 Perfectly good morning, Enriquez. Come on, man. I need to talk to you for a second. Serious, please? What is it? It's my bunkie. Johnson is sick. Real sick, man. And I don't need to be catching no diseases up in here. If I'm walking around sick, people are gonna think I got AIDS or something. Probably just got a bad head cold. Nah, man. It's got something really nasty. Like what? First off, he's coughing all the time. And he sweats a lot too, especially in the middle of the night. He wakes up his clothes are soaking wet. He's lost a lot of weight also. I'll check it out. And if you don't believe him, you can check for yourself. He's right over there on the other side of the yard. Johnson, you okay? Why are you asking? Notice you haven't been looking too well lately. I don't know. It's a little better. Think I'm coming down with some sort of cold. How long you got that cough? I don't know. Couple of weeks, maybe. How much weight you lost? I don't know. What do you think? He's going to sick call right now. Whatever. Johnson says he's been coughing for three weeks now. He's losing weight. He has night sweats and in general feels really sick. I'll notify infection controllers, Tetley, that we have a TB suspect in isolation and that we're starting the diagnostic workup. We'll need three sputum specimens for acid fast bacilli and we'll need to redo his PPD. I'll also need a set of baseline liver function tests and a chest x-ray. We'll need to make arrangements to get him over to St. Christopher's Hospital. I'll call the watch commander and arrange transport. As a suspected case of TB, we'll keep him in isolation till we're sure the treatment's working. Okay. If his sputum smears are negative and his symptoms and chest x-ray show improvement, we'll consider releasing him from isolation in a couple of weeks. In the interim, you'll want to counsel him on HIV and see if he'll agree to be tested. Since we know that a large percentage of TB cases in prison are also HIV positive, that's a pretty important test. What did he have to say about any possible exposure to active TB? Johnson told me that several months ago when he was on parole, he ran into an old friend of his in the neighbor. It seems that the friend at the time was quite ill. He was presenting some of the symptoms that Johnson is suffering from now. What do we know about him? Well, according to Johnson, the word on the street had it that his friend, Jamal, had TB. He wasn't taking his pills. Let's get those tests worked up as soon as possible. I'm on it. So how's Johnson doing? Williams, you know that's confidential. There's something around here called procedure. There's anything you need to know about. You'll be notified by the watch commander. Right. Williams, don't worry. We'll tell you if you need to take respiratory precautions. Poor jobs. There's such a waste of time. He needs a chest x-ray, doesn't he? You don't go on many of these, do you? Nope. Man, don't touch your respirators. What is wrong with you? Don't you know how dangerous that is? Come on, Morgan. I just need a smoke. I'm right next to an open window for crying out loud. Let's be clear about what we're dealing with here. Johnson is on respiratory isolation precautions, which means he could be contagious. So it's important that we keep these on. Fine. Then why the open windows? It's freezing outside. We should try to keep as much fresh air coming into the vehicle as possible. Even though Johnson is wearing a mask, there could still be germs floating in the air. And the less germs there are in the air, the better for us. Well, isn't that the whole reason for wearing these respirators? Yeah. The respirator should give us plenty of protection as long as they're fitted correctly. Right. You did get trained on how to use one of these things, right? Sure did. Good. Don't worry, Johnson. We'll be to the hospital in about five more minutes. I've heard that the infection control nurse was coming over to see me. How are you, Tracy? Oh, pretty good, Depp Soup. How about you? Not too bad. Can I get you a cup of coffee? Oh, no thanks. Have a seat. Well, so I hear we have an inmate with TB, huh? That's right. We've identified a TB case and need to plan a contact investigation. Of course, we'll want to work with your office in planning and implementing the trace. Well, we haven't had a case of TB in the facility for quite a while. It certainly has been a long time. I'm trying to figure out how we handle the logistics the last time around. Oh, here it is. Okay. Tracy, you've been working in corrections for as long as I can remember. We used to have a lot of TB cases, right? That's right. We definitely had our fair share over the years. So what happened? Well, after the TB outbreak in 1991, Doc started working with the state health department on a plan for TB control. Our infection control unit took the bull by the horns and confronted this thing head on. We stepped up surveillance. That is, we started looking for inmates with signs and symptoms of TB disease and immediately put suspects in isolation to stop transmission. We used directly observed therapy where we had a nurse watch inmates take their pills to ensure infected individuals were taking their meds and completing their treatment. We also implemented yearly testing of staff and inmates as a result, both the number of TB cases as well as the TB conversion rates of staff and inmates have been dropping steadily ever since. You know, it's a good thing that Officer Williams was on top of this thing. Oh, yes it was. This is