protocols and tests for the identification of individuals with infectious tuberculosis are not perfect and may also be imperfectly implemented. Recently, a Pennsylvania prison that contracts to house detainees of the U.S. Immigration and Naturalization Service (INS) received a detainee with infectious, multidrug-resistant tuberculosis following a “paperwork error” (Lang, 2000; Lebo and Scolforo, 2000). News stories have cited county officials as planning to improve the “sieve-like” system of transferring medical records. As noted in Chapter 1, INS was recently cited by OSHA for failing to protect workers from known hazardous conditions that put workers at risk of exposure to tuberculosis (OSHA Region 6, 2000).
Jails A study of tuberculosis cases associated with a Nassau County (New York) jail found that 24 percent of the cases in the county were associated with the jail (Pelletier et al., 1993). Most of the cases involved prisoners, but one case involved a correctional officer. DNA analysis of M. tuberculosis isolates suggested that transmission of the disease was occurring within the jail. The jail did not screen detainees or workers for tuberculosis infection or active tuberculosis.
Jones and colleagues (1999) reported on an outbreak in the Memphis city jail that involved 38 inmates and five guards who were diagnosed with active tuberculosis between January 1995 and December 1998. Among the 24 inmates with positive cultures, DNA fingerprinting matched the isolates from 19 inmates to isolates found among 2 or more other inmates. For the two culture-positive guards, isolates from both individuals matched the dominant inmate strain. Among a randomly selected sample of 43 isolates from patients with tuberculosis identified in the community, 6 percent matched the dominant inmate strain and 4 of these came from individuals who had been incarcerated in the jail. Of 686 jailers evaluated in October 1997, 1.2 percent had a skin test conversion following a negative test the previous year.
In addition, the article of Jones and colleagues (1999) cited 14 published reports of outbreaks of tuberculosis in U.S. prisons since 1985 but identified only 2 published reports of outbreaks in U.S. jails, with one report dating back to 1977. It also noted that nearly 10 million individuals were admitted to local jails and that 6 percent of the nation’s jails housed 50 percent of jail inmates.
Nursing homes, chronic care units of hospitals for veterans, long-term psychiatric facilities, and other similar settings often serve elderly people and others at increased risk of tuberculosis. They also typically offer the opportunity for the sustained close contact that facilitates the transmission of tuberculosis.