Public Health and Corrections: A Model of Program Collaboration

and Service Integration (PCSI)

2016 Southeastern TB Controllers Meeting| October 7, 2016

Jason Cummins, MPHProgram Manager & Senior Epidemiologist

CDC’s NCHHSTP – 2009 White Paper

• Program Collaboration and Service Integration• Programmatic “silos” vs “synergy”• Overlapping risk factors for disease• Opportunities for:

– Targeted screening and testing– Increased efficiency– Reduced cost– Assured treatment– Enhanced disease surveillance– Continuity of care upon release

http://www.cdc.gov/nchhstp/programintegration/About.htm

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TB Control & Prevention in Corrections

Incarcerated Population

• Newly incarcerated inmates have an increased prevalence of HIV, syphilis, chlamydia, gonorrhea, and Mycobacterium tuberculosis1

• The U.S. Department Justice reports that at least 95% of all state prisoners will be released from prison at some point

• Primary and secondary prevention– Education– Screening and testing– Treatment during incarceration

1Bick, Joseph A. Infection Control in Jails and Prisons. Clinical Infectious Diseases. 2007; 45:1047-55.

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Framework for Integrated Diagnostics

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TDOC IntakePrisons

State Lab

CEDEP

Tennessee Department of Correction (TDOC)

• 14 state prisons within TDOC located in 11 counties in Tennessee

• 29,323 inmates (May 2016)• One intake facility for male and female inmates each

TDOC Intake Facilities

Tennessee Prison for Women (TPW)

Bledsoe County Correctional Complex (BCCX)

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Planning and Implementation

Identify Stakeholders

• Inmates• Tennessee Department of Correction (TDOC)• Tennessee Department of Health

– Tuberculosis Elimination Program (TTBEP)– HIV/STD/Viral Hepatitis Program– Information Technology Division (ITSD)– Division of Laboratory Services

• General population

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Planning Steps

• Review of current intake screening and testing procedures– What tests were being done?– Where were the tests being sent for analysis?– How were the prisons receiving the results?

• Proposed “new” screening and testing procedures– Implement use of QuantiFERON® TB-Gold In-Tube (QFT) testing to

replace tuberculin skin test (TST)– Blood collection for HIV testing to replace oral swab testing

• Information technology (IT) needs at each intake facility• Physical equipment• Firewalls

• Training TDOC staff• Transportation of specimens• Cost comparison (old process vs. new process)

Proposal: New TDOC Intake Screening Process

• TST placed and read in-house by prison medical staff

• QFT drawn as ordered by MD

• Additional labs drawn:– HIV (oral swab)– RPR– Gonorrhea (urine)– Chlamydia (urine)

• Labs sent to Garcia Clinical Laboratory in Michigan via FedEx

• Lab reports available in Garcia portal

• QFT replaced TST as method for testing for TB infection and sent to state lab

• Additional labs drawn:– HIV (blood)– RPR– Gonorrhea (urine for men, vaginal

swab for women)– Chlamydia (urine for men, vaginal

swab for women)• Labs sent to state lab via state

courier• Lab results available in Patient

Tracking Billing Management Information System (PTBMIS)

• Lab results accessed and routed to appropriate health dept. program

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Old Process New Process

Implementation Timeline

• April 2015– Internal CEDEP meeting with different programs

• May 2015– Kick-off meeting (CEDEP, TDH lab & TDOC)– Visit to TPW and BCCX

• June-September 2015– Various meetings to discuss logistics of implementation

• October 2015– Tennessee Prison for Women (TPW)

• November 2015– Bledsoe County Correctional Complex (BCCX)

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Implementation Logistics• Equipment

– New computers– Incubators

• IT implementation– Setting up PTBMIS accounts– Supplying label printers to each site– Training on Lab Order Entry (LOE)– Accessing results

• Transporting specimens to the state lab– Additional routes for courier

• Timeframe requirements from prisons– Screenings and evaluations completed prior to prisoner classification

