correctional Facilities, Washington, DC: U.S.
Department of Justice, National Institute of Justice,
July 1999, NCJ 176344.

16. Morris, S.M., H.J. Steadman, and B.M. Veysey,
“Mental Health Services in United States Jails: A Survey
of Innovative Practices,” Criminal Justice and Behavior
24 (1) (1997): 3–19.
17. Ibid.

14. Carr, K., B. Hinkle, and B. Ingram, “Establishing
Mental Health and Substance Abuse Services in Jails,”
Journal of Prison and Jail Health 10 (2) (1991): 77–89;
Nielsen, E.D., “Community Mental Health Services in
the Community Jail,” Community Mental Health Journal
15 (1) (1979): 27–32; Dvoskin, J.A., “Jail-Based Mental
Health Services,” pp. 64–90 in H.J. Steadman (ed.),
Effectively Addressing the Mental Health Needs of Jail
Detainees, Washington, DC: National Institute of
Corrections, June 1990, NCJ 151850: 80–83.
15. Amann, A., J. O’Keefe, and P. Kovacs, “Interdisciplinary Approach to Managing Mentally Ill Offenders,”
Corrections Compendium 23 (8) (1998): 4–6.

18. Conly, C. Coordinating Community Services for
Mentally Ill Offenders: Maryland’s Community Criminal
Justice Treatment Program, Program Focus, Washington,
DC: U.S. Department of Justice, National Institute of
Justice, March 1999, NCJ 177397.
19. Morris, Steadman, and Veysey, “Mental Health
Services in United States Jails” (see note 16).
20. Edens, J.F., R.H. Peters, and H.A. Hills, “Treating
Prison Inmates With Co-Occurring Disorders: An
Integrative Review of Existing Programs,” Behavioral
Science and Law 15 (4) (1997): 439–457.

59

Chapter 7. Policy Recommendations

The expert panels assembled for The Health Status
of Soon-To-Be-Released Inmates project (see chapter 2, “History of the Project”) developed policy
recommendations for improving the health care of
prison and jail inmates. The project steering committee refined the panels’ list of recommendations.
This chapter presents the final list of recommendations organized by major topic areas.

Background to the Policy
Recommendations
The policy recommendations are based on an expert
consensus that sufficient—if not always definitive—
scientific evidence exists to justify their implementation. Much of this scientific evidence has been
presented in previous chapters of this report. Recommendations related to general immunization programs, expansion of correctional treatment programs
for alcohol and other drugs, and smoking cessation
programs, while not substantiated in this report,
have strong empirical justification in the scientific
literature.1 Several of these recommendations also
reflect guidelines developed by the Centers for
Disease Control and Prevention (CDC) that have
been applied by the expert panels and steering committee to correctional settings. Endnotes after the
pertinent recommendations provide the relevant CDC
guidelines. It is important to note, however, that the
endnotes refer to current CDC recommendations.
These recommendations may change over time.
Other recommendations derived from the literature
on correctional health care and aids to ethical decisionmaking, although not “empirically” supported,
were felt by the expert panels and steering committee to be unquestionably warranted.
The expert panels considered many other interventions and policy changes that the steering committee
did not include in the final set of recommendations
listed below because currently too little scientific
evidence exists to recommend their implementation.

Many jails and prisons, however, have implemented
interventions that reflect these missing recommendations. That the report does not include an intervention that correctional agencies are currently
implementing does not mean that these agencies
should discontinue the intervention or that other
systems should not consider introducing it. The recommendations presented here are not exhaustive.
The National Commission on Correctional Health
Care (NCCHC) and other professional organizations
will develop other recommendations in the future
as clinical studies demonstrate the effectiveness of
additional interventions.
The policy recommendations are followed by
actions that the steering committee proposes specified Government agencies take in order to support
implementation of the recommendations. A bibliography at the end of the chapter identifies publications that provide additional information related to
selected policy recommendations.

Policy Recommendations
The expert panels and the steering committee recommend that the actions presented below (summarized
in “Summary of Policy Recommendations”) be taken
on nationwide to improve the physical and mental
health of inmates, protect the public from communicable disease, and reduce the huge cost to society of
inmate illnesses that go untreated or undertreated.

Surveillance2
The principal use of disease surveillance in correctional facilities is to monitor disease incidence,
prevalence, and outcomes in the inmate population.
Surveillance includes collecting health data and
evaluating the data collection system to assist correctional health officials in characterizing the health
status of the inmate population. The information
obtained from the surveillance system is used to
plan, implement, and evaluate health needs of the

60

Summary of Policy Recommendations
I. Promote surveillance of selected communicable diseases, chronic diseases, and mental illnesses
among inmates in all correctional jurisdictions.
II. Promote the use of nationally accepted evidence-based clinical guidelines for prisons and jails to
assure appropriate use of resources for preventing, diagnosing, and treating selected communicable
diseases, common chronic diseases, and mental illnesses that are prevalent among inmates.
III. Establish a federally funded national vaccine program for inmates to protect them and the public
from selected vaccine-preventable communicable diseases.
IV. Develop and maintain a national literature database for correctional health care professionals,
including a compendium of policies, standards, guidelines, and peer-reviewed literature.
V. Establish a national advisory panel on ethical decisionmaking by correctional and health authorities
to help them address ethical dilemmas encountered in correctional health care.
VI. Identify and eliminate barriers to successful implementation of public health policy.
VII. Support research in correctional health care to identify and address problems unique to
correctional settings.
VIII. Improve the delivery of inmate health care in correctional systems.
IX. Implement primary and secondary disease prevention measures.
X. Provide prerelease planning of health care and related services for all soon-to-be-released inmates.

inmate population and their anticipated health needs
upon release.

2. Mandate national reporting of these
prevalence data.

I. Congress should promote surveillance of selected
communicable diseases, chronic diseases, and
mental illnesses among inmates in all correctional jurisdictions. Appropriate Federal agencies in
partnership with national health-related organizations should:

3. Design an information system and make
it available for use by local, State, and
Federal correctional authorities to measure
and report the data with the ability to categorize the data by age, race, and gender.

A. Develop surveillance guidelines to promote uniform national reporting of selected conditions
to enhance epidemiologic research of these
conditions and assist with accurate health care
planning. Ensure that data collected in prisons
and jails as part of the surveillance program
are collected in the same manner as they are
collected in the community.3 Surveillance
guidelines should incorporate processes for
protecting confidentiality of data.
B. Create a national correctional health care
database.
1. Develop standardized definitions and measures for reporting to assess the prevalence
of selected communicable diseases, chronic
diseases, and mental illnesses.4

C. Produce statistical reports of local, State, and
national rates of selected communicable diseases, chronic diseases, and mental illnesses
in prisons and jails to aid in planning correctional and public health programs and allocating local resources.5
D. Evaluate the utility of surveillance activities
and implement improvements as appropriate.

Clinical guidelines
Clinical guidelines provide definitions and abbreviated decision trees for the diagnosis and management of various diseases and conditions. They guide
the clinician in areas where scientific evidence of
the value of selected interventions exists to improve
survival and clinical outcomes and to reduce mor-

61

bidity and the cost of care. Clinical guidelines are
widely used outside corrections.

the public from selected vaccine-preventable
communicable diseases.

II. Congress should promote the use of nationally
accepted evidence-based clinical guidelines for
prisons and jails. This will help assure appropriate
use of resources to prevent, diagnose, and treat
selected communicable diseases, common chronic
diseases,6 and mental illnesses that are prevalent
among inmates. Appropriate Federal agencies in
partnership with national health-related organizations should:

A. The vaccination program should be similar to
the National Vaccine Program for Children.

A. Ensure that the clinical guidelines are consistent with nationally accepted disease definitions and evidence-based guidelines used for
the nonincarcerated population.7
B. Disseminate the clinical guidelines to correctional health care professionals, public health
agencies, and public policymakers.
C. Update the clinical guidelines as often as
needed.
D. Develop standardized performance measures
for State and local correctional authorities to
determine adherence to nationally accepted
clinical guidelines.
E. Train correctional health and public health
professionals in the use of these clinical
guidelines and performance measures.
F. Develop tools for correctional systems to
assess over-prescribing and under-prescribing
of psychotropic medications.

Immunizations
Immunizations prevent the development of a variety
of communicable diseases in individuals. In the
case of diseases such as hepatitis B, poliomyelitis,
measles, mumps, or rubella, immunizations prevent
the transmission of disease to susceptible individuals
in the general population. Such immunizations are
nationally accepted and promoted by the Centers
for Disease Control and Prevention. Some immunizations are directly cost saving and others are
highly cost effective.
III.Congress should establish and fund a national
vaccine program for inmates to protect them and

B. The program should conform to the recommendations of the CDC’s Advisory Committee
on Immunization Practices (ACIP).8

National correctional health care literature
database
To function competently, correctional health care
clinicians require access to the medical literature,
especially as it relates to correctional health care
issues. Existing resources do not provide this level
of specificity.
IV. Congress, through appropriate Federal agencies
and health-related national organizations, should
develop and maintain a national literature database for correctional health care professionals,
including a compendium of policies, standards,
guidelines, and peer-reviewed literature.

Ethical decisionmaking
Correctional health care professionals function
in a uniquely restrictive environment with limited
opportunity for peer review of medical policies and
administrative actions. A national forum is needed
to discuss issues such as confidentiality, informed
consent, clinical management of hepatitis C 9 and
HIV, and the availability of biomedical research.
V. Congress should establish a national advisory
panel on ethical decisionmaking among correctional and health authorities to assist those
authorities in addressing ethical dilemmas
encountered in correctional health care.

Eliminate barriers to inmate health care
In correctional facilities, health care professionals
face unique barriers to the delivery of health services.
These include constraints on policy, budgets, priorities, and staffing. Correctional institutions are positioned to provide individual care to inmates and
protect the public health through aggressive health
promotion and disease prevention efforts. At all
levels of government, public policymakers should

62

recognize that eliminating barriers to health care for
inmates provides long-term public health benefits.
VI. Congress, through appropriate Federal and State
agencies and health-related national organizations, should identify and eliminate barriers to
the successful implementation of public health
policy.
A. Reduce obstructions to effective public
health programs within correctional facilities
and in the community.
B. Promote continuity of inmate health care by
maintaining Medicaid benefits for eligible
inmates throughout their incarceration.
C. Promote continuity of ex-offender health
care by mandating immediate Medicaid eligibility upon release.
D. Provide incentives to jails and prisons to
expand their alcohol and other drug treatment
programs. These services should be gender
specific and made available to inmates from
admission through release, with special
attention paid to inmates with both mental
illness and substance abuse problems.

Correctional health care research
Too little is known about the epidemiology of disease
in correctional populations and too little has been
done to evaluate programs designed to improve
inmate health.
VII. Congress, through appropriate Federal agencies
and health-related national organizations, should
support research in correctional health care to
identify and address problems unique to correctional settings.
A. Fund projects to evaluate models that
emphasize creative, cost-effective options
for continuity of care following release.
B. Fund research programs to define effective
health education and risk reduction strategies for inmates. These strategies need to
deal with relevant differences between
inmate and noninmate populations. The
research programs should work through
public, private, and community-based
health care agencies.

C. Fund research programs to identify correctional system barriers that prevent correctional health care staff from implementing
prudent medical care and public health
recommendations.

Improve delivery of health care
For a variety of reasons, the scope and content of
correctional health care services vary.10 The quality
of care is not as high as it might be, resulting in
unnecessary morbidity, premature mortality, and
increased costs.
VIII. Congress, through appropriate Federal agencies
and medically based accrediting organizations,
should promote improvements to the delivery
of inmate health care.11
A. Require Federal, State, and local correctional
systems to adhere to nationally recognized
standards for the delivery of health care
services in corrections.12 These standards
should include access to care, quality of
care, quality of service, and appropriate
credentialing of health care professionals.
B. Provide sufficient resources for correctional
systems to adhere to national standards.
C. Weigh the correctional system’s adherence
to national standards for health care delivery
whenever determining funding levels for the
system.

Disease prevention
Primary prevention is designed to keep disease from
occurring. Examples include lifestyle choices and
vaccination against selected communicable diseases.
Primary prevention is widely believed to be the best
and most cost-effective use of health care dollars.
In some cases, it is also cost saving—that is, the
prevention program saves more money than it costs
to implement. Secondary prevention (screening) is
the early detection of disease that already exists but
may not be apparent to the patient.13
IX. Congress, through appropriate Federal agencies
and national organizations, should encourage
primary and secondary disease prevention efforts.

63

A. Promote primary disease prevention measures
by requiring Federal, State and local correctional agencies to:

disease and infection, and provide preventive treatment for inmates with latent
TB infection.

1. Provide all inmates with a smoke-free correctional environment. Offer tobacco cessation programs for all staff and inmates as a
method of achieving tobacco-free facilities.

b. Promote the use of short-course preventive therapy (delivered over 2 months)
in correctional settings.

2. Offer heart-healthy choices on institutional
menus and in commissaries.
3. Make daily aerobic exercise available to
all inmates.
4. Consistent with the recommendations of
the ACIP, make hepatitis B vaccines available to all inmates, even when their length
of incarceration is short or indeterminate.
5. Screen all females for pregnancy. Test
those women found to be pregnant for hepatitis, HIV infection, syphilis, gonorrhea,
and chlamydia. Provide HIV treatment in
HIV-infected mothers to prevent transmission of the disease to the newborn.
6. Although not a correctional system responsibility, administrators should seek to collaborate with community health care providers
to ensure the timely immunization of all
infants born to mothers who test positive
for hepatitis B.
7. Offer scientifically based risk-reduction
education on HIV infection and STD to
all inmates.
B. Promote secondary disease prevention measures by using nationally accepted evidencebased clinical guidelines as appropriate.
1. Provide hypertension, obesity, asthma, and
seizure disorder screening for all prison
inmates.
2. Provide diabetes and hyperlipidemia screening for jail and prison inmates at high risk.
3. Provide suicide prevention programs,
including timely screening for inmates at
high risk for suicide.
4. Prevent the spread of tuberculosis.
a. Consistent with nationally accepted guidelines,14 routinely screen inmates for TB

c. Strengthen the link of TB control efforts
between correctional facilities and public health departments.
d. On employment and annually thereafter,
screen all correctional staff who have
inmate contact for latent TB infection.
5. Prevent the spread of HIV infection.
a. Encourage voluntary HIV counseling
and testing of inmates.
b. Provide appropriate treatment for HIVpositive, pregnant inmates to prevent
HIV transmission to their babies.15
6. Screen inmates for syphilis, gonorrhea, and
chlamydia routinely upon reception at prisons and jails, and treat inmates who test
positive for these infections.16

Prerelease planning
Many inmates are released into the community
while still being treated for communicable and
chronic diseases or mental illness. Ensuring continuity of care upon release can reduce health risks to
the public such as in cases of tuberculosis and sexually transmitted diseases. Continuity of care upon
release for inmates with co-occurring mental illness
and substance abuse disorders can reduce the risk of
illicit drug use in the community. It is cost effective
to the community to provide continuity of care on
release for inmates with chronic disease.
X. Congress, through appropriate Federal agencies
and national organizations, should encourage
Federal, State, and local correctional facilities to
provide prerelease planning for health care for all
soon-to-be-released inmates.
A. Address the medical, housing, and postrelease
needs of inmates in prerelease planning, and
make use of appropriate resources and new
technologies.

64

B. Coordinate discharge planning efforts between
appropriate public agencies—such as correctional, parole, mental health, substance abuse,
and public health agencies—to prevent disease transmission and to reduce society’s
costs resulting from untreated and undertreated illness.

