Chad Garrett: My clock says it is time to begin, so we're gonna go ahead and begin.

Well, welcome today to the NIC's Breaking the Cycle, Tuberculosis Prevention and Management Behind Bars.

This session is called Case Studies in Correctional Tuberculosis: Lessons from the Frontline. My name is

Captain Chad Garrett, and I am the Health Programs Manager with the National Institute of Corrections.

And I can just tell you that I am very thrilled for you to join us for this uh informative series.

The series so far has been amazing, and I feel that today uh we'll also be

Probably the best one out of all of them. Before we begin today's session, just a couple housekeeping rules. Uh

this webinar is gonna last approximately one hour. It is

going to be recorded and once captioned and made 508 compliant

This recording as all the recordings will be available on the NIC website.

Microphones are muted

But this is going to be a participation heavy presentation. It's going to be case studies.

We're going to ask lots of questions as we go. You can answer through the chat feature.

And I'm going to try to fix our hand raising question, but if not, we're going to go ahead and do the chat feature

to answer these questions. as we go through. We'll try to address as many other questions

at the end of the presentation with a little question and answer session

If you're having any audio difficulties, we recommend that you connect to the webinar via the telephone number that was provided in your registration

confirmation email. Now, let me just take one second To

hand you over to our librarian extraordinaire from the NIC

Information Service for a brief public service announcement.

So, Mary, the mic is yours.

Mary Coffman: Thank you, Chad. I am Mary Coffman.

I am one of four information specialists here at NIC, and my job is to help you.

If you have any questions related to the corrections field, please email us at support@nicic.gov.

And we have four of us who will respond to you. I put it into the chat so you can reach us at support@nicic.gov.

We also run our website at nicic.gov.

You can find free trainings there like this webinar and other trainings. We also have a free Learn

Center where you can take self-paced e-courses at your own pace.

On our website, you can also find Overdrive, which is a free e-book and audiobook application.

If you have any questions about it, you can reach us at support@nicic.gov and we can walk you through it And

lastly, we have an e we have a research database you can use called EBSCOhost that we highly recommend.

You can do the research yourself on EBSCOHost or we'll do it for you. Just contact us.

Thank you, Chad.

Chad Garrett: Outstanding, let me introduce our speaker for today. Captain

Rhodes has spent more than 27 years proving that healthcare leadership rarely comes with a quiet day And that

busy is usually just the beginning. Her career began as a newly commissioned U. S.

Army nurse at Triple Earth

Army Medical Center in Hawaii, followed by specialized service in mental health at Tripler

and Wynn Army Community Hospital. In 2005, she joined the

United States Public Health Service and stepped into correctional health care, first caring for thousands of

detainees in Texas before joining the Federal Bureau of Prisons in Houston At

FDC Houston, Captain Rhodes

learned correctional medicine from the ground up and at full speed, conducting intakes, triage

Medication lines, emergency emergency responses, and follow-up

care while serving as the sole medical provider for approximately a thousand inmates during evenings and weekends.

It was as she may say, a fairly

effective introduction to prioritization. In twenty

fourteen, she began the facilities infectious disease coordinator and quickly developed a reputation as a trusted tuberculosis troubleshooter

She

managed more than 75 TB cases overseeing the full spectrum of care from isolation and investigation to treatment, side effect monitoring, and coordination with outside partners

In

2016, her reach expanded from facility to field when she became the South Central Region's quality improvement

slash infection control consultant.

Guiding infectious disease prevention and treatment across five states, 21 facilities, and more than 15,000 incarcerated individuals.

Today she serves as a regional subject matter expert helping facilities Spot, stop

, and solve infectious disease challenges.

With 12 years of TB case management experience, Captain Rhodes represents the BOP on the Advisory Council for the Elimination

of tuberculosis and serves on correctional and educational committees with the National Tuberculosis Controllers Association.

She holds a Bachelor's of Science in Nursing from Bloomberg University, a Master

in Science with an Education Concentration from Aspen

University, and a national healthcare disaster certification.

From Army hospitals to detention centers, from bedside care to regional

and national leadership, Captain Rhodes has built a career returning

complicated clinical challenges and coordinated practical solutions. Her specialty to sum it up

is remaining calm under pressure, sharp on the details and always ready for the next challenge.

Because in correctional health care, there's only one predictable thing, and that is that every day is going to be unpredictable.

And with that Captain Rhodes, the mic is yours.

And we can't hear you.

Technology there.

Well, ladies and gentlemen, just as I said, uh

believe it or not, we did troubleshoot all this right before we started. We spent the half an hour before

working on that. And of course the unpredictable is predictable.

So we'll wait just a minute as Captain Rhodes gets a microphone that hopefully works here. As

we continue

to wait, if those of you who have joined us would take just a second and put where you're from.

In the chat box, that would be awesome. It's in the bottom right-hand corner

I think Captain Rhodes is just trying to make my my last couple

presentations a little more interesting.

