Federal Bureau of Prisons, all 50 state systems, and a number of large local jail systems (37 for the first two surveys, 41 for the third survey) (NIJ, 1996, 1999). All of the federal and state systems responded to the surveys, as did approximately 80 percent of the local jail systems.

The first two surveys predated the official publication of CDC guidelines for correctional facilities (CDC, 1996b), although earlier agency and other guidelines covered high-risk populations and tuberculosis control measures applicable to facilities treating or housing people with tuberculosis (ATS, 1992; NCCHC, 1992; CDC, 1990b, 1994b). The survey questions for correctional facilities differed somewhat from those for hospitals, so comparisons are not always possible. For example, the first two surveys apparently did not include questions about screening of correctional facility staff. Responses to the third survey indicated that more than 90 percent of federal and state systems and almost all local jail systems reported screening of new employees. Roughly three-quarters reported periodic retesting. For each survey, reported use of negative-pressure rooms (in infirmaries or community hospitals, or both) for the isolation of inmates with suspected or confirmed infectious tuberculosis increased: from approximately 30 percent (1992–1993) to approximately 65 percent (1994–1995) to nearly all (98 percent) of the federal and state systems and 85 percent of the local jail systems (1996–1997). The reported use of directly observed therapy for all inmates with active tuberculosis also increased from 77 to 94 to 98 percent for federal and state systems and from 84 to 90 to 95 percent for local jail systems, for the three surveys, respectively.

The 1996–1997 survey included validation surveys of institutions within 13 systems. These surveys showed some differences between system-level and institution-level policies. For example, for systems with policies requiring four-drug initial treatment of active tuberculosis, only three-quarters of the individual institutions in those systems reported having the same policy.

In the 1996–1997 survey, nearly one-third of the federal and state systems failed to report whether or not they had cases of tuberculosis. Reporting on tuberculin skin testing programs was even more incomplete, with more than half of the state and federal prison systems and more than a third of the jail systems failing to report conversion data. The authors suggest that cases of tuberculosis in prisons may be undercounted because reporting is incomplete.

A separate survey of staff in Texas correctional facilities reported lack of knowledge of how tuberculosis is transmitted and how it can be prevented and treated (Woods et al., 1997). A survey of 225 health care workers in the Maryland Department of Corrections noted similar gaps in tuberculosis-related knowledge among frontline correctional health care workers (DeJoy et al., 1995). For example, 30 percent of the workers thought that a

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