Recommended Actions by
Government Agencies
The steering committee and expert panels recognized
that many Federal agencies have a role in affecting
the health status of soon-to-be-released inmates.
Within the Department of Health and Human Services,
for example, agencies such as the Centers for Disease
Control and Prevention (CDC), the Health Resources
and Services Administration (HRSA), the Substance
Abuse and Mental Health Services Administration
(SAMHSA), the National Institute on Drug Abuse
(NIDA), the Office of Women’s Health (OWH), the
Public Health Service (PHS), the Indian Health
Service (IHS), and the Office of Minority Health
(OMH) are actively engaged in health services programs that impact on inmates. In addition, within
the Department of Justice, agencies such as the
National Institute of Justice (NIJ), the Immigration
and Naturalization Service (INS), the Bureau of
Prisons (BOP) including the National Institute of
Corrections (NIC), the Corrections Program Office
(CPO), and the Office of Justice Programs (OJP)
conduct programs and activities that ultimately
influence inmate health. Finally, the Office of
the Surgeon General (OSG) and the White House
Executive Office of National Drug Control Policy
(ONDCP) also impact the health care of inmates.
The steering committee and expert panels recommend
that Congress provide the necessary authorization,
funding, and other assistance to the appropriate
agencies to implement the following recommendations.
I.

The Secretary of the U.S. Department of Health
and Human Services (DHHS) should direct
appropriate agencies to collaborate with other
agencies in analyzing the potential economic
benefits to the community of early diagnosis
and treatment of communicable diseases,
chronic diseases, and mental illnesses.

II. The Secretary should direct CDC to collaborate
with NIJ, NIC, CPO, and other Department of
Justice divisions in developing tools to assist
State and local agencies in deciding when and
whom to screen for communicable diseases in
correctional settings.
III. The Secretary should direct all appropriate
agencies within the department to work toward
reducing interagency regulatory and bureaucratic barriers to testing and counseling for
HIV, TB, and STDs among inmates.
IV. The Secretary and the Attorney General should
involve correctional health professionals in public health planning and the evaluation of correctional health care programs.
V. The Secretary and the Attorney General should
direct appropriate agencies to support field tests
of innovative medical information systems to
improve the continuity of care for inmates transferred between correctional facilities or released
into the community. These efforts should concentrate on removing barriers that impede the
transfer of appropriate medical information.
VI. The Secretary and the Attorney General should
direct appropriate agencies to develop educational programs to inform policymakers and the
public about the public health and social benefits of investing in health care for inmates.
VII. A Federal interagency task force, currently
established and co-chaired by CDC and NIJ,
should report annually to the Secretary and the
Attorney General on the status of correctional
health care in the Nation and on progress made
toward implementing the recommendations
included in this report.

Bibliography
The following publications identify sources of
additional information related to each of the policy
recommendations presented in this chapter. The
publications are listed under the topic headings
used above.

65

Surveillance
Ditton, P.M. Mental Health and Treatment of
Inmates and Probationers. Washington, D.C.: U.S.
Department of Justice, Bureau of Justice Statistics,
July 1999. NCJ 174463.
Hammett, T.M., P. Harmon, and L.M. Maruschak.
1996–1997 Update: HIV/AIDS, STDs, and TB
in Correctional Facilities. Issues and Practices.
Washington, D.C.: U.S. Department of Justice,
National Institute of Justice, July 1999. NCJ
176344.
Hammett, T.M., P. Harmon, and W. Rhodes. “The
Burden of Infectious Disease Among Inmates and
Releasees From Correctional Facilities.” Paper prepared for the National Commission on Correctional
Health Care, Chicago, Illinois, May 2000. (Copy in
volume 2 of this report.)
Hornung, C.A., B.J. Anno, R.B. Greifinger, and
S. Gadre. “Health Care for Soon-To-Be-Released
Inmates: A Survey of State Prison Systems.” Paper
prepared for the National Commission on Correctional
Health Care, Chicago, Illinois, 1998. (Copy in volume 2 of this report.)
Hornung, C.A., R.B. Greifinger, and S. Gadre.
“A Projection Model of the Prevalence of Selected
Chronic Diseases in the Inmate Population.” Paper
prepared for the National Commission on Correctional
Health Care, Chicago, Illinois, 1998. (Copy in volume 2 of this report.)
Hutton, M.D., G.M. Cauthen, and A.B. Bloch.
“Results of a 29-State Survey of Tuberculosis in
Nursing Homes and Correctional Facilities.” Public
Health Reports 108 (1993): 305–314.
Jordan, B.K., W.E. Schlenger, J.A. Fairbank, and
J.M. Caddell. “Prevalence of Psychiatric Disorders
Among Incarcerated Women II: Convicted Felons
Entering Prison.” Archives of General Psychiatry 53
(6) (1996): 513–519.
Metzner, J.L., R.D. Miller, and D. Kleinsasser.
“Mental Health Screening and Evaluation Within
Prisons.” Bulletin of the American Academy of
Psychiatry and the Law 22 (3) (1994): 451–457.

Regier, D.A., M.E. Farmer, D.A. Rae, B.Z. Locke,
S.J. Keith, L.L. Judd, and F.K. Goodwin. “Comorbidity of Mental Disorders With Alcohol and Other
Drug Abuse: Results From the Epidemiological
Catchment Area (ECA) Study.” Journal of the
American Medical Association 264 (19) (1990):
2511–2518.
Spencer, S.S., and A.R. Morton. “Tuberculosis
Surveillance in a State Prison System.” American
Journal of Public Health 79 (4) (1989): 507–509.
Steadman, H.J., S.M. Morris, and D.L. Dennis.
“The Diversion of Mentally Ill Persons From Jails
to Community-Based Services: A Profile of
Programs.” American Journal of Public Health
85 (12) (1995): 1630–1635.
Teplin, L.A. “The Prevalence of Severe Mental
Disorder Among Male Urban Jail Detainees:
Comparison With the Epidemiologic Catchment
Area Program.” American Journal of Public Health
80 (6) (1990): 663–669.
Teplin, L.A. “Psychiatric and Substance Abuse
Disorders Among Male Urban Jail Detainees.”
American Journal of Public Health 84 (2) (1994):
290–293.
Teplin, L.A., K.M. Abram, and G.M. McClelland.
“Prevalence of Psychiatric Disorders Among
Incarcerated Women: I. Pretrial Jail Detainees.”
Archives of General Psychiatry 53 (1996): 505–512.
Teplin, L.A., K.M. Abram, and G.M. McClelland.
“Mentally Disordered Women in Jail: Who Receives
Services?” American Journal of Public Health 87
(4) (1997): 604–609.
Torrey, E.F. “Editorial: Jails and Prisons—
America’s New Mental Hospitals.” American
Journal of Public Health 85 (12) (1995):
1611–1613.
Valway, S.E., S.B. Richards, J. Kovacovich, R.B.
Greifinger, J.T. Crawford, and S.W. Dooley. “Outbreak of Multi-Drug-Resistant Tuberculosis in a
New York State Prison, 1991.” American Journal
of Epidemiology 140 (2) (1994): 113–122.

66

Veysey, B.M., and G. Bichler-Robertson. “Prevalence
Estimates of Psychiatric Disorders in Correctional
Settings.” Paper prepared for the National Commission on Correctional Health Care, Chicago, Illinois,
n.d. (Copy in volume 2 of this report.)

Clinical guidelines
Condelli, W.S., B. Bradigan, and H. Holanchock.
“Intermediate Care Programs to Reduce Risk and
Better Manage Inmates With Psychiatric Disorders.”
Behavioral Science and Law 15 (4) (1997):
459–467.

National correctional health literature
database
Centers for Disease Control and Prevention.
“General Recommendations on Immunization:
Recommendations of the Advisory Committee on
Immunization Practices (ACIP).” Morbidity and
Mortality Weekly Report 43 (RR-01) (1994): 1–38.
Centers for Disease Control and Prevention.
“Prevention and Control of Influenza: Recommendations of the Advisory Committee on
Immunization Practices (ACIP).” Morbidity and
Mortality Weekly Report 48 (RR–04) (1999): 1–28.

Hornung, C.A., R.B. Greifinger, and S. Gadre.
“A Projection Model of the Prevalence of Selected
Chronic Diseases in the Inmate Population.” Paper
prepared for the National Commission on Correctional
Health Care, Chicago, Illinois, 1998. (Copy in volume 2 of this report.)

Centers for Disease Control and Prevention.
“Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on
Immunization Practices (ACIP).” Morbidity and
Mortality Weekly Report 46 (RR–08) (1997): 1–24.

Metzner, J.L. “Guidelines for Psychiatric Services
in Prisons.” Criminal Behavior and Mental Health 3
(1993): 252–267.

Centers for Disease Control and Prevention.
“Recommended Childhood Immunization
Schedule—United States, 1998.” Morbidity and
Mortality Weekly Report 47 (1) (1998): 8–12.

Immunizations
Centers for Disease Control and Prevention.
“General Recommendations on Immunization:
Recommendations of the Advisory Committee on
Immunization Practices (ACIP).” Morbidity and
Mortality Weekly Report 43 (RR–01) (1994): 1–38.
Centers for Disease Control and Prevention.
“Prevention and Control of Influenza: Recommendations of the Advisory Committee on
Immunization Practices (ACIP).” Morbidity and
Mortality Weekly Report 48 (RR–04) (1999): 1–28.
Centers for Disease Control and Prevention.
“Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on
Immunization Practices (ACIP).” Morbidity and
Mortality Weekly Report 46 (RR–08) (1997): 1–24.
Centers for Disease Control and Prevention.
“Recommended Childhood Immunization
Schedule—United States, 1998.” Morbidity and
Mortality Weekly Report 47 (1) (1998): 8–12.

Hornung, C.A., B.J. Anno, R.B. Greifinger, and S.
Gadre. “Health Care for Soon-To-Be-Released
Inmates: A Survey of State Prison Systems.” Paper
prepared for the National Commission on Correctional
Health Care, Chicago, Illinois, 1998. (Copy in volume 2 of this report.)

Aid ethical decisionmaking
Anno, B.J., and N.N. Dubler. “Ethical Considerations
and the Interface With Custody.” Chapter 4 in B.J.
Anno. Correctional Health Care: Guidelines for
the Management of an Adequate Delivery System.
Washington, D.C.: U.S. Department of Justice,
National Institute of Corrections, forthcoming.
Anno, B.J., and S.S. Spencer. “Medical Ethics and
Correctional Health Care.” In M. Puisis, ed. Clinical
Practice in Correctional Medicine. St. Louis,
Missouri: Mosby, 1998.

Eliminate health barriers
Edens, J.F., R.H. Peters, and H.A. Hills. “Treating
Prison Inmates With Co-Occurring Disorders: An
Integrative Review of Existing Programs.” Behavioral
Science and Law 15 (4) (1997): 439–457.

67

Greifinger, R.B., N.J. Heywood, and J.B. Glaser.
“Tuberculosis in Prison: Balancing Justice and
Public Health.” Journal of Law, Medicine, & Ethics
21 (1993): 332–341.

McDonald, D.C. Managing Prison Health Care
Costs. Issues and Practices. Washington, D.C.: U.S.
Department of Justice, National Institute of Justice,
May 1995. NCJ 152768.

Jordan, B.K., W.E. Schlenger, J.A. Fairbank, and
J.M. Caddell. “Prevalence of Psychiatric Disorders
Among Incarcerated Women, II. Convicted Felons
Entering Prison.” Archives of General Psychiatry
53 (6) (1996): 513–519.

Metzner, J.L., G.E. Fryer, Jr., and D. Usery. “Prison
Mental Health Services: Results of a National
Survey of Standards, Resources, Administrative
Structure, and Litigation.” Journal of Forensic
Sciences 35 (2) (1990): 433–438.

Morris, S.M., H.J. Steadman, and B.M. Veysey.
“Mental Health Services in United States Jails: A
Survey of Innovative Practices.” Criminal Justice
and Behavior 24 (1) (1997): 3–19.

National Advisory Mental Health Council. “Health
Care Reform for Americans With Severe Mental
Illnesses: Report of the National Advisory Mental
Health Council.” American Journal of Psychiatry
150 (10) (1993): 1447–1465.

Segal-Maurer, S., and G.E. Kalkut. “Environmental
Control of Tuberculosis: Continuing Controversy.”
Clinical International Disease 19 (1994): 299–308.

Correctional health care research
Hammett, T.M., J.L. Gaiter, and C. Crawford.
Watson, “Reaching Seriously Ill At-Risk Populations:
Health Interventions in Criminal Justice Settings.”
Health Education and Behavior 25 (1) (1998):
99–120.
Hornung, C.A., R.B. Greifinger, and S. Gadre.
“A Projection Model of the Prevalence of Selected
Chronic Diseases in the Inmate Population.” Paper
prepared for the National Commission on Correctional
Health Care, Chicago, Illinois, 1998. (Copy in volume 2 of this report.)
Roesch, R., J.R. Ogloff, and D. Eaves. “Mental
Health Research in the Criminal Justice System:
The Need for Common Approaches and International Perspectives.” International Journal of
Law and Psychiatry 18 (1) (1995): 1–14.

Improve delivery of health care
Anno. B.J. Prison Health Care: Guidelines for
the Management of an Adequate Delivery System.
Chicago, Illinois: National Commission on
Correctional Health Care, 1991.
Cohen, F., and J. Dvoskin. “Inmates With Mental
Disorders: A Guide to Law and Practice.” Mental
and Physical Disability Law Reporter 16 (3–4)
(1992): 39–46, 462–470.

National Commission on Correctional Health Care.
Standards for Health Services in Jails. Chicago,
Illinois: Author, 1992.
National Commission on Correctional Health Care.
Standards for Health Services in Prisons. Chicago,
Illinois: Author, 1997.
National Commission on Correctional Health Care.
Correctional Mental Health Care. Standards and
Guidelines for Delivering Services. Chicago,
Illinois: Author, 1999.

Disease prevention
Alcabes, P., P. Vossenas, R. Cohen, C. Braslow, D.
Michaels, and S. Zoloth. “Compliance with Isoniazid
Prophylaxis in Jail.” American Review of Respiratory
Diseases 140 (1989): 1194–1197.
DuRand, C.J., G.J. Burtka, E.J. Federman, J.A.
Haycox, and J.W. Smith. “A Quarter Century of
Suicide in a Major Urban Jail: Implications for
Community Psychiatry.” American Journal of
Psychiatry 152 (7) (1995): 1077–1080.
Hammett, T.M., P. Harmon, and L.M. Maruschak.
1996–1997 Update: HIV/AIDS, STDs, and TB in
Correctional Facilities. Washington, D.C.: U.S.
Department of Justice, National Institute of Justice,
July 1999. NCJ 176344.
Hammett, T.M., P. Harmon, and W. Rhodes. “The
Burden of Infectious Disease Among Inmates and
Releasees From Correctional Facilities.” Paper prepared for the National Commission on Correctional

68

Health Care, Chicago, Illinois, October 1999. (Copy
in volume 2 of this report.)
Hornung, C.A., R.B. Greifinger, and S. Gadre.
“A Projection Model of the Prevalence of Selected
Chronic Diseases in the Inmate Population.” Paper
prepared for the National Commission on Correctional
Health Care, Chicago, Illinois, 1998. (Copy in volume 2 of this report.)

Mellitus Among Prisoners in the United States.”
Paper prepared for the National Commission on
Correctional Health Care, Chicago, Illinois, n.d.
(Copy in volume 2 of this report.)
Valway, S.E., S.B. Richards, J. Kovacovich, R.B.
Greifinger, J.T. Crawford, and S.W. Dooley. “Outbreak of Multi-Drug-Resistant Tuberculosis in a
New York State Prison, 1991.” American Journal
of Epidemiology 140 (2) (1994): 113–122.