a good example of why we need officers like Williams to stay alert to the possibility of infectious diseases. And once they've seen or heard something to notify the medical unit as quickly as possible. Agreed. So what can facility administration do? Well, we'll need to do a PPD on all staff and inmates who are in contact with Johnson. Now first we'll check the people who had the most contact with the case during the time period that he was contagious. Now some TB cases are more contagious than others. So the decision on who to test is made in conjunction with Docs Health Services and the State Health Department if necessary. And then there's a second test later, right? That's right. It can take up to 12 weeks for a person to show infection after an exposure. So the contacts who test negative on the first test will be retested in three months. Staff never seemed too keen on coming in for the retest though. Really? Well, you know, all the excitement has died down and all of a sudden it doesn't seem as important to them. Of course that's the more important of the two tests. It was naturally. If the first test is negative and the 12 week test is positive it shows that the source case was contagious. And if that happens, we'll expand the investigation to include individuals who've had less contact with the diseased inmate. That sounds like a long timeline. It must get pretty complicated. It's a lot of work for all of us. That's why we're so insistent that anyone with symptoms be put in isolation until TB disease is ruled out. Docs spend a lot of money on the isolation rooms but they're worth every penny when it comes to preventing transmission. Tracy, what about the folks who have tested positive previously? Years ago we had officers that tested positive. Of course there were a lot more cases then because of the poor controls. But what about them? Well, contacts who are already positive, both staff and inmates alike are checked for symptoms of active disease. And any contacts who are ill are of course further evaluated with chest x-ray or possibly sputum tests. Okay, I'll review this with the executive team. Now, Tracy, you usually meet with the union reps to make sure that everyone is well informed, right? Oh yes, I'll call the safety and health reps. It's been a while since they've had to speak with the officers about this issue. But also, I'll need your assistance in getting the inmate housing lists from class and movement for the time period that Johnson was contagious. I'll also need a list of employees working in Johnson's housing units, programs, and work assignments. Now I'll put all that together with what Johnson tells me about his routine activities and then we can set up the testing dates. And of course, we'll be especially alert for inmates and staff with some of the classic symptoms of TB disease, like productive cough, fever, chill, night sweats, fatigue, and weight loss. So when will we be ready for notification of staff? Not until you get the list to me, Deb. Now once I get those, I'll be able to look up the previous test results on the contacts and prepare the notification letters. And would you like me to get the letters out or would you like the watch commander to handle it at roll call? Let me discuss that with the executive staff and I'll get back to you on that. Oh, and we'll also remind the officers that testing is a requirement and not an option. Thank you. Okay, and I'll have those lists to you on your desk tomorrow morning. All right. Tracy, as always, it's been a pleasure. Thank you. Thank you. All right, Johnson, I need you to verify some information for me. Whatever. Hey, look, when are these jobs gonna start kicking in anyway? Hold on a minute. First, you need to give me some answers. How are we up there? Your house and cell block B, your bunkmate is John Enriquez. You go to drug counseling and attend woodworking classes. This information correct? Well, it looks like you already got the answers. So the answer is yes to all of the above. Yes, ma'am. Okay, other than what I've just mentioned, are there any other places you hang out? Like where? Well, for example, do you play cards? Do you get any visitors? Well, who do you hang with in the block? That sort of stuff. Well, that's gonna take me a minute. I'm a pretty popular guy, you know. Johnson, you don't wanna make your buddies sick, and some of them will get sick if you don't pitch in and help us out here. Give me a second. I'm thinking. Hey, let me ask you something. That mask might keep you safe, but if I'm that contagious, what's to stop my germs from floating on out of here every time you open that door? Well, this room has something called negative pressure. It's the difference in pressure between this room and the outside corridor. This negative pressure creates a one-way flow of air into this room, which means that air comes in from the corridor and then gets exhausted to the outside. Right. Whatever. When are these germs gonna start kicking in? Well, give them a couple of weeks and you'll feel the world of difference, I promise. Now, let's get back to concentrating on who you hang out within your block, your workplace, school, or in any special program you attend. So, Officer Morgan, how are we doing today? Well, I was mining my own business when I get this letter from the ICN. Very funny. I'm not talking about the skin test, Jen. I mean, I heard the good news and wanna know how you're doing. Oh, this? Well, I'm three months along, wishing it was nine. That good, huh? Well, I wish you all the