• Testing logistics– Chlamydia and Gonorrhea testing

• TPW—sending vaginal swabs• BCCX—sending urine samples

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Training TDOC Staff

• QFT collection and handling• Electronic ordering via

PTBMIS• Accessing electronic lab

results• Utilizing the statewide

courier system

Results through August 31, 2016

Men’s Intake Facility ResultsNovember 2015-August 2016

0

1000

2000

3000

4000

5000

6000

QFT HIV Syphilis Chlamydia Gonorrhea

Num

ber o

f Results

Test

UnsatisfactoryIndeterminatePositiveNegative

Women’s Intake Facility ResultsOctober 2015-August 2016

0

100

200

300

400

500

600

700

QFT HIV Syphilis Chlamydia Gonorrhea

Num

ber o

f Results

Test

UnsatisfactoryIndeterminatePositiveNegative

QFT Results

Tennessee Prison for Women (TPW)Positive (%) Negative 

(%)Indeterminate 

(%)Unsatisfactory 

(%)Total

2015 4 (2.0) 193 (97.5) 1 (0.5) 0 (0.0) 1982016 21 (5.4) 362 (93.5) 3 (0.8) 1 (0.3) 387Total 25 (4.3) 555 (94.9) 4 (0.7) 1 (0.2) 585

Bledsoe County Correctional Complex (BCCX)Positive (%) Negative 

(%)Indeterminate 

(%)Unsatisfactory 

(%)Total

2015 25 (4.4) 497 (88.0) 43 (7.6) 0 (0.0) 5652016 236 (5.4) 4140 (94.1) 2 (0.05) 20 (0.5) 4398Total 261 (5.3) 4637 (93.4) 45 (0.9) 20 (0.4) 4963

HIV Results

Tennessee Prison for Women (TPW)Positive (%) Negative (%) Unsatisfactory (%) Total

2015 0 (0.0) 181 (92.8) 14 (7.2) 1952016 2 (0.5) 382 (99.2) 1 (0.3) 385Total  2 (0.3) 563 (97.1) 15 (2.6) 580

Bledsoe County Correctional Complex (BCCX)Positive (%) Negative (%) Unsatisfactory (%) Total

2015 8 (1.5) 510 (98.5) 0 (0.0) 5182016 31 (0.7) 4343 (99.2) 0 (0.0) 4376Total 39 (0.8) 4853 (99.2) 0 (0.0) 4894

RPR Results

Tennessee Prison for Women (TPW)Positive (%) Negative (%) Total

2015 2 (1.0) 192 (99.0) 1942016 8 (2.1) 377 (97.9) 385Total 10 (1.7) 569 (98.3) 579

Bledsoe County Correctional Complex (BCCX)Positive (%) Negative (%) Total

2015 4 (0.8) 514 (99.2) 5182016 33 (0.8) 4344 (99.2) 4377Total 37 (0.8) 4858 (99.2) 4895

Chlamydia Results

Tennessee Prison for Women (TPW)Positive (%) Negative (%) Total

2015 0 (0.0) 113 (100) 1132016 5 (1.4) 358 (98.6) 363Total 5 (1.1) 471 (98.9) 476

Bledsoe County Correctional Complex (BCCX)Positive (%) Negative (%) Total

2015 14 (2.7) 508 (97.3) 5222016 98 (2.2) 4272 (97.8) 4370Total 112 (2.3) 4780 (97.7) 4892

Gonorrhea Results

Tennessee Prison for Women (TPW)Positive (%) Negative (%) Total

2015 0 (0.0) 113 (100) 1132016 1 (0.3) 362 (99.7) 363Total 1 (0.2) 475 (99.8) 476

Bledsoe County Correctional Complex (BCCX)Positive (%) Negative (%) Total

2015 0 (0.0) 522 (100) 5222016 6 (0.1) 4364 (99.9) 4370Total 6 (0.1) 4886 (99.9) 4892

Conclusions, Limitations & Next Steps

Limitations

• No explanation regarding the low rates of chlamydia and gonorrhea in the inmate population when compared to Tennessee state rates

• No explanation regarding the higher rate of chlamydia in the male inmates vs. female inmates

• Incomplete information regarding additional risk factors for disease among inmates being tested

Next Steps

• Cost-effectiveness study• Compare test results and treatment outcomes for TB

infection

Acknowledgements

• TDH Central Office– Dr. Jon Warkentin– Dr. Carolyn Wester– Trudy Stein-Hart– Bob Herdman– Mike Newman– Michael Creighton– Shirley Gore– Ernest Miser

• TDH Laboratory Services– Dr. Richard Steece– Jim Gibson– Paula Gibbs– DeAnne Sharp– Wayne Pearson

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• Southeast Region Staff– Debbie Walker– Mary Elbell

• TDOC– Dr. Kenneth Williams– Marie Wright– Tennessee Prison for

Women medical staff– Bledsoe County

Correctional Complex medical staff

• QIAGEN staff

Thank you

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