Kraut, J.R., A.C. Haddix, V. Carande-Kulis, and
R.B. Greifinger. “Cost-Effectiveness of Routine
Screening for Sexually Transmitted Diseases
Among Inmates in United States Prisons and Jails.”
Paper prepared for the National Commission on
Correctional Health Care, Chicago, Illinois,
February 2000. (Copy in volume 2 of this report.)

Varghese, B., and T.A. Peterman. “Cost-Effectiveness
of HIV Counseling and Testing in U.S. Prisons.”
Paper prepared for the National Commission on
Correctional Health Care, Chicago, Illinois, n.d.
(Copy in volume 2 of this report.)

National Commission on Correctional Health Care.
Standards for Health Services in Prisons. Chicago,
Illinois: Author, 1992.

Veysey, B.M., and G. Bichler-Robertson. “Prevalence
Estimates of Psychiatric Disorders in Correctional
Settings.” Paper prepared for the National Commission on Correctional Health Care, Chicago, Illinois,
n.d. (Copy in volume 2 of this report.)

Centers for Disease Control and Prevention.
“Prevention and Control of Tuberculosis in
Correctional Facilities: Recommendations of
the Advisory Council for the Elimination of
Tuberculosis.” Morbidity and Mortality Weekly
Report 45 (RR–08) (1996): 1–27.
Sanchez, V.M., F. Alvarez-Guisasola, J.A. Cayla, and
J.L. Alvarez. “Predictive Factors of Mycobacterium
Tuberculosis Infection and Pulmonary Tuberculosis
in Prisoners.” International Journal of Epidemiology
24 (1995): 630–636.
Shuter, J. “Communicable Diseases in Inmates:
Public Health Opportunities.” Paper prepared for the
National Commission on Correctional Health Care,
Chicago, Illinois, n.d. (Copy in volume 2 of this
report.)
Taylor, Z., and C. Nguyen. “Cost-Effectiveness of
Preventing Tuberculosis in Prison Populations.”
Presentation prepared for the National Commission
on Correctional Health Care, Chicago, Illinois, n.d.
(Copy in volume 2 of this report.)
Tomlinson, D.M., and C.B. Schechter. “CostEffectiveness Analysis of Annual Screening and
Intensive Treatment for Hypertension and Diabetes

Prerelease planning
Mahoney, B., B.D. Beaudin, J.A. Carver III, D.B.
Ryan, and R.B. Hoffman. Pretrial Services Programs:
Responsibilities and Potential. Washington, D.C.:
U.S. Department of Justice, National Institute of
Justice, September 2000. NCJ 181939.
Steadman, H.J., and B.M. Veysey. Providing Services
for Jail Inmates With Mental Disorders. Research
in Brief. Washington, D.C.: U.S. Department of
Justice, National Institute of Justice, 1997. NCJ
162207.
Veysey, B.M., and G. Bichler-Robertson. “Providing
Psychiatric Services in Correctional Settings.” Paper
prepared for the National Commission on Correctional
Health Care, Chicago, Illinois, n.d. (Copy in volume 2
of this report.)

Notes
1. See, for example, Healthy People 2000: National
Health Promotion and Disease Prevention Objectives,
Washington, DC: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention,
Washington, DC, September 1990; and U.S. Department
of Health and Human Services, Mental Health: A Report

69

of the Surgeon General, Rockville, MD: Substance
Abuse and Mental Health Services Administration, 1999.
2. Surveillance is the ongoing and systematic collection,
analysis, and interpretation of health data.
3. See, for example, National Center for Health Statistics,
National Health and Nutrition Examination Survey III
[NHANES–III], Atlanta, GA: U.S. Department of Health
and Human Services, Centers for Disease Control and
Prevention, 1997.
4. The definitions of mental disorders and discussion of
their prevalence in American Psychiatric Association,
Diagnostic and Statistical Manual of Mental Disorders,
4th ed., Washington, DC: American Psychiatric Press,
1994, are a good illustration of the standardized definitions and measures that are needed in the field of correctional health care.
5. “Summary of Notifiable Diseases, United States
1998,” Morbidity and Mortality Weekly Report 47 (53)
(December 31, 1999): 1–93.
6. See Greifinger, R.B., “Correctional Health Clinical
Guideline Series” in appendix D to volume 1 of this
report. See also American Diabetes Association, “Clinical
Practice Recommendations 2000: Standards for Medical
Care for Patients with Diabetes Mellitus,” Diabetes Care
23 (supp. 1) (2000): 1–23; American Diabetes Association,
“Clinical Practice Recommendations 1998: Management
of Diabetes in Correctional Institutions,” Diabetes Care
21 (supp. 1) (1998): S80–S81; National Institutes of
Health, National Asthma Education and Prevention
Program, Expert Panel Report 2: Guidelines for the
Diagnosis and Management of Asthma, Bethesda, MD:
National Heart, Blood, and Lung Institute, February
1997; National Institutes of Health, Sixth Report of the
Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure,
Bethesda, MD: National Heart, Lung, and Blood
Institute, November 1997; Clinical Guidelines: Report of
the NIH Panel to Define Principles of Therapy of HIV
Infection and Guidelines for the Use of Antiretroviral
Agents in HIV-Infected Adults and Adolescents,
Bethesda, MD: National Institutes of Health (updated
May 5, 1999); and “Clinical Guidelines: 1999 USPHS/
IDSA Guidelines for the Prevention of Opportunistic
Infections in Persons Infected with Human Immunodeficiency Virus,” Morbidity and Mortality Weekly Report
48 (RR–10) (August 20, 1999): 1–59.

7. See, for example, Guidelines for the Use of
Antiretroviral Agents in HIV-Infected Adults and
Adolescents, Washington, DC: U.S. Department of
Health and Human Services, January 28, 2000.
8. The recommendations of the CDC’s Advisory
Committee on Immunization Practices can be found at
Web site: http//www.cdc.gov/nip/publications/ACIPlist.htm.
9. See Centers for Disease Control and Prevention,
“Recommendations for Prevention and Control of
Hepatitis C Virus (HCV) Infection and HCV-Related
Chronic Disease,” Morbidity and Mortality Weekly
Report 47 (RR–19) (October 16, 1998): 1–39.
10. Ibid.
11. For a comparison of accreditation services for correctional institutions see Anno, B. J., Correctional Health
Care: Guidelines for the Management of an Adequate
Delivery System, Washington, DC: U.S. Department of
Justice, National Institute of Corrections (in press).
12. See National Commission on Correctional Health
Care, Standards for Health Services in Prisons, and
Standards for Health Services in Jails, Chicago, IL:
Author (in press).
13. A detailed discussion of the differences between primary and secondary prevention may be found in Last,
J.M., Public Health and Human Ecology, 2d ed.,
Stamford, CT: Appleton & Lange, 1998.
14. An excellent source for a tuberculosis clinical guideline is the Centers for Disease Control and Prevention at
their Web site: www.cdc.gov
15. See U.S. Department of Health and Human Services,
Guidelines for the Use of Antiretroviral Agents (see note 7).
16. See Centers for Disease Control and Prevention,
“HIV Prevention Through Early Detection and Treatment
of Other Sexually Transmitted Diseases—United States
Recommendations of the Advisory Committee for HIV
and STD Prevention,” Morbidity and Mortality Weekly
Report 47 (RR–12) (July 31, 1998): 1–24.

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Appendix A. NCCHC/NIJ Project Participants,
Author/Experts, Consultants
Steering Committee
B. Jaye Anno, Ph.D., CCHP–A
Consultants in Correctional Care
Santa Fe, New Mexico
R. Scott Chavez, M.P.A., PA–C, CCHP
National Commission on Correctional Health Care
Chicago, Illinois

Clyde Schechter, M.D.
Mt. Sinai School of Medicine
New York, New York
Donna Tomlinson, M.D., M.Sc.
Beth Israel Medical Center
New York, New York
Panel Members

Cheryl Crawford, M.P.A., J.D.
National Institute of Justice
Washington, D.C.

Hazel Dean-Gaitor, Sc.D., M.P.H.
Centers for Disease Control and Prevention
Atlanta, Georgia

Andrew Goldberg, M.A.
National Institute of Justice
Washington, D.C.

Lori de Ravello, M.P.H.
Centers for Disease Control and Prevention
Atlanta, Georgia

Robert Greifinger, M.D.
National Commission on Correctional Health Care
Dobbs Ferry, New York

Rod Gottula, M.D.
University of Colorado Health Science Center
Denver, Colorado

Edward Harrison, M.M., CCHP
National Commission on Correctional Health Care
Chicago, Illinois

Lambert King, M.D., Ph.D.
St. Vincent’s Medical Center
New York, New York

John Miles, M.P.A.
Centers for Disease Control and Prevention
Atlanta, Georgia

Maureen Mangotich, M.D.
Pfizer Health Solutions
Santa Monica, California

Marilyn Moses, M.S.
National Institute of Justice
Washington, D.C.

W. Paul McKinney, M.D.
University of Louisville
Louisville, Kentucky

Laura Winterfield, Ph.D.
National Institute of Justice
Washington, D.C.

Joseph Paris, M.D., Ph.D., CCHP
Georgia Department of Corrections
Atlanta, Georgia

Chronic Disease Panel

Michael Puisis, D.O.
Addus HealthCare’s Correctional Division
Evanston, Illinois

Authors
Carlton Hornung, Ph.D., MPH
University of Louisville
Louisville, Kentucky

72

Dianne Rechtine, M.D., CCHP–A
Florida Reception Center
Orlando, Florida

Phyllis E. Cruise, B.A.
Texas Department of Health
Austin, Texas

Ron Shansky, M.D., M.P.H.
Correctional Medicine Consultant
Chicago, Illinois

Hazel Dean-Gaitor, Sc.D., M.P.H.
Centers for Disease Control and Prevention
Atlanta, Georgia

Communicable Disease Panel
Authors

Anne De Groot, M.D.
Brown University
Providence, Rhode Island

Theodore Hammett, Ph.D.
Abt Associates
Cambridge, Massachusetts

Theodore Hammett, Ph.D.
Abt Associates
Cambridge, Massachusetts

Julie Kraut, Ph.D.
Centers for Disease Control and Prevention
Atlanta, Georgia

T. Stephen Jones, M.D.
Centers for Disease Control and Prevention
Atlanta, Georgia

Rob Lyerla, Ph.D.
Centers for Disease Control and Prevention
Atlanta, Georgia

Newton Kendig, M.D.
Federal Bureau of Prisons
Washington, D.C.

Jonathan Shuter, M.D.
Consultant
New Rochelle, New York

Fred Martich, B.S.
Centers for Disease Control and Prevention
Atlanta, Georgia

Zachary Taylor, M.D., M.S.
Centers for Disease Control and Prevention
Atlanta, Georgia

Eric Mast, M.D., M.P.H.
Centers for Disease Control and Prevention
Atlanta, Georgia

Beena Varghese, Ph.D.
Centers for Disease Control and Prevention
Atlanta, Georgia

Margaret Oxtoby, M.D.
New York State Department of Health
Albany, New York

Panel Members

Betty Rider, M.A., M.S.
North Carolina Department of Corrections
Durham, North Carolina

Frederick L. Altice, M.D.
Yale University School of Medicine
New Haven, Connecticut
Eran Bellin, M.D.
Montefiore Medical Center
Bronx, New York
John H. Clark, M.D., M.P.H., CCHP–A
Los Angeles County Sheriff’s Department.
Los Angeles, California

George Schmid, M.D., M.Sc.
Centers for Disease Control and Prevention
Atlanta, Georgia
Anne Spaulding, M.D.
Rhode Island Department of Corrections
Cranston, Rhode Island

73

Steven Szebenyi, M.D., FACP
Blue Shield of Northeastern New York
Albany, New York

Juarlyn Gaiter, Ph.D.
Centers for Disease Control and Prevention
Atlanta, Georgia

David Thomas, M.D., J.D.
Florida Department of Corrections
Tallahassee, Florida

Martin Horn, M.A.
Pennsylvania Department of Corrections
Camp Hill, Pennsylvania

Rich Voigt, M.A.
Centers for Disease Control and Prevention
Atlanta, Georgia

Holly Hills, Ph.D.
The Gains Center
Tampa, Florida

Mental Illness Panel
Author

Pradan Nathan, M.D.
Texas Department of Criminal Justice
Huntsville, Texas

Bonita Veysey, Ph.D.
Rutgers University, School of Criminal Justice
Newark, New Jersey

Hal Smith
Central New York Psychiatric Institute
Marcy, New York

Panel Members

Henry Steadman, Ph.D.
The National GAINS Center
Delmar, New York

Tim Akers, Ph.D.
Centers for Disease Control and Prevention
Atlanta, Georgia
Carl C. Bell, M.D., FAPA, CCHP, FAC Psych.
Community Mental Health Council & Foundation, Inc.
Chicago, Illinois
Elissa Benedek, M.D.
University of Michigan Medical Center
Ann Arbor, Michigan
Tom Conklin, M.D., CCHP–A
Hampden County Correctional Facility
Ludlow, Massachusetts

Linda Teplin, Ph.D.
Northwestern University Medical School
Chicago, Illinois
Henry C. Weinstein, M.D., J.D., CCHP
New York University Medical Center
New York, New York

75

Appendix B. Biographies of Contributors

FREDERICK L. ALTICE, M.D., is associate professor of medicine, AIDS Program, at Yale University
School of Medicine. He is also director of the HIV in
Prisons Program in the State of Connecticut and the
Community Health Care Van Project. A graduate of
Emory University, he is a researcher, writer, and lecturer who is active in the American Public Health
Association, the Infectious Disease Society of
America, and the Society for Correctional Physicians.
He is also one of the founders of HEPP News (HIV
Education Prison Project), a forum for correctional
problem solving. He has written numerous articles
and papers. His chapters, “Overview of HIV Care”
and “Use of Antiretroviral Agents in the Treatment
of HIV,” in the 1998 publication Clinical Practice in
Correctional Medicine were cited for distinction. He
served as a member of the NCCHC–NIJ expert panel
on communicable disease.
B. JAYE ANNO, Ph.D., CCHP–A, is a criminologist specializing in correctional health administration and compliance with national correctional
health care standards. She operates a correctional
health care consulting firm. Dr. Anno is an experienced researcher, lecturer, and author in correctional
health care. She is the principal author of the major
reference book for the field, Prison Health Care:
Guidelines for the Management of an Adequate
Delivery System, and has written numerous other articles and reports on correctional health care topics.
She is a past editor of the Journal on Correctional
Health Care and currently writes a column, “Q & A
on NCCHC Standards,” for the quarterly newspaper
CORRECTCARE. Dr. Anno received the Distinguished
Service Award of the American Correctional Health
Services Association and the NCCHC’s Award of
Merit. In 1999, she received the “Award of Excellence
in Correctional Health Care Communications” from
the National Commission on Correctional Health
Care. She served on the steering committee of the
NCCHC–NIJ project on The Health Status of
Soon-To-Be-Released Inmates.