best. Thanks. Karen, I know I've had these tests before, but I gotta tell you, now that I'm pregnant, I'm starting to have a few concerns. Like what? For starters, what exactly do I get injected with every time I have one of these tests? Jen, there's nothing to worry about. Before I forget, are you working Wednesday? Yes, I am. Great. I'll need to read the test in two days. If you're going to have a reaction, it'll show up by then. Anyway, getting back to your question, the injection I'm going to give you today contains a small amount of purified protein derivative called tuberculin. I know what you're thinking, and no, you can't catch TB from the test. Good. That sort of stuff should have been covered in your TB training. Don't you remember? Sort of. It was quite a while ago. Let's talk a little bit about tuberculosis, what causes it, and how it's transmitted. To begin with, it's an airborne disease, transmitted by coughing or sneezing, not by food or objects, and it's not in the blood or saliva, like some of the other diseases that we learned about. TB bacteria can remain in the air for several hours, but it's not real easy to catch. It usually requires prolonged contact. Most people with TB have it in the lungs, and that's called pulmonary TB. But TB can occur elsewhere, like in the bones, kidneys, or other organs. That's called extra pulmonary TB. The training made the difference between infection and disease very clear. A healthy immune system often traps the TB bacteria in the lungs. This is called latent TB infection, and it usually is indicated by a positive PPD test. In latent infection, there are no symptoms, and the person is not contagious. People with positive skin tests are further evaluated to rule out TB disease. The most important thing to remember is that treatment for latent TB infection will reduce the risk of active disease in the future. People with active pulmonary TB also have a positive PPD test, but unlike those with just the infection, people with active TB are contagious. They have an abnormal chest X-ray and often have symptoms. Treatment will make them non-infectious in a few weeks, but they have to stay on drugs for six months or more to make sure they're cured. Any questions about any of it we covered so far? Jen? All finished. Thanks. No problem. Take care. So, Mr. Johnson, you've been out of isolation for several weeks now. How are you feeling? Well, just like you said, after a couple of weeks I felt better, and now I'm okay. Good. It appears that you'll be leaving us next month. Yes, ma'am, and I'm making no plans on visiting this place any time soon. Well, I just need to go over some discharge planning with you to make sure that there are no misunderstandings. And I was just starting to like you, too. Three months ago, you were diagnosed with TB disease since then you've been on medication. So? You experienced no serious side effects or liver damage. Your TB disease is under control, but you'll still need to keep taking these meds for the next three months. Whatever. According to the address information you provided us, the nearest health clinic to your location is the Jay Street Clinic. I've already contacted them and scheduled an appointment for you the day after your release. It's mighty kind of you. You'll be on directly observed therapy after your release. The clinic will assign someone to your case and you will continue taking your medication and visiting the clinic for regular checkups until your treatment is finished. I will be contacting your parole officer and they will be involved in your treatment as well. What is this, an IBI contract or something? No, Mr. Johnson, this is an agreement that contains everything that I just went over with you. By signing it, you're agreeing to the terms of your treatment for TB. Your parole officer will have a copy as well and will be keeping an eye on you to make sure that you are in fact taking all of your medication. I can't get out of this place quick enough. I think we're done here. Have a nice day, Mr. Johnson. I'm scheduled to have my next good day sometime next month. I'm really curious. I never saw you at the medication window before. Keep it down, man. So what? My follow-up TB test came back positive. Don't forget to take your medication and listen to the nurse. Doc says if I wanna kill this infection, I gotta take pills twice a week for the next nine months. Nine months? Yeah. Listen to the nurse, Henriques. So, we discussed the medication that you'll be taking. Yup. You'll be coming here to the med window twice a week to take your INH. Now, while you're taking these pills, it's very important that you let me know if you begin experiencing any of the side effects that I spoke to you about. Could you go over those again? I must have zoned out during that part. Sure. Serious side effects due to liver damage include loss of appetite, general weakness, upset stomach, vomiting, rashes, and having your skin and the whites of your eyes turned yellow. All right. Let's get this over with. Open up. Okay. I'll see you later this week. Great. I'm the one everyone should be thanking. If it wasn't for me, this whole place would have got sick. I mean, if it wasn't for us, whatever. Let's quickly review some of the principles to controlling TB in prisons and jails. Early identification, isolation, medical evaluation, respiratory precautions, contact investigation, annual PPG testing, annual training, discharge planning, and directly observed therapy. Controlling TB in prisons and jails is a team effort.