CARL C. BELL, M.D., FAPA, CCHP, FAC
Psych., is president and chief executive officer,
Community Health Council & Foundation, Inc., and
a Clinical professor of psychiatry and public health,
University of Illinois. He is coprincipal investigator
of the Chicago African-American Youth Health
Behavior Project, Health Research and Policy
Center. He is a collaborator of the Chicago HIV
Prevention and Adolescent Mental Health Project
(CHAMP) and a coprincipal Investigator of the
Informed Consent in Urban AIDS and Mental
Health Research Project, University of Illinois
Department of Psychiatry. He is a founding and current member and past board chairman of the National
Commission on Correctional Health Care. During his
30 years of psychiatric practice, Dr. Bell has published more than 200 articles on mental health
issues. He is author of many publications including
Getting Rid of Rats: Perspectives of a Black
Community Psychiatrist, and coauthor of Suicide
and Homicide Among Adolescents. He is a member
of the Violence Against Women Advisory Council
appointed by Janet Reno, Attorney General, and
Donna Shalala, Secretary, Department of Health
and Human Services, 1995–2000. He served as a
member of the NCCHC–NIJ expert panel on mental
illness.
ERAN BELLIN, M.D., is the director of the
Montefiore Medical Center Department of Outcomes
Analysis and Decision Support and an associate professor of epidemiology and social medicine at the
Albert Einstein College of Medicine. From 1974
to 1977, Dr. Bellin directed the Montefiore Rikers
Island Health Program, which provided ongoing
medical care for approximately 100,000 inmates.
He served as director of infectious disease services
on Rikers from 1989 to 1994, developing the plans
for and serving as consultant to the 140-bed negative pressure respiratory isolation facility built in
the jail. His case control study published in 1993
in the Journal of the American Medical Association
demonstrated the risk of clinical tuberculosis from
incarceration in the New York City jail. He served

76

as a member of the NCCHC–NIJ expert panel on
communicable disease.
ELISSA P. BENEDEK, M.D., is clinical professor
of psychiatry at the University of Michigan Medical
Center. She is past president of the American
Psychiatric Association (1990–91). She served as
director of research and training at the Center for
Forensic Psychiatry in Ann Arbor, Michigan, for 25
years. The center trains psychiatric fellows to work
in correctional psychiatry and forensic psychiatry.
Her research interest focuses on violence and violent
behavior in child, adolescent, and adult populations.
She served as a member of the NCCHC–NIJ expert
panel on mental illness.
R. SCOTT CHAVEZ, M.P.A., PA–C, CCHP, is
vice president for the National Commission on
Correctional Health Care and served as project coordinator for the NCCHC–NIJ The Health Status
of Soon-To-Be-Released Inmates project. Mr.
Chavez’s responsibilities with NCCHC include technical assistance on health care standards, quality
improvement, risk management, and organizational
development in correctional health care systems. Mr.
Chavez is principal investigator for a CDC grant to
the NCCHC on “Hepatitis Curricula for Correctional
Officers and Inmates.” He has authored chapters
on physician assistant utilization in corrections for
Health Care Management Issues in Corrections and
Physician Assistant: A Guide to Clinical Practice.
He has a master’s degree in public administration
from the University of Nebraska, Omaha, and is a
Ph.D. candidate at the Health Services Division of
Walden University. His dissertation is on the differences, trends, and predictors of quality health care in
public and private correctional health care systems.
JOHN H. CLARK, M.D., M.P.H., CCHP–A, is the
chief medical officer for the Los Angeles County
Sheriff’s Department. Dr. Clark graduated from
Meharry Medical College in 1971 and trained at the
University of Southern California Medical Center
and Martin Luther King Jr., General Hospital in Los
Angeles, California. He received a master’s in health
services and hospital administration from the
University of California–Los Angeles. His professional activities include the American Correctional
Health Services Association (Past President),
American Jail Association (Board of Directors),
and he is a Certified Correctional Health

Professional–Advanced. Dr. Clark has published
on a variety of topics in the correctional health profession including managing tuberculosis, paraplegics,
inmate self-medication programs, and developing
HIV disease policies for the correctional environment. He has lectured nationally and has served as
a consultant and expert witness dealing with civil
rights litigation related to correctional health care
issues. He served as a member of the NCCHC–NIJ
expert panel on communicable disease.
THOMAS J. CONKLIN, M.D., CCHP–A, is currently director of health services at the Hampden
County Correctional Center in Ludlow, Massachusetts.
He has developed a public health model of care for
corrections that effectively stresses assessment,
effective treatment, education, prevention, and
continuity of care by referring inmates to their
neighborhood health centers following discharge.
Dr. Conklin is board certified in psychiatry and is
certified in administration by the American Psychiatric
Association. Dr. Conklin was the first chairman of the
department of psychology and neurology in the
Touro Infirmary in New Orleans, Louisiana. He is
a fellow of the American Psychiatric Association.
He also has numerous publications and presentations focusing on health care in hospitals and in
corrections. He served as a member of the NCCHC–
NIJ expert panel on mental illness.
CHERYL CRAWFORD, M.P.A., J.D., is Deputy
Director, Office of Development & Communications,
National Institute of Justice (NIJ). NIJ was established
by Congress to develop and disseminate knowledge
that will reduce crime, enhance public safety, and
improve the administration of justice. She coordinates project management and integrative services
for three divisions (Communications, Development,
and International) in NIJ’s Office of Development
& Communications. From 1987 to 1998, Ms.
Crawford managed NIJ’s correctional health care
research and dissemination portfolio. She has spoken and written extensively on correctional health
care issues, including the impact of HIV/AIDS and
TB in corrections and the costs of correctional
health care. Currently, she manages the Reentry
Partnership Initiative, a multiagency, multisite effort
focused on transitioning offenders from prison to
community; this effort includes health components.
She received her B.A. in criminal justice from the

77

University of Wisconsin–Platteville and her master’s
in public administration and J.D. from the University
of Wisconsin–Madison. Ms. Crawford served as a
member of the steering committee of the NCCHC–
NIJ project on The Health Status of Soon-To-BeReleased Inmates.
PHYLLIS E. CRUISE, B.A., received her B.A. in
education in psychology from Southern Illinois
University. She has been employed at Centers for
Disease Control and Prevention since 1978. She is the
senior public health advisor assigned to the Texas
Department of Health Tuberculosis Elimination
Division. Ms. Cruise developed and implemented the
Texas legislation that mandates TB screening for
staff and inmates. Ms. Cruise supervises the project
that monitors the mandated screening activities, and
includes contact, followup, tracking and continuity
of care of inmates and staff with active TB disease
or who have been exposed to active tuberculosis.
Ms. Cruise is the author of Prevention and Control
of Tuberculosis in Correctional Facilities—
Recommendations of the Advisory Council for
the Elimination of Tuberculosis. She has appeared
as an expert panel member and developed national
satellite programs, training seminars, and videos
addressing issues affecting the control of tuberculosis
in correctional facilities. She has also provided consultation to local, State and Federal correctional agencies. She served as a member of the NCCHC–NIJ
expert panel on communicable disease.
HAZEL D. DEAN-GAITOR, Sc.D., M.P.H.,
earned her B.S. in biology from Spelman College
and her M.P.H. and Sc.D. from Tulane University
School of Public Health and Tropical Medicine. She
is an epidemiologist at the Centers for Disease
Control and Prevention (CDC) in the National
Center for HIV, STD, and TB Prevention. She is
responsible for formulating, implementing, and evaluating CDC’s national HIV/AIDS surveillance system
among racial/ethnic minorities and special populations (e.g., incarcerated persons). She conducts complex statistical and epidemiological analyses of
racial/ethnic minorities and special populations collected through this surveillance system. She serves as
the HIV/AIDS Surveillance Branch’s primary technical resource on surveillance of racial/ethnic minorities and special populations. Dr. Dean-Gaitor
represents the CDC on the United States Department
of Health and Human Services Crisis Response

Team to Combat HIV/AIDS in Racial and Ethnic
Minority Populations and the NCCHC–NIJ expert
panels on Communicable and Chronic Disease. She
has written or contributed to numerous reports,
papers, and presentations on HIV/AIDS, with special emphasis on persons reported from correctional
settings, trends among foreign-born persons with
AIDS, and AIDS in bisexual minority men.
ANNE DE GROOT, M.D., is the head of the
TB/HIV research laboratory at the International
Health Institute, where she and colleagues are working on the development of HIV and TB vaccines.
She received her B.A. from Smith College in 1978
and her M.D. from the University of Chicago. She
trained in internal medicine at the New England
Medical Center in vaccine research, and received her
specialized training in infectious diseases at the New
England Medical Center. She is a faculty member of
the Brown University School of Medicine. Dr. De
Groot has provided HIV care to incarcerated individuals at a number of different corrections institutions
since 1989. She founded and directed the HIV clinic
at the Massachusetts Correctional Institution at
Framingham. She also served on the Governor’s
AIDS Task Force. Dr. De Groot has been working on
developing a standard of care for HIV-infected and
at-risk incarcerated women. She founded and
cochairs the HIV Education Prison Project (HEPP)
at the Brown University AIDS Program, which publishes a monthly newsletter on HIV management in
prisons and jails that reaches more than 2,000 correctional HIV professionals. She served as a member
of the NCCHC–NIJ expert panel on communicable
disease.
LORI DE RAVELLO, M.P.H., has more than 9
years of experience in international and domestic
public health program operations and management.
Since 1996, she has worked as a public health advisor in the Division of Reproductive Health, National
Center for Chronic Disease Prevention and Health
Promotion at the Centers for Disease Control and
Prevention in Atlanta, Georgia. Her duties include
that of project officer for an HIV-prevention training
intervention in U.S. reproductive health settings, primary investigator for a retrospective research study
looking at the reproductive health status of pregnant
inmates in the State of Georgia, and chair of the
Cross-Center Corrections Work Group. She has a
bachelor’s degree in international relations/Latin

78

American studies from the University of New
Mexico and a master’s degree in international public health with a concentration in administration and
management from the University of Alabama at
Birmingham. She served as a U.S. Peace Corps volunteer in Honduras from 1990 to 1991. Ms. de
Ravello served as a member of the NCCHC–NIJ
expert panel on chronic disease.
PETER FINN, M.A., is a research associate at Abt
Associates Inc. He received his B.A. in history
from Harvard College and M.A. in history from
the University of California at Berkeley. The U.S.
Department of Justice, National Institute of Justice
(NIJ), has published his series of reports on life skills
programs for prison and jail inmates and job placement programs for ex-offenders. In 2000, NIJ published Addressing Correctional Officer Stress:
Programs and Strategies, a companion report to
his study, Developing a Law Enforcement Stress
Program for Officers and Their Families, also published by NIJ. Mr. Finn was part of the research
team that visited prisons and interviewing health
care administrators and providers as part of Abt
Associates’ comprehensive assessment of prison
health services in Washington State. He served as
technical writer for the NCCHC–NIJ The Health
Status on Soon-To-Be-Released Inmates project.
JUARLYN L. GAITER, Ph.D., is a supervisory
behavioral scientist in the Behavioral Intervention
Research Branch at the Center for Disease Control
and Prevention. She received her master’s and Ph.D.
in experimental child psychology from Brown
University and certification as a clinical psychologist
at the George Washington University. Dr. Gaiter initiated and established the first HIV/AIDS Prevention
research project for prison populations at the CDC.
She has written and coauthored articles in this area
and has held a number of research and management
positions during her 10-year career in public health.
Her research interests focus on maternal and child
health, faith, health and healing, pediatric and developmental psychology, and the effects of racism on
health outcomes for African-Americans. She served
as a member of the NCCHC–NIJ expert panel on
mental illness.
ANDREW L. GOLDBERG, M.A., is a social science analyst in the Office of Research and Evaluation

at the National Institute of Justice. He received his
B.A. from Drew University in political science in
1990 and his M.A. from the University at Albany
(NY) in criminal justice in 1992. At NIJ, Mr.
Goldberg’s areas of focus include correctional health
care, sentencing, and adjudication research projects.
He served as a member of the steering committee
for the NCCHC–NIJ project on The Health Status
of Soon-To-Be-Released Inmates.
RODERIC GOTTULA, M.D., is an assistant professor in the department of family medicine at the
University of Colorado Health Sciences Center.
He is immediate past president of the Society of
Correctional Physicians. He received his M.D. at
the University of Nebraska College of Medicine in
1975, and completed his family medicine residency
at Iowa Lutheran Hospital in Des Moines, Iowa, in
1978. From 1991 to 1995, Dr. Gottula served as the
medical director for the Colorado Department of
Corrections. He has remained active in the area of
health care and criminal justice. He has lectured at
national and local conferences on criminal justice
and health care. He served as a member of the
NCCHC–NIJ expert panel on chronic disease.
ROBERT B. GREIFINGER, M.D., is a medical
management consultant. His work focuses on the
design, management, quality improvement, and
utilization management systems in managed care
organizations and correctional health care systems.
He has extensive experience in the development and
management of complex community and institutional
health care programs, and demonstrated strengths in
leadership, negotiation, communication, and the
bridging of clinical and public policy interests. His
current clients include managed care organizations
and state and local correctional systems. He has a
variety of assignments as a court-appointed expert to
investigate and design remedies for ailing correctional health care systems. Dr. Greifinger has published
extensively in the area of correctional health care.
He is a frequent speaker on public policy, communicable disease control, and quality management in
corrections. He works closely with the National
Committee for Quality Assurance (NCQA) and sits
on a variety of national health care advisory committees. Through NCCHC, Dr. Greifinger is the
principal investigator for the NIJ-funded project on
The Health Status of Soon-To-Be-Released Inmates.

79

THEODORE M. HAMMETT, Ph.D., is a Vice
President at Abt Associates Inc., a leading policy
research firm with headquarters in Cambridge,
Massachusetts. Dr. Hammett’s work has focused on
public health, corrections, and criminal justice. Since
1985, he has directed a series of nine national studies of HIV/AIDS, STDs, and TB in correctional
facilities under the joint sponsorship of the National
Institute of Justice, U.S. Department of Justice and
the Centers for Disease Control and Prevention
(CDC). He is coprincipal investigator of the evaluation and program support center for seven grants to
States for enhancement of HIV prevention, treatment, and continuity of care in correctional settings.
He is also directing an evaluation of the Hampden
County (Massachusetts) correctional centers public
health model of correctional health care. Dr.
Hammett has spoken before national and international conferences, testified before the National
Commission on AIDS, and participated in an invited
consultation on HIV/AIDS in Prisons at the World
Health Organization in Geneva. He has published
many books, articles, and reports on HIV/AIDS,
TB, and STDs as they affect criminal justice agencies,
inmates, and drug-involved populations. Dr. Hammett
served as a member of the NCCHC–NIJ expert panel
on communicable disease.
EDWARD A. HARRISON, M.M., CCHP, is president of the National Commission on Correctional
Health Care, overseeing a not-for-profit organization
that develops programs and policies aimed at
improving the delivery and quality of health services
in detention and correctional facilities throughout the
United States. He has spoken and written extensively
on public health and correctional health care matters,
addressing State legislatures; county commissioners;
the United States Congress; and public and private
local, State, and national agencies. In advocating
higher quality correctional medical services, Mr.
Harrison has focused the NCCHC’s resources on
improved standards for health services delivery,
more educational opportunities and better recognition
for correctional health care professionals, increased
quality assessment and improvement programs for the
field, and greater research and better understanding
of all aspects of correctional health care. He earned
his master’s of management from Northwestern
University’s J.L. Kellogg Graduate School of
Management. Mr. Harrison served as a member of

the steering committee for the NCCHC–NIJ project
on The Health Status of Soon-To-Be-Released
Inmates.
HOLLY A. HILLS, Ph.D., is an associate professor
in the department of community mental health at the
Louis de la Parte Florida Mental Health Institute,
University of South Florida (USF). She is a licensed
clinical psychologist who received her Ph.D. in clinical and health psychology from the University of
Florida. Since joining the USF faculty in 1990, Dr.
Hills has conducted research and supervised clinical
work that focused on individuals with comorbid
mental illness and substance use disorders. Over
much of the past decade she has worked with the
Florida Department of Corrections as a lead consultant in the development and evaluation of prison-based
residential treatment programs for male and female
inmates with co-occurring disorders. Dr. Hills has
been a collaborator and consultant on the national
GAINS Center project, a Federal partnership that
promotes improved services for people with cooccurring disorders in the justice system. Her recent
efforts include being awarded funds by the Center for
Substance Abuse Treatment (CSAT) as a coinvestigator to develop a practice and research collaborative
(PRC) in the Tampa Bay area. This initiative seeks to
improve collaboration among researchers, practitioners, policymakers, and criminal justice personnel
who work with substance-involved individuals in the
justice system. Dr. Hills served as a member of the
NCCHC–NIJ expert panel on mental illness.
MARTIN F. HORN, M.A., is the former
Pennsylvania Secretary of Corrections. He has 30
years of varied corrections experience, having served
as a parole officer, senior parole officer, director of
parole operations and executive director and chief
operating officer for the New York State Division of
Parole. He also was assistant professor of criminal
justice at State University College at Utica, N.Y. Mr.
Horn served as director of temporary release, assistant commissioner, and prison superintendent for the
New York Department of Correctional Services. He
earned a bachelor’s in government from Franklin
and Marshall College in Lancaster, Pennsylvania,
and a master’s in criminal justice from John Jay
College, City University of New York. He serves
as vice chairman of the Law Enforcement and Corrections Technology Advisory Committee, and is a
member of the American Correctional Association, the

80

Association of State Corrections Administrators, and
the Pennsylvania Prison Wardens Association. Mr.
Horn served as a member of the NCCHC–NIJ expert
panel on mental illness.
CARLTON A. HORNUNG, Ph.D., M.P.H., is professor of medicine; director of the Center for
Epidemiology and Clinical Investigation; and director
of the clinical research, epidemiology, and statistics
training program at the University of Louisville
School of Medicine. Dr. Hornung completed his
bachelor’s at the State University of New York at
Buffalo, his master’s and Ph.D. degrees at the
Maxwell Graduate School of Syracuse University,
and his postdoctoral and master’s of public health
training at the Johns Hopkins University. Before
moving to the University of Louisville in 1997, Dr.
Hornung was professor of medicine and adjunct professor of epidemiology and biostatistics at the
University of South Carolina. He has served as visiting professor of medicine at the University of
Medicine and Pharmacy in Cluj-Napoca, Romania,
and as member of the Romanian National Advisory
Committee on Cardiovascular Disease. His research
interests focus on atherosclerotic vascular disease. He
was a vanguard investigator for the NIH Antihypertensive, Lipid Lowering to Prevent Heart Attack
Trial (ALLHAT) and a coinvestigator in the New
Approaches to Coronary Intervention (NACI)
Registry. He has authored or coauthored more than
70 peer-reviewed publications and more than 200
abstracts. Dr. Hornung served as a member of the
NCCHC–NIJ expert panel on chronic disease.
T. STEPHEN JONES, M.D., M.P.H., has been
the associate director for science of the Centers for
Disease Control and Prevention (CDC), Division of
HIV/AIDS Prevention—Intervention Research and
Support since 1997 and has been the special assistant for substance abuse and HIV prevention in the
Division of HIV/AIDS Prevention since 1990. He
has worked on HIV prevention related to drug injection since 1987, with major interests in HIV serologic
studies of injection drug users (IDUs), HIV
counseling and testing in drug treatment programs,
evaluation of syringe exchange programs, and making sterile injection equipment more available to
IDUs. From 1979 to 1987 he worked on CDC international health programs promoting childhood
immunization in Latin America and child survival
programs in Africa. He participated in the World
Health Organization’s smallpox eradication programs

in India, Bangladesh, and Somalia. He received his
M.D. from Columbia University, and his M.P.H.
at the University of Michigan. Dr. Jones served as a
member of the NCCHC–NIJ expert panel on communicable disease.
CAPTAIN NEWTON KENDIG, M.D., Medical
Director, Federal Bureau of Prisons (BOP), began
his career with the Bureau of Prisons as the chief
physician and the chief of infectious diseases at the
Central Office in 1996. Before transferring to the
BOP, Captain Kendig was the medical director of the
Maryland Division of Corrections from 1991 to 1996.
He completed his internship/residency in internal
medicine at the University of Rochester Strong
Memorial Hospital in Rochester, New York, in 1986.
He completed his fellowship in infectious diseases at
Johns Hopkins University in Baltimore, Maryland,
and was a clinical associate of the U.S. Public
Health Service at the National Institute of Aging,
National Institutes of Health, Baltimore, Maryland.
Captain Kendig has received numerous awards,
including Outstanding Service Medal 1998, Outstanding Unit Citation 1998, Commendation Medal
1997, Unit Commendation 1997, and Alpha Omega
Alpha Honor Society 1983. Captain Kendig served
as a member of the NCCHC–NIJ expert panel on
communicable disease.
LAMBERT N. KING, M.D., Ph.D., is the medical
director and senior vice president for medical and
academic affairs of St. Vincent’s Hospital and
Medical Center of New York. He is also vice dean
and professor of clinical community and preventive
medicine at New York Medical College. Dr. King
received his B.A. in the honors program from the
University of Kentucky where he was elected to Phi
Beta Kappa. Dr. King received his M.D. and Ph.D.
in experimental pathology from the University of
Chicago in 1971. He completed a residency in internal medicine at Cook County Hospital in 1974 and
is a Diplomate of the American Board of Internal
Medicine. He is a Fellow of The New York Academy
of Medicine. Dr. King has made numerous presentations and published extensively concerning health
care delivery needs and systems in jails and prisons.
He contributed to the identification of B19 parvovirus
as a treatable cause of aplastic anemia in patients
with HIV infection. Dr. King has been a consultant
or director for numerous advisory boards and committees, and has served as a member of a court-appointed
physician panel and as special master reviewing the

81

medical care provided at Menard Correction Center
in Illinois. He has served as cochairman of the New
York State AIDS Center Liaison Committee since
1988 and the New York AIDS Center Advisory
Committee since 1997. Dr. King served as a member of the NCCHC–NIJ expert panel on chronic
disease.
JULIE R. KRAUT, Ph.D., is a prevention effectiveness postdoctoral fellow at the Centers for Disease
Control and Prevention. She received her Ph.D. in
economics from Pennsylvania State University in
1998. She is based in a health services research and
evaluation group in the Division of Sexually Transmitted Diseases (STD) Prevention. During her tenure
at CDC, she has conducted economic and demographic analyses of access to care and health care
utilization issues, and taught economic analysis
methods including cost-benefit, cost-effectiveness,
and cost-utility analysis methods. Dr. Kraut was a
facilitator for the preconference skill-builder at the
Prevention ’99 Conference and for the Prevention
Effectiveness Methods Course taught at CDC. Dr.
Kraut presented at the 1999 Population Association
of America Meeting and did a poster presentation at
the 1999 International Society for Sexually Transmitted Diseases Research Meeting. Her work on estimating the costs and benefits of various screening
and treatment strategies for STDs in incarcerated
populations resulted in her serving as a consultant
to the NCCHC–NIJ expert panel on communicable
disease.
ROBERT LYERLA, Ph.D., is an epidemiologist
in the Hepatitis Branch, Division of Viral and
Rickettsial Diseases at the Centers for Disease
Control and Prevention. He received his B.S. in biochemistry from Bradley University, and his Ph.D. in
Statistics from Southern Illinois University. He is a
former member of the CDC’s Epidemic Intelligence
Service, Class of 1995, serving in Russia (diphtheria
epidemic), Copenhagen, and Madrid as well as with
the Atlanta Olympic Games Health Staff. His research focuses on hepatitis in dialysis units, among
injecting drug users, incarcerated individuals, and
other high-risk groups. He is an officer in the Commissioned Corps of the United States Public Health
Service. Dr. Lyerla served as a member of the
NCCHC–NIJ expert panel on communicable disease.

MAUREEN MANGOTICH, M.D., M.P.H., is a
medical director for Pfizer Health Solutions (PHS).
She works on clinical content development for a
proprietary disease management application and
other custom development projects and provides
clinical sales and implementation support for PHS
disease management programs. Before joining
Pfizer, Dr. Mangotich developed procedure-based
appropriateness guidelines at Value Health Sciences
(now Protocare Sciences). Her medical management
experience includes positions at Health Alliance
Plan (associate medical director for quality improvement) and Aetna Health Plans (corporate medical
director for provider quality). She frequently lectures
on quality improvement in health care. She has been
a National Committee for Quality Assurance (NCQA)
surveyor since 1991, is a member of the NCQA Review
Oversight Committee (ROC), and serves on the planning committee and faculty for NCQA’s Credentialing
and Delegation conferences. Dr. Mangotich is a
board-certified general internist who completed her
internal medicine residency and a master’s in public
health at University of California, Los Angeles. She
received her M.D. from the University of Arizona.
She served as a member of the NCCHC–NIJ expert
panel on chronic disease.
FRED A. MARTICH, B.S., has been the deputy
chief of the Behavioral Interventions and Research
Branch, Division of STD Prevention, Centers for
Disease Control and Prevention in Atlanta, Georgia,
since October 1998. He has served as chairman of
CDC’s Cross Centers Correctional Work Group and
is currently a member of the Planning Committee
for this group. Before his current position, he was
deputy chief of HIV Prevention Operations for 2
years. Before that, he served as project officer for
STD/HIV prevention with State health departments
and community-based organizations for 10 years.
He worked in STD prevention field assignments
with CDC for 23 years in Ohio, Chicago, Wisconsin,
and Alabama. He received his B.S. from Duquesne
University in Pittsburgh, Pennsylvania, and attended
graduate studies in public administration at Oshkosh
University in Oshkosh, Wisconsin. He served as a
member of the NCCHC–NIJ expert panel on communicable disease.

82

ERIC E. MAST, M.D., M.P.H. is chief of the
Surveillance Unit, and acting chief of the Prevention
Research Unit in the Hepatitis Branch at the Centers
for Disease Control and Prevention. He received his
A.B. in Biology at the University of Illinois in Urbana,
his M.D. at the University of Illinois in Chicago/Peoria,
and his M.P.H. at the Harvard School of Public
Health. His postgraduate training included a pediatric residency at the University of Wisconsin and
a preventive medicine residency at the Centers for
Disease Control and Prevention (CDC). From 1985
to 1987 he was medical program director for Save
the Children in UmRuwaba, Sudan. He joined the
CDC in 1987 as an epidemic intelligence service
officer and he has worked in the Hepatitis Branch
since 1990. He has published numerous articles on
the epidemiology and prevention of viral hepatitis.
Dr. Mast served as a member of the NCCHC–NIJ
expert panel on communicable disease.
W. PAUL MCKINNEY, M.D., is the V.V. Cooke
Professor of Medicine and chief of the Division of
General Internal Medicine and Geriatrics, Department
of Medicine, at the University of Louisville. He is
also the director, Center for Health Services and
Policy Research, and acting director of the Institute
for Public Health Research at that institution. Dr.
McKinney completed his M.D. at the University of
Texas/Southwestern Medical School at Dallas and
his internship and residency at the University of
Minnesota, Minneapolis-St. Paul. From 1996 through
1999 he was editor of the SGIM Forum, the national
newsletter for the Society of General Internal Medicine
and served as an ex officio member of their council. In
1999, he also served as a U.S. Public Health Service
Primary Care Policy Fellow representing SGIM. He
has active interests in health services research and
research involving medical informatics, clinical epidemiology, and preventive services delivery. Since
1998, Dr. McKinney has been a liaison member of
the Advisory Committee on Immunization Practices
of the Centers for Disease Control and Prevention.
He served as a member of the NCCHC–NIJ expert
panel on chronic disease.
JOHN R. MILES, B.A., M.P.A., is the Special
Assistant for Corrections and Substance Abuse,
Office of the Director, National Center for HIV/
AIDS, STD, and TB Prevention. His assignments as
a public health advisor with CDC span a career of

33 years and have included diverse public health
program development and management experiences
from grassroots community crossroads to the large
urban centers of Chicago and New York City. Before
his assignment with CDC in Atlanta, he spent 12
years with the New York City Department of Health
as Program Coordinator STD Control, AIDS Program Director, and Assistant Director and Director
of the Bureau of STD Control. As Special Assistant
for Corrections and Substance Abuse, he works to
develop and strengthen effective intra-agency collaborations between the Department of Health and
Human Services and Department of Justice agencies, and national, State, and local organizations to
effect policies that will improve access and continuity of care for HIV, STD, and TB among drug users
and incarcerated populations. Mr. Miles received
his master’s of public administration from Baruch
College, City University of New York, and a B.A.
from the University of Kansas. He served on the
steering committee for the NCCHC–NIJ project on
The Health Status of Soon-To-Be-Released Inmates.
MARILYN C. MOSES, M.S., has been a social
science program analyst with the National Institute
of Justice (NIJ) since June 1991. Ms. Moses has
been the NIJ program manager for “The Health
Status of Soon-To-Be-Released Inmates” project.
Ms. Moses has a bachelor’s in paralegal studies
from the University of Maryland and a master’s in
criminal justice from the University of Baltimore.
She is working on a second master’s in publication
design. Ms. Moses specializes in correctional health
care, female offenders, children of incarcerated
parents, correctional industry enhancement, the
development of public-private criminal justice partnerships, correctional training and education,
offender job training and placement, offender reentry, mental health in corrections, correctional officer
stress, and rural crime and policing. Ms. Moses has
published widely in these areas. Ms. Moses was
cited as one of the “Best in the Business” by the
American Correctional Association for her work on
behalf of children of incarcerated parents. She is the
creator and editor for Civic Research Institute’s
Offender Employment Report—a first-of-its-kind
publication that is published six times per year. She
served on the steering committee for the NCCHC–
NIJ project on The Health Status of Soon-To-BeReleased Inmates.

83

PRADAN A. NATHAN, M.D., is the associate
division director for health services at the Texas
Department of Criminal Justice. He received his
medical degree from Madurai University Medical
College in India. He completed residencies in psychiatry at the National Institute of Mental Health
and Neurosciences in India and the Texas Research
Institute of Mental Sciences at Houston, Texas, and
he completed a fellowship in forensic psychiatry at
University Hospitals, Cleveland, Ohio. Dr. Nathan
has worked in court psychiatric clinics, community
mental health centers and state hospital systems,
and private practice. He has been associated with
the Texas Department of Criminal Justice as a unit
psychiatrist, a regional psychiatrist, and a clinical
director of a 550-bed psychiatric inpatient unit. He
is an instructor in institutional and correctional
health, Departments of Preventive Medicine and
Community Health at University of Texas Medical
Branch at Galveston. He is board certified in
general psychiatry and forensic psychiatry by the
American Board of Psychiatry and Neurology. Dr.
Nathan served as a member of the NCCHC–NIJ
expert panel on mental illness.
MARGARET J. OXTOBY, M.D., is director of the
Bureau of Tuberculosis Control at the New York
State Department of Health. Since coming to the
TB Program in 1993, she has worked closely with
the New York State Department of Correctional
Services in developing effective TB prevention and
control activities in the state prison system. She
received her B.A. from Harvard University and her
M.D. from Case Western Reserve University. She
completed a pediatric residency at Duke University
and a preventive medicine residency at the Centers
for Disease Control and Prevention, where she
worked as a medical epidemiologist focusing first
on bacterial diseases and later on pediatric AIDS.
Dr. Oxtoby served as a member of the NCCHC–NIJ
expert panel on communicable disease.
JOSEPH E. PARIS, Ph.D., M.D., CCHP, obtained
his M.D. from Boston University and is board certified
in internal medicine. He began his career in correctional medicine in 1985 in the Florida Department
of Corrections. In 1995, he came to the Georgia
Department of Corrections in Atlanta and became
statewide medical director. Dr. Paris is a founding
member and the 1999–2000 President of the Society

of Correctional Physicians. He is a past president of
the Florida Chapter of the American Correctional
Health Services Association (ACHSA), a Certified
Correctional Health Professional, and the author
of more than 50 specialized correctional publications or national presentations, including three
chapters in Clinical Practice in Correctional
Medicine. He organized and hosted the 1999 ACHSA
Multidisciplinary Conference in Atlanta, Georgia.
Dr. Paris served as a member of the NCCHC–NIJ
expert panel on chronic disease.
MICHAEL PUISIS, D.O., is corporate medical
director for Addus HealthCare’s Correctional
Division. He is the editor of Clinical Practice in
Correctional Medicine. He participated on the task
force for standards revision for the 1996 NCCHC
jail standards and served on the committee to revise
the correctional health care standards for the American
Public Health Association. Dr. Puisis served as a member of the advisory board for the evaluation of the
Centers for Disease Control and Prevention guidelines for TB control in jails in 1999. Dr. Puisis
served as a member of the NCCHC–NIJ expert
panel on chronic disease.
DIANNE RECHTINE, M.D., CCHP–A, is a medical executive director for the Florida Department
of Corrections. Her duties include managing the
health care for approximately 15,000 offenders
housed in several major institutions. Dr. Rechtine
received her undergraduate and medical education
at West Virginia University. She is a Fellow of the
American Academy of Family Physicians and practiced in southwest Florida before coming to work
for the prison system 14 years ago. She has been a
physician surveyor for the National Commission on
Correctional Health Care for several years and
serves on their Surveyor Advisory Committee. She
has served as a member of the Standards Revision
Committee for the American Correctional Association.
Dr. Rechtine is a charter member of the Society of
Correctional Physicians and serves as chairman of
the Council of Chapters of the American Correctional
Health Services Association. She is certified as a
Correctional Health Professional and has achieved
Advanced status. She is chairman of the Florida
Department of Corrections Continuing Medical
Education, was chairman of the Committee for
Chronic Care, and has been a faculty member of

84

the Mini-Residency Program for Correctional HIV
since its inception 3 years ago. Dr. Rechtine served as
a member of the NCCHC–NIJ expert panel on
chronic disease.
BETTY RIDER, M.A., M.S., is director of managed care services for the North Carolina Division
of Prisons Health Services Section. Her correctional
health care experience includes senior management
positions with major national managed care companies providing health care to correctional facilities
and the uniformed services. In 1999 Ms. Rider served
on the joint CDC–National Tuberculosis Center
task force that developed new guidelines for TB
education/training in corrections. She is an associate
editor of HEPP News, a national journal published
by the Brown University School of Medicine’s
Correctional HIV Program. She has presented and
published extensively on correctional managed care
issues, pharmacoeconomics of antiretroviral therapies,
and correctional health care delivery systems. Ms.
Rider received a M.S. in healthcare administration
from Trinity University, a M.A. in counseling psychology from Eastern Kentucky University, and a B.A. in
social science/economics from Trinity University.
She is a member of the American Correctional
Association, the American Correctional Health Services Association, the American College of Health Care
Executives, and the Healthcare Financial Management
Association. She is a member of the National Minority HIV Council’s advisory board and served as a
member of the NCCHC–NIJ expert panel on communicable disease.
CLYDE B. SCHECHTER, M.A., M.D., is director
of medical education and associate professor in the
Department of Community & Preventive Medicine
at Mount Sinai School of Medicine, New York City.
He received his B.A. and M.A. in mathematics and
his M.D. from Columbia University. He is board
certified in internal medicine, general preventive
medicine, and public health. He has published
extensively on simulation modeling of screening
and treatment of chronic diseases including hypertension, tuberculosis, and cervical cancer. His research
interests focus on mathematical models of health
processes, and cost-effectiveness analysis, particularly as applied to population screening. He has
served on the editorial boards of Medical Decision
Making and the Mount Sinai Journal of Medicine,

and is a regular reviewer of research grants submitted to the National Board of Medical Examiners.
He has been a consultant to many corporations on
aspects of health benefit management. Dr. Schechter
served as an expert consultant to the NCCHC–NIJ
expert panel on chronic disease.
GEORGE P. SCHMID, M.D., M.Sc., is assistant
branch chief for Science, Program Development,
and Support Branch, Division of STD Prevention,
Center for HIV, STD, and TB Prevention, Centers
for Disease Control and Prevention (CDC). He is a
subspecialist in infectious diseases, with training in
internal medicine and family medicine, and has a
M.Sc. in Health Services Management from the
London School of Hygiene and Tropical Medicine.
Dr. Schmid has spent 20 years at CDC, the past 16
in the Division of STD Prevention. He has considerable experience in the epidemiologic, clinical, laboratory, programmatic, and economic aspects of STD
prevention. His position centers on the transfer of
research findings into clinical practice. He is the
coordinating editor of the STD Collaborative Review
Group within the Cochrane Collaboration; section
editor on sexual health, Clinical Evidence; and
chairman, CDC Institutional Review Board for Emergency Response. Dr. Schmid served as a member of
the NCCHC–NIJ expert panel on communicable
disease.
RONALD M. SHANSKY, M.D., M.P.H., is a consultant in correctional medicine and the Federal
court-appointed receiver for medical and mental
health services for the Washington, D.C. jail. He
received his B.S. in philosophy at the University of
Wisconsin and his M.D. from the Medical College
of Wisconsin. He has obtained a master’s in public
health and is Board certified in internal medicine
and quality assurance. He has been a surveyor for
the JCAHO and is currently a board member of the
National Commission on Correctional Health Care
(NCCHC). Dr. Shansky is a Fellow of the Society
of Correctional Physicians and was the first recipient of the Society’s Armond Start Award for
Excellence in Correctional Medicine. He is an associate editor and contributor to the textbook The Clinical
Practice of Correctional Medicine. He served as a
member of the NCCHC–NIJ expert panel on chronic
disease.

85

JONATHAN SHUTER, M.D., is the director of
clinical research in the AIDS Center of Montefiore
Medical Center. He received his M.D. from Boston
University School of Medicine. He is a member of
the Division of Infectious Diseases in the Department
of Medicine at Montefiore Medical Center. He is an
assistant professor of internal medicine at the Albert
Einstein College of Medicine. Dr. Shuter was the
director of infectious diseases for Rikers Island
Health Services between 1994 and 1997. He has published a number of articles pertaining to tuberculosis,
sexually transmitted diseases, and HIV infection
in the correctional setting. In 1998–99, Dr. Shuter
served as an expert consultant to the NCCHC–NIJ
expert panel on communicable disease.
HAL SMITH is the executive director and chief
executive officer of Central New York Psychiatric
Center and its satellite mental health clinics that
provide a comprehensive system of mental health
services to the New York State and local correctional systems. He is associate professor of administrative psychiatry at the SUNY Upstate Health Science
Center and adjunct professor of law at the Syracuse
University College of Law. He was director of forensic services for the New York State Office of Mental
Health and has held a variety of clinical and administrative positions in forensic and correctional mental
health settings. He provides mental health/criminal
justice consultation services. He was appointed to
the NCCHC–NIJ expert panel on Mental Illness.
ANNE SPAULDING, M.D., graduated from
Brown University and Medical College of Virginia.
After a residency at Brown, she moved on to a fellowship in infectious diseases at the University of
Massachusetts Medical Center, Worcester, Massachusetts, where she pursued bench research in flaviviruses. She is now on the staff at Rhode Island
Hospital and attends in an HIV clinic. She is a clinical assistant professor at Brown University School
of Medicine. She also serves as the medical program director for the Rhode Island Department of
Corrections. Dr. Spaulding is president-elect of the
Society of Correctional Physicians. Dr. Spaulding
served as a member of the NCCHC–NIJ expert
panel on communicable disease.
HENRY T. STEADMAN, Ph.D., is president of
Policy Research Associates, Inc. Previously Dr.

Steadman ran a nationally known research bureau
for 17 years for the New York State Office of Mental
Health. His work has resulted in 6 books, over 100
articles in a wide range of professional journals,
18 chapters, and many reports. Dr. Steadman’s major
research focus is persons with co-occurring disorders in the justice system, violence risk assessment,
homelessness and mental illness, and women with
co-occurring disorders. Dr. Steadman received his
B.A. and M.A. in sociology from Boston College
and his Ph.D. in sociology at the University of
North Carolina at Chapel Hill. In 1987 Dr. Steadman
received the Amicus Award from the American
Academy of Psychiatry and the Law. He also
received the Philippe Pinel Award from the International
Academy of Law and Mental Health in 1988, the
Saleem A. Shah Award in 1994 from the State Mental
Health Forensic Directors, the 1998 Distinguished
Contribution to Forensic Psychology from the American
Academy of Forensic Psychology, and the 1999 Isaac
Ray Award from the American Psychiatric Association
for his outstanding contributions to the psychiatric
aspects of jurisprudence. Dr. Steadman served as a
member of the NCCHC–NIJ expert panel on mental
illness.
STEVEN SZEBENYI, M.D., is the former head of
the Division of HIV Medicine and professor,
Department of Medicine, at Albany Medical
College in Albany, NY. He was also director of the
AIDS Treatment Center at Albany Medical Center
Hospital and medical director of the correctional
health program at Albany Medical Center. He was
extensively involved with HIV/AIDS education programs for correctional health practitioners, including a nationally broadcast videoconference series,
an HIV fellowship program, a telemedicine project
and frequent lecturing. Dr. Szebenyi was a member
of the New York State Department of Health AIDS
Institute Medical Care Criteria Committee and the
New York State Department of Correctional Services HIV Practice Guidelines Committee. He is
medical director for Blue Shield of North-eastern
New York in Albany, NY. He served as a member
of the NCCHC–NIJ expert panel on communicable
disease.
ZACHARY TAYLOR, M.D., M.S., is chief of the
Prevention Effectiveness Section, Division of
Tuberculosis Elimination, National Center for HIV,

86

STD, and TB Prevention, Centers for Disease
Control and Prevention. He received his B.S. in
chemistry at LaGrange College, his M.S. at the
University of Maryland at Baltimore, and his M.D.
at the Medical College of Georgia. His research
interests focus on the cost-effectiveness of screening for tuberculosis and evaluation of tuberculosis
control programs. Dr. Taylor served as a member of
the NCCHC–NIJ expert panel on communicable
disease.
LINDA A. TEPLIN, Ph.D., is professor of psychiatry and director of the Psycho-legal Studies Program
at Northwestern University Medical School. She
received her Ph.D. from Northwestern University in
1975. She has done research on the criminalization
of the mentally ill, epidemiologic characteristics of
jail detainees, and correlates of violence. Her honors
include the American Psychological Association’s
career award for “Distinguished Contributions to
Research in Public Policy” (1992), the MERIT Award
from the National Institute of Mental Health (1995),
and the Young Scientist Award from the National
Alliance for the Mentally Ill (1990). Dr. Teplin is
conducting two studies: (1) the Northwestern Juvenile
Project and (2) the Northwestern Victimization Project.
The Northwestern Juvenile Project is a longitudinal
study of a sample of 1,800 youth who previously
had been subjects in a study of juvenile detainees.
The project examines the changing alcohol, drug,
and mental health service needs of these high-risk
youth, their use of services, and the behaviors that
put them at increased risk for violence, IV drug
use, and HIV/AIDS. The Northwestern Victimization Project is a unique study of criminal victimization patterns among severely mentally ill persons
who live in the community. Both studies are funded
by a consortium of Federal agencies and private foundations. Dr. Teplin served as a member of the
NCCHC–NIJ expert panel on mental illness.
DAVID L. THOMAS, M.D., J.D., began his correctional career as an institutional physician, later
as a regional physician, and the Chief of Clinical
Services, and is now the Director of Health Services,
all within the Florida Department of Corrections.
From 1984 until 1994 he was a member of the
Florida House of Representatives, and he served as
the Republican Whip for 6 years. Dr. Thomas is a
Vietnam veteran who achieved the rank of Permanent
Captain (Acting Major) in the U.S. Army and was

awarded the Bronze Star. Dr. Thomas has published
two novels on drug smuggling in Florida and the Gulf
Coast, and has been lead author on several publications in peer-reviewed medical journals. Dr. Thomas
served as a member of the NCCHC–NIJ expert panel
on communicable disease.
DONNA TOMLINSON, M.D., M.Sc., is a research
fellow in preventive cardiology at Beth Israel
Medical Center in New York. She graduated from
St. George’s University, School of Medicine in
1996. She completed a preventive medicine residency at Mount Sinai Medical Center and received her
M.Sc. in community medicine from Mount Sinai
School of Medicine in 1999. She is board certified
in general preventive medicine and public health.
Her clinical interest is in the prevention of cardiovascular disease through lifestyle modifications. Her
research interests are in simulation modeling and
cost benefit analysis. Dr. Tomlinson served as a
consultant on the NCCHC–NIJ expert panel on
chronic disease.
BEENA VARGHESE, Ph.D., is a health economist
with the Division of HIV/AIDS Prevention at the
Centers for Disease Control and Prevention. She is
also member of the International Health Economic
Association and Cochrane Economics Methods
Group. She received her M.S. in agriculture economics from North Dakota State University in
1993 and her Ph.D. in health economics from the
University of Memphis in l997. In 1997–98, she
was a short-term consultant for UNAIDS, Geneva,
and the Ministry of Health, Kazakhstan. She has
presented her work at various national and international conferences. Her research interests include
decision analysis, cost-effectiveness and prevention
effectiveness methods. Dr. Varghese served as a
consultant to the NCCHC–NIJ expert panel on communicable disease.
BONITA M. VEYSEY, Ph.D., is an assistant professor in the Rutgers University School of Criminal
Justice and the director of the Center for Justice and
Mental Health Research. Dr. Veysey worked as a
researcher in mental health services and corrections
policies for 15 years before joining the Rutgers faculty. She served as both the associate director and
the director of the Women’s Core of the National
GAINS Center for Persons with Co-occurring
Disorders in the Criminal Justice System. She has

87

participated in several national advisory groups on
issues relating to the supervision and treatment of
offenders’ mental illnesses. Her research interests
include interactions between the mental health and
criminal justice systems, correctional supervision of
female offenders, and public health risks as they relate
to continuity of care. She received her doctorate in
sociology from the State University of New York at
Albany in 1993. Dr. Veysey served as a consultant
to the NCCHC–NIJ expert panel on mental illness.
RICH VOIGT, M.A., is assistant to the branch chief,
Division of STD Prevention, Centers for Disease
Control and Prevention. He received his M.A. in sociology at Wichita State University, Wichita, Kansas.
His program interests focus on providing technical
assistance for implementing early health screening
and treatment services for incarcerated people. He
served as a member of the NCCHC–NIJ expert panel
on communicable disease.
HENRY C. WEINSTEIN, M.D., is the director of
the program in Psychiatry and the Law at New York
University Medical Center and the Bellevue Hospital
Center. For more than 20 years he was the director
of the Forensic Psychiatry Service (the psychiatric
prison ward) at Bellevue. He represents the American
Psychiatric Association on the Board of Directors of
the National Commission on Correctional Health
Care and is the president of the Caucus of Psychiatrists
Practicing in Criminal Justice Settings. He chaired
the APA Task Force that revised the APA Guidelines
on Psychiatric Services in Jails and Prisons. Dr.
Weinstein served as a member of the NCCHC–NIJ
expert panel on mental illness.

LAURA WINTERFIELD, Ph.D., joined the
Office of Research and Evaluation of the National
Institute of Justice in August 1997 where she managed the drug treatment portfolio and developed
researcher-practitioner partnerships. She has been
Division Director for the Justice Systems Divisions
since mid-l999. From 1984 to 1993, she worked at
the Vera Institute researching career criminals, evaluating prosecutorial and court-based innovations,
and assessing the appropriateness and effectiveness
of New York City’s alternative-to-incarceration programs. From 1993 to 1997, she worked at the New
York City Criminal Justice Agency. She developed a
release-on-recognizance prediction tool for adult
court arraignment judges and predictive tools for
identifying offenders most likely to receive a
sanction within the range targeted for an alternative
disposition. She has been actively involved in all
aspects of criminal justice research since the early
1970s, including courts, field services, alternatives
to incarceration, and treatment approaches. Her
areas of expertise include delinquency and crime
prevention, the development of prediction models
for criminal justice decisionmaking, estimating the
impacts of diversion programs on incarceration, and
evaluation research. She received her Ph.D. in sociology from the University of Colorado. Dr. Winterfield
served on the steering committee for the NCCHC–
NIJ project on The Health Status of Soon-To-BeReleased Inmates.

89

Appendix C. Prevalence of Chronic Diseases
and Chronic Mental Disorders in Prisons:
NCCHC/NIJ Survey Instrument
Name of Prison System: ____________________________________________________________________
Person Responding:
Name: ___________________________________________________________________________________
Title: ____________________________________________________________________________________
Address: _________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Telephone:Voice (_____)_______-_________ Fax (_____)_______-___________
E-mail: __________________________________________________________________________________

I. Population
Number of Facilities: _________
Today’s Population: __________(Total)
Avg. Daily Census: __________ (Total)
Total Annual Intake: ____________ (Most recent year available: ______)
Total Annual Releases: __________ (Most recent year available: ______)
Is there a computerized system for recording inmate demographic data?

______Yes

______No

Do you have the capability of determining the current population by their
demographic characteristics?

______Yes

______No

90

If yes,
Can you determine the population by gender?

______Yes

______No

Can you determine the population by race (e.g., White, African American,
Hispanic, other)?

______Yes

______No

Can you determine the population by age?

______Yes

______No

Can you break down the population by age, race, and gender (i.e.,
number of white males less than 40 yrs old)?

______Yes

______No

II. Chronic Diseases
In this section we are interested in collecting information about inmates with chronic conditions (particularly
asthma, diabetes, hypertension, and heart disease).
1. Some systems designate certain facilities for housing inmates with specific chronic diseases or cluster
inmates with chronic conditions in certain facilities. Does your system designate one or more facilities to
manage inmates with chronic diseases, or do you cluster inmates with chronic conditions in certain facilities or, do all of your facilities usually manage all of their own inmates with chronic medical conditions?
_______In our system, certain facilities are designated for inmates with chronic diseases.
_______We do not designate facilities for care of chronic conditions but we cluster inmates in certain facilities.
_______We do not transfer or house inmates in specific facilities for routine care of chronic medical
conditions such as asthma, diabetes, hypertension, or heart disease.
2. Except for those who refuse, do you routinely test or screen inmates at intake for:
Fasting Blood Sugar ______Yes

______No

Blood Pressure ______Yes

3. By policy, do you provide hepatitis B vaccine to all susceptible inmates?

______Yes

______No
______No

4. Do you have data on the number of inmates (i.e., the prevalence) with chronic diseases by diagnoses?
______Yes
______No
If yes, how many, or what percent, of inmates in your system have been diagnosed with the following
chronic conditions?
Number
of Inmates
Asthma

-or-

______

Percent
of Inmates
______%

Diabetes (Types 1 and 2)

______

______%

Hypertension

______

______%

Heart Disease

______

______%

5. Can you determine the number of inmates in your system with chronic
diseases according to their age, race, gender, and diagnosis?

______Yes

If yes, please complete the following table with the most recent data you have available.

______No

91

PREVALENCE OF CHRONIC DISEASES
Number
of Inmates
Asthma

Gender:
Age:
Race:

Diabetes (Type 1 and 2)

Gender:
Age:
Race:

Hypertension

Gender:
Age:
Race:

Heart Disease

Gender:
Age:
Race:

-or-

Percent
of Inmates

Male
Female
<40
≥40
White
Black
Hispanic
Other

________
________
________
________
________
________
________
________

________%
________%
________%
________%
________%
________%
________%
________%

Male
Female
<40
≥40
White
Black
Hispanic
Other

________
________
________
________
________
________
________
________

________%
________%
________%
________%
________%
________%
________%
________%

Male
Female
<40
≥40
White
Black
Hispanic
Other

________
________
________
________
________
________
________
________

________%
________%
________%
________%
________%
________%
________%
________%

Male
Female
<40
≥40
White
Black
Hispanic
Other

________
________
________
________
________
________
________
________

________%
________%
________%
________%
________%
________%
________%
________%

Please indicate the source and time period from which the above data are taken.
Time Period ____________ intake History and Physical _______ other Medical Record Data_______
6. Do you have systemwide clinical protocols for the management of:
Asthma

______Yes

______No

Diabetes

______Yes

______No

Hypertension ______Yes

______No

Heart Disease ______Yes

______No

If yes, please include a copy of the relevant protocols with your completed survey.

92

7. For the most recent time period for which data are available, can you provide the number of inmates who
were taking the following medications?
a. Inhaled asthma meds (e.g., beta-agonists) _______
b. Insulin or oral hypoglycemic

_______

c. Anti-hypertensive medications

_______

d. Anti-ischemic agents

_______

e. Anti-arrhythmic

_______

Indicate time period for the above data:

_______

8. Are your pharmacy data computerized?

______Yes

______No

9. Do you have a policy and procedure on discharge planning for patients
with chronic diseases?

______Yes

______No

If yes, please include a copy of the relevant discharge planning policies and procedures
with your completed survey.
10. Are inmates with chronic medical conditions given a supply of
medication when they are released?

______Yes

______No

If yes, please include a copy of your policies and procedures for releasing inmates with
medications with your completed survey.
11. Could you determine which inmates have been released within the past
6 months?

______Yes

______No

If yes, please provide a list of inmates released within
the past 6 months broken down by age, race, and gender.

______Yes

______No

Could you identify inmates released within the past 6 months by diagnosis
of chronic conditions?

______Yes

______No

Name of person completing this section:______________________________________________________
Telephone number (_______) ____________-____________

III. Mental Health
In this section we are interested in collecting information about inmates with mental disorders in your system.
1. Some systems designate certain facilities for housing inmates with mental disorders. Does your system
designate one or more facilities to manage inmates with mental disorders, or do all or most of your
facilities manage all of their own inmates with mental disorders?
______ In our system, certain facilities are designated for inmates with mental disorders.
______ We do not transfer or house inmates in specific facilities for routine care of mental disorders.
2. Do you have data on the number of inmates with mental
disorders by diagnoses (i.e., prevalence)?
If yes, are diagnoses classified by DSM–IV using Axis 1, 2, and 3?
If no, how are diagnoses classified?

______Yes

______No

______Yes

______No

93

3. How many inmates are there in your system with each of the following diagnoses?
(Count only one diagnosis per person.)
Number

-or-

Percent

A. Chronic Mental Illness

1. Schizophrenia
2. Schizo/Affective Disorder
3. Psychotic Disorder (NOS)

________
________
________

________%
________%
________%

B. Affective Disorders

1. Major Depression
2. Bipolar Disorder
3. Dysthyrnic Disorder

________
________
________

________%
________%
________%

C. Anxiety

1. Panic Disorder

________

________%

2. PTSD

________

________%

________

________%

________

________%

D. Delusions, Dementia, and Amnesia 1. Cognitive Disorders
2. Organic Brain Syndrome

Please indicate the source and time period from which the above data are taken.
Time Period ____________ intake History and Physical _______ other Medical Record Data _______
4. Among the inmates with diagnosed mental disorders, how many or what percent have a co-occurring:
A. Alcohol Disorder

________

or

______%

B. Substance Dependency Disorder

________

or

______%

5. Is the information on the mental disorders kept in a computerized database?
_____Yes

______No

If no, please indicate the period and source of the information on prevalence given above (i.e., record
review, etc.).__________________________________________________________________________
6. Could you determine the prevalence of the mental disorders listed in item 3 according to:
A. Age of inmate

______Yes

______No

B. Gender

______Yes

______No

C. Race

______Yes

______No

D. Age/race/gender (e.g., number of white males less than 40 years old)

______Yes

______No

7. Do you have statewide protocols or guidelines for the management of inmates
with mental disorders?
______Yes

______No

If yes, please forward a copy of these protocols or guidelines for the conditions in item 3 along, with your
completed survey.
8. Do you have statewide policies and procedures for discharge planning of
inmates with mental disorders?

______Yes

______No

If yes, please forward a copy of these protocols or guidelines for the conditions in item 3 along with your
completed survey.

94

9. Is it your policy to give inmates with chronic mental disorders a supply
of medication on release?

______Yes

______No

If yes, please forward a copy of these protocols or guidelines for the conditions in item 3 along with
your completed survey.
10. Can you identify inmates with chronic mental disorders who have been released within the past:
A. 3 months

______Yes

______No

B. 6 months

______Yes

______No

C. 12 months

______Yes

______No

Name of person completing this section: _______________________________________________________
Telephone number (_______) ____________-____________

95

Appendix D. Sample Draft Clinical Guidelines

The sample guideline “Asthma Chronic Care” was
drafted by Ronald M. Shansky, M.D., M.P.H., and is
presented here in draft form. Once adopted by the
National Commission on Correctional Health Care,
it will become part of the NCCHC Clinical Guideline
Series. The Clinical Guideline Series is spearheaded
by a panel of correctional health physicians representing the NCCHC and The Society of Correctional
Physicians (SCP), including Glenn Johnson, M.D.,
CCHP–A (chair); Lannette Linthicum, M.D.,

CCHP; James McAuley, M.D., M.P.H.; Joseph
Paris, M.D., Ph.D., CCHP; Michael Puisis, D.O.;
John Robertson, M.D.; and Ronald Shansky, M.D.
The sample guideline “Minimum Standards for
Care of Chronic Disease in Prison” was prepared
by Robert B. Greifinger, M.D., for this project and is
currently under consideration for adoption by the
NCCHC and the SCP.

97

National Commission on Correctional Health Care
Recommended Correctional Clinical Guideline
Asthma Chronic Care
Ronald M. Shansky, M.D., M.P.H.

Introduction
Correctional settings tend to house large numbers of
patients with asthma, and the phenomenon can lead
to serious problems with morbidity and mortality.
This Recommended Correctional Clinical Guideline
on Asthma Chronic Care is the result of modifications to The Expert Panel Report: Guidelines for
the Diagnosis and Management of Asthma, National
Asthma Education Program. The modifications
were designed to simplify and be more cautious due
to the special challenges of providing services in the
correctional setting.

Background
Over the last two decades, much has been learned
about asthma. In particular, health professionals
have come to understand that asthma is primarily
an inflammatory process that results in susceptible
individuals having recurrent episodes of coughing,
wheezing, chest tightness, and difficulty in breathing. Inflammation is thought to sensitize the airways to a variety of stimuli, such as tobacco smoke,
allergens, chemical irritants, cold air, and exercise.
In treating patients, asthma specialists have learned
of the critical need to form a partnership with their
patients. Such a partnership, based on imparting to
the patient an understanding of the disease process,
better enables the patient to become aware of those
things that trigger attacks, record the use of medications and the frequency of attacks, learn proper
technique for inhaler use, learn proper use of a peak
flow meter, and learn when to consult a physician
regarding management concerns. The result has been
a significant improvement in long-term morbidity
and mortality.

Diagnosis
Asthma is defined as a disease process manifested
by reversible airway obstruction. The elements used
to make the diagnosis include history, symptomatic

March 12, 2000
episodes such as wheezing or coughing, physical
examination with findings of obstruction on auscultation, and abnormal diagnostic results such as from
peak flow meter readings, pulmonary function tests,
or chest x-rays.

Management Overview
To successfully manage this illness in the corrections
environment, NCCHC recommends categorizing
patients according to the severity of their illness. In
general, out of 100 patients with asthma, about 80–85
percent will have mild asthma. These individuals
may occasionally use a beta-agonist inhaler on an
as-needed basis or may have symptoms only during
a particular allergy season, but in general do not
require a great deal of attention. On the other hand,
15–20 percent of patients can be categorized as having moderate or severe disease, and it is these patients
on whom the correctional health care programs should
focus their energies and attention. By educating these
patients and working carefully with them, correctional settings can also achieve much improved clinical
outcomes.
It is critical that all patients be categorized on entry
to the system, and be reassessed on an ongoing
basis. The patient’s problem list should contain not
just the diagnosis of asthma, but the categorization
of the disease with regard to severity. Further, correctional health care professionals should understand
the need to educate and work with patients in a therapeutic partnership as vital to successful outcomes.

Treatment Goals
The object in working with a patient who has
asthma is to assist him or her in diminishing the
frequency of symptoms. This includes:
●

decreasing the frequency and severity of asthma
episodes,

●

minimizing medication use and side effects,

98

●

preventing emergency visits and hospitalization,

●

normalizing exercise capacity,

●

minimizing nocturnal symptoms, including
wheezing, and

a. use of 1–1.5 canisters of beta-agonist inhaler
per month,

●

preventing progression to acute respiratory
failure and death.

b. use of inhaled steroids, or

Success in minimizing symptoms requires providerpatient teamwork in understanding what is needed
regarding medications, patient education, monitoring
with peak flow meters, and environmental controls
(e.g., smoking cessation, smoke-free environments, etc.).

2. Moderate asthma. A patient can be categorized as
moderate if any of the following are true:

c. the observation of peak flow decrease during
an acute attack to 40 percent or less of personal best.
3. Severe asthma. A patient should be categorized as
severe if any of the following are true:
a. history of intubation or ICU admission,

Assessment on Entry to the System

b. more than two hospitalizations in previous
year,

There are three aspects of assessment upon a
patient’s entry into the correctional system.

c. use of systemic steroids for greater than a
2-week period of time,

1. Initial History. The history with regard to asthma
should include age of onset, hospitalizations, intubations, frequency of emergency room visits, prior
use of inhaled steroids, prior use of systemic steroids,
current medication use including the number of
canisters of beta-agonist inhalers per month and
the number of puffs of inhaled steroids per day, as
well as the personal best peak flow measure at
home. The history should also include questions
regarding sinus infections, allergies, seasonal
attacks, smoking history, and a history of gastrointestinal reflux.

d. decrease of peak flow to less than 30 percent
of personal best during acute attack, or

2. Physical Exam. The physical exam should include
a complete set of vital signs, a full physical
exam with a focus on the respiratory exam, and a
peak expiratory flow measurement.
3. Diagnostic Studies. A baseline chest x-ray is recommended.

Categorization of Severity of Disease
Using the information collected from the intake history, physical exam, and chest x-ray, the patient’s
severity of disease should be documented. NCCHC
recommends the use of three categories as defined
below.
1. Mild asthma. Mild asthma is characterized by use
of a beta-agonist inhaler no more than 2–3 days
per week on average, and use of no more than one
beta-agonist canister every 4–6 weeks.

e. use of more than two canisters of betaagonist inhalers per month.
Over time, the severity categorization of a given
patient may be upgraded or downgraded based on
the degree of symptoms and disease control that the
patient manifests.

Frequency of Followup Visits
Based upon the patient’s category of illness as defined
above, the following frequency for followup visits is
recommended.
1. Mild asthma—The frequency of followup visits
should be based on the categorization of the severity
of the disease. Patients with mild disease who are
controlled should initially be seen every 3–4
months. If their control persists, this may
decrease to twice per year.
2. Moderate asthma—Patients should be seen at
least every 2–3 months, if they are controlled.
3. Severe asthma—Patients should be seen at least
every 1–2 months, if they are controlled.
For all of these, if the disease process is not adequately controlled, the patients should be seen more
frequently.

99

Content of Followup Visits
1. History. During followup visits, the patient’s
recent history should be obtained and documented. The history should focus on whether or not
the patient knows how and when to effectively
use medications, i.e., inhaler technique, frequency
of use of each type of canister, such as PRN use
for beta-agonist and fixed regimes for inhaled
steroids. For patients who by history appear to be
inadequately controlled, they should be encouraged to record the frequency, time of day of
attacks, and beta-agonist use in a diary.
2. Objective Data. At each followup visit, vitals
should be taken, peak flow meter results should be
documented, and a lung exam should be recorded.
3. Assessment. At each followup visit, the doctor
should record:
a. the degree of control as being good, fair, or
poor, and
b. the status in relationship to the previous visit
as improved, unchanged, or worsened.
4. Vaccination. Pneumococcal vaccine should be
offered once, and influenza vaccine should be
offered in the flu season.

Definitions of Control
Good control. No more than one beta-agonist canister used per month. No visits to onsite ER. No
nighttime coughing or awakening from asthma
symptoms.
Fair control. No more than one beta-agonist canister inhaler used per month. No more than once
per week awakening with asthma symptoms. No
more than one onsite ER visit in the past month.
Poor control. Use of more than one canister of
beta-agonist inhaler per month. More than one
onsite ER visit per month. More than three awakenings with asthma symptoms per week.

Definitions of Status
Improved status. Less use of beta-agonist inhalers
and less frequent symptom presentation.
Unchanged status. Both the use of beta-agonists
and frequency of symptoms have not changed.

Worsened status. Greater use of beta-agonist,
more acute symptoms, or an increase in emergency room visits.

Use of the Assessment to Guide
Treatment Efforts
If the assessment of the patient is either fair or poor
or if the status of the patient is worsened, the clinician’s plan should reflect new efforts to work with
the patient to improve these outcome measures.
A. Treatment Strategies
1. Mild asthma. Patients with mild disease should
require no more than beta-agonist inhalers on
an “as-needed” basis. Ordinarily, the treatment
would be two puffs of beta-agonist inhaler as
needed.
2. Moderate asthma. Patients with moderate disease should be using beta-agonist inhalers, two
puffs as needed. In addition, these patients
require inhaled steroids, and inflammation is
best controlled by starting at a high routine
dose, e.g., Aerobid, 4 puffs b.i.d., and then
decreasing the dose as the patient’s clinical
presentation warrants. If the patient is known
to take his or her medications as prescribed and
is not well controlled with high-dose inhaled
steroids, he or she should be reclassified as having severe disease.
3. Severe asthma. These patients should use betaagonist inhalers as needed, as well as inhaled
steroids to be used as described above. If they
are still not controlled, they should be started on
systemic steroids, e.g., prednisone 40 mg daily
times 2 weeks. This regimen is used to gain
control of the inflammation. After achieving
control as measured by reduced symptoms and
improved peak flow measurements, attempts
should be made to reduce the systemic steroids
while adequately controlling the patient with
inhaled steroids and beta-agonist regimens. The
addition of further medication such as long-acting Theophylline, Leukotriene inhibitors or
long-acting beta-agonist inhalers is presently
unsettled. There are not yet good data available
to recommend one strategy over another. Most
patients can be controlled without their use. If
it is thought that a patient needs one of those

100

third-line drugs, an asthma specialist should be
consulted.
B. Immunizations
1. Pneumococcal vaccine should be offered once,
and

Correctional Barriers
Impediments commonly found in the correctional
environment to treating asthma include the following.
●

lack of smoke-free housing

●

inadequate ventilation systems

●

restrictions on “keep-on-person” medication
programs

●

lack of timely urgent care access

●

lack of adequate system to ensure medication
continuity

2. Smoke-free environments in housing, eating
areas, and work or recreation areas can eliminate a common cause of asthma irritation.

●

lack of followup assessment and treatment modification by the primary care physician following
emergency room visit

3. Work-related chemical irritants can be a major
contributor to inflammatory episodes, and
should be eliminated or the patient should be
reassigned to work projects not involved with
such irritants.

Simple Quality Improvement Monitors

2. influenza vaccine should be offered in the flu
season.
C. Environmental controls
1. For patients who smoke, smoking cessation
programs can be an effective way of reducing
symptoms of asthma.

Understanding the Therapeutic Process
Any decrease in control of the disease as manifested
by the use of two canisters of beta-agonist inhalers
in a month or a visit to an emergency room setting is
cause for review of previous care and implementation
of appropriate corrective measures. Particularly for
newer patients in the system, an attack or emergency
room visit usually exists against a background of relatively easily correctable problems. The most common
of these problems are:
a. underassessment of prior degree of control,
b. inadequate strategies to encourage adherence to medication use,
c. underestimation of frequency of beta-agonist
use,
d. delay in increasing inhaled steroid dosage
or in the use of early systemic steroids, and
e. problems like sinus infections, seasonal
allergies, gastroesophogeal reflux disease,
or irritant exposures.

The following quality improvement monitors are
suggested, but are not intended to be an exhaustive
list of steps that could be taken to assure a successful
chronic asthma disease management program.
1. The ratio of beta-agonist inhalers issued by the
pharmacy to the patient in comparison to the
number of inhaled steroid canisters issued to the
patient over a month. This ratio of beta-agonist
to inhaled steroid inhaler should not exceed 1:1.
2. If under the assessment part of the note, control
is categorized as fair or poor, or the status of the
patient is listed as worsened, the plan should
include a strategy for gaining control by working
with the patient.
3. Immunizations offered.

101

Minimum Standards for Care of Chronic Disease in Prison (evidence based on current,
nationally accepted guidelines—January 25, 2000)

Parameter

Diabetes Type
1 & 21,2

Definition

untreated preprandial
blood glucose >110 mg/dL

Applies

all diabetics, both
insulin & non-insulin
dependent
complete, including
nutrition, medications,
monitoring, known
complications

Initial history

Admission physical
examination
Physician, NP or
PA visits
(controlled disease)
Office procedure
each visit
Laboratory, initial
every 3 months, until
controlled, then at
least every 6 months
Laboratory, initial
and annual for
controlled disease
Vaccine
Medication as
appropriate

Routine referral
Special needs

complete, including BP,
EKG, cardiovascular,
dilated retinal referral,
and foot
At least quarterly until
controlled, then at
least every 6 months
foot exam, including
monofilament testing,
weight, annual EKG
glycated hemoglobin
fasting glucose

Robert B. Greifinger, MD
Asthma3

Hypertension4

HIV5,6

on or should be on
medication; ≥1ß-agonist
inhaler/month
limited to moderate
persistent, and severe
persistent
complete, including
triggers, medications,
use of PEFR

systolic >140 or diastolic >90 mm Hg or on
Rx (130/85 for diabetics)
all risk groups

known infection

complete, including
nutrition, medications,
known complications,
smoking, alcohol

complete, including
peak flow

complete, including
BP, weight,
EKG fundoscopy

complete, including
nutrition, medications,
TB infection status,
STD status, known
complications
complete, all systems

At least quarterly until
controlled, then at
least every 6 months
peak flow measure
(PEFR)

At least quarterly until
controlled, then at
least every 6 months
blood pressure weight
annual EKG

theophylline level
(if on)

fasting lipid, urinary
microalbumin
annual influenza
1 pneumoccal
inhaled steroid if
on ≥1ß-agonist
inhaler/month

annual dilated retinal
exam by eye care
specialist
daily access to glucose
monitor, exercise, diet,
insulin timed with meals

daily access to peak
flow monitoring,
environmental control

3 mos CD4+ <500
6 mos CD4+ >500
system review weight
CD4+ & RNA
viral load

fasting lipid,
urine protein

annual influenza
1 pneumococcal
insulin, oral
hypoglycemics,
aspirin

all; asymptomatic
and symptomatic

b-blocker, diuretic add
appropriate ACE
inhibitor, Ca+ blocker,
aspirin, etc.

exercise, diet

RPR GC &
Chlamydia screen,
Pap (6 months)
annual influenza
1 pneumococcal
with symptomatic
disease; as
appropriate for viral
load & trend; OI
prophy <500 CD4+
HIV knowledgeable
physician
diet, exercise,
appropriately timed
medications

1. Standards of Medical Care for Patients with Diabetes Mellitus, Clinical Practice Recommendations 2000, Diabetes Care, American Diabetes
Association 2000; vol 23 supp 1: pp 1–23.
2. Management of Diabetes in Correctional Institutions, Clinical Practice Recommendations 2000, Diabetes Care, American Diabetes Association
2000; vol 21 supp 1: pp 1–3.
3. National Asthma Education and Prevention Program, Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, National
Heart, Lung, and Blood Institute, NIH, February 1997.
4. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National Heart,
Lung, and Blood Institute, NIH, November 1997, NIH 98–4080.
5. Report of the NIH Panel to Define Principles of Therapy of HIV Infection and Guidelines for the Use of Antiretroviral Agents in HIV-Infected
Adults and Adolescents, May 5, 1999, update.
6. Centers for Disease Control, 1999 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Inflected with Human
Immunodeficiency Virus, Morbidity and Mortality Weekly Report 48 (RR–10), August 20, 1999.

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Appendix E. Information About the National
Commission on Correctional Health Care and
Its Position Statements
The National Commission on Correctional Health
Care (NCCHC) is a not-for-profit, 501(c)(3) organization committed to improving the quality of care in
our nation’s jails, prisons, and juvenile detention and
confinement facilities. The NCCHC is supported by
national organizations listed below representing the
fields of health, law, and corrections.
In the early 1970s the American Medical Association
(AMA) studied the conditions in jails. Finding inadequate, disorganized health services and a lack of
national standards to guide correctional institutions,
the AMA in collaboration with other organizations
established a program that eventually, in the early
1980s, became the National Commission on
Correctional Health Care. The NCCHC’s early mission was to evaluate, formulate policy, and develop
programs for a floundering area clearly in need of
assistance.
Today, NCCHC’s leadership in setting standards for
health services and improving health care in correctional facilities is widely recognized. NCCHC’s
Standards for Health Services are written in separate volumes for prisons, jails, and juvenile confinement facilities. The Standards represent NCCHC’s
recommended requirements for the management of
a correctional health services system, covering the
general areas of care and treatment, health records,
administration, personnel, and medical-legal issues.
The Standards have helped the Nation’s correctional
and detention facilities improve the health of their
inmates, staff, and the communities to which they return;
increase the efficiency of their health services delivery; and strengthen their organizational effectiveness.
As well as establishing standards, each year NCCHC
sponsors correctional health care’s major educational
and scientific conferences. Each fall the annual
National Conference on Correctional Health Care
draws physicians, nurses, psychologists, scientists,
and other health care providers and researchers to
learn about contemporary practices and issues in the

field of correctional health care. Each spring the
Clinical Updates conference provides the latest
information on infectious and chronic disease
research and treatments, as well as other timely
clinical issues in correctional health care.
With a network of nationally recognized experts in
health care administration and delivery, NCCHC
offers an accreditation program for correctional facilities that meet NCCHC standards, provides technical
assistance and quality improvement reviews on correctional health care management and policy issues,
and develops and publishes research on the correctional health care field. In addition, NCCHC operates
the national certification program for correctional
health professionals, sponsors other educational
and training programs, and publishes numerous
support texts.
The members of the NCCHC volunteer Board of
Directors set policies and guide the organization’s
program efforts. Each is appointed to the board by
one of 34 supporting organizations.
American Academy of Child & Adolescent
Psychiatry
Louis Kraus, M.D.
American Academy of Pediatrics
James W.M. Owens, M.D., M.P.H., CCHP
American Academy of Physician Assistants
Peter C. Ober, PA-C, J.D., CCHP
American Academy of Psychiatry & the Law
Charles A. Meyer, Jr., M.D., CCHP–A
American Association of Physician Specialists
Jere G. Sutton, D.O.
American Association of Public Health Physicians
Jonathan B. Weisbuch, M.D., M.P.H.

104

American Bar Association
Susan L. Kay, J.D.

American Public Health Association
Robert Cohen, M.D.

American College of Emergency Physicians
William Haeck, M.D., CCHP

American Society of Addiction Medicine
H. Blair Carlson, M.D., CCHP

American College of Healthcare Executives
Eugene A. Migliaccio, Dr.P.H., CCHP

John Howard Association
Charles A. Fasano

American College of Neuropsychiatrists
Bernard Feigelman, D.O.

National Association of County and City
Health Officials
Douglas A. Mack, M.D.

American College of Physicians
John M. Robertson, M.D., M.P.H.
American Correctional Health Services Association
JoRene Kerns, B.S.N., CCHP
American Counseling Association
Nancy B. White, L.P.C., M.A.C.
American Dental Association
Thomas E. Shields, II, D.D.S., CCHP
American Diabetes Association
Samuel Eichold, II, B.S., M.D.
American Dietetic Association
Jenny Roper, M.S., R.D.
American Jail Association
Beverley Wilber
American Medical Association
Alvin J. Thompson, M.D., M.A.C.P., CCHP
American Nurses Association
Kleanthe Caruso, R.N., M.S.N., CCHP
American Osteopathic Association
George J. Pramstaller, D.O., CCHP
American Pharmaceutical Association
Robert L. Hilton, R.Ph., CCHP
American Psychiatric Association
Henry C. Weinstein, M.D., CCHP

National Association of Counties
Kenneth J. Kuipers, Ph.D.
National District Attorneys Association
The Honorable Richard A. Devine
National Juvenile Detention Association
David W. Roush, Ph.D.
National Medical Association
Carl C. Bell, M.D., CCHP
National Sheriffs’ Association
Sheriff Richard L. Warren
Society for Adolescent Medicine
Ronald Feinstein, M.D.
Society of Correctional Physicians
Ronald M. Shansky, M.D.
In addition to the standards, NCCHC periodically
adopts position statements that address issues of
importance in the management of health care in
corrections. The following are available as of the
date of this publication.
Automated External Defibrillators in Correctional
Settings
Charging Inmates a Fee for Health Care Services
Competency for Execution
Continuity of Care

American Psychological Association
Thomas J. Fagan, Ph.D.

Correctional Health Care and the Prevention of
Violence

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DNA Analysis

Management of HIV in Correctional Facilities

Drug Testing of Correctional Staff

Management of Tuberculosis in Correctional
Facilities

Health Care Funding for Incarcerated Youth
Mental Health Services in Correctional Settings
Health Services to Adolescents in Adult Facilities
Telemedicine Technology in Correctional Facilities
Licensed Health Care Providers in Correctional
Institutions
Management of Hepatitis B in Correctional
Facilities
Management of Hepatitis C in Correctional
Facilities

Third Party Reimbursement for Correctional
Health Care
Women’s Health Care in Correctional Settings

National Commission on Correctional Health Care
1300 West Belmont Avenue
Chicago, Illinois 60657–3240
phone: (773) 880–1460
fax: (773) 880–2424
e-mail: ncchc@ncchc.org
www.ncchc.org