Captain Rhodes, if you're having trouble with your microphone, uh you can try calling in.

Okay

Captain Rhodes, you may have to uh uh

sign out and sign back in if your WebEx is truly and utterly stuck.

Thank you guys for putting in where you're from. I s really appreciate it.

And again, I appreciate your patience.

I just want to tell everyone out there that it is great to see so many people from so many different departments and from so many different places.

I see a lot of our uh public health partners

Tara Rhodes: Oh my goodness. Can you hear me?

Chad Garrett: Oh, I can hear you now.

Tara Rhodes: I am. Sorry, y'all. I don't even know. It just decided to completely stop.

Let's see if I can get our slideshow back. Let's go. So I am never meeting myself again, just so you know.

So you will hear whatever

is in the background. Sound good?

Chad Garrett: You are so good I can hear you.

Tara Rhodes: Okay, perfect. Let's get back to where we were going in our slides.

Thank you for that lovely introduction. Let's see. You can see me now too, everybody. Hi.

Okay, so today, like Chad said, we're going to try to do some interaction. We're going to talk about

a couple different case studies. And if you attended the first

presentation that I did on latent TB infection or just TB infection, and then that Cassidy presented for me on TB disease

Some of this will be playing into that. In large presentations like this, it's kind of no

hard to know the experience level of everybody on here.

So some of this may be review for those of you that have been in TV for a long time and Just get more

Yeah.

Chad Garrett: Your screen is black.

Are you kidding me? No.

Tara Rhodes: Why is why is this making why is life so difficult right now? Why is it

This all worked, Chad, before we started.

Chad Garrett: I no, I told him that. I

chaos is the only constant.

Tara Rhodes: Share. Let's do this again.

Three, you can see my webinar, right?

Chad Garrett: I cannot see

Tara Rhodes: Can you see anything?

Chad Garrett: I only see a black screen that is you.

Here.

Tara Rhodes: Okay, we're gonna share.

Chad Garrett: This hold on. I have a different

Tara Rhodes: It's like connecting all the time. You wanna pull yours up?

But then you won't see me, but I guess it's okay.

It just is taking a long time to

Chad Garrett: it is

Tara Rhodes: share.

Chad Garrett: Okay, can you guys see or

Tara Rhodes: can you see mine? Am I sharing now?

Chad Garrett: I'm still just seeing the black screen.

Tara Rhodes: All right, just do you. You guys won't be able to see my

I'm all dressed up too in my uniform that I put on for y'all. And you won't be able to see.

Chad Garrett: Because I'm seeing your WebEx.

Tara Rhodes: Okay, good. Then let me, if you're seeing my WebEx, then that's where my slideshow is going to pop up.

So let me start my slideshow. Now you can see it?

Chad Garrett: You are awesome. Oh problem solved.

Tara Rhodes: Goodness gracious. I don't know why we're having so much trouble today. Oh, I'm here

a minute, you'll be able to see me. There we go. Can y'all see me now?

Chad Garrett: Yup, there you are.

Tara Rhodes: Okay, perfect. Yes, look, I dressed up for y'all.

Like we were talking about today, it may be a refresher for you.

It may be if you're brand new to TV, this may be challenging and some of these questions you may not know.

That's perfectly fine because we're going to give you the answers, the best kind of test, right? So

what I kind of want to go over today is we'll start with an on comp an uncomplicated

TB infection case and then we'll kind of add a little twist to it. Then we'll go over a smear

positive TB case

Then we'll move into kind of the difference of what we look for when we have culture negative cases because we do see quite a few of those

in the Bureau of Prisons. And then just a few short takeaways for you guys.

before we take off and hopefully we'll get lots of participation.

Okay, this is our favorite pathogenesis slide that we have and that we use all of the time. So

uh We all know if you're exposed to TB, it can kind of go two directions, right?

You can either have no infection and you move along with your life. Or you could get a

TB infection. And that can go two ways. The first way we're going to talk about it is

those who get a lung infection.

percent of those people actually never develop disease, but we do have that 10% of

the population that after getting latent TB or TB infection, it

turns into TB disease. So we're going to start with our case study here. We're going to start with a female.

And so we have Inmate Smith and she arrives to FCI Anywhere on Saturday, 10 425.

She's been brought to the institution by the Border Patrol without any medical paperwork. Very common, right?

So Inmate Smith needs TB clearance before she can go to general population.

She has traveled from Mexico. What's our next step?

Brand new coming in. This is your information we have. What do we need to do?

Chad Garrett: You guys can go ahead and answer those questions on chat for right now.

Tara Rhodes: Yeah, and I won't be able to see chat. Uh Chad, so you can just kinda let me know.

Chad Garrett: Uh let's see here. T B screen, screen and test, T B screen, T B

test, T S T or Igra. Plant PPD, screening and testing.

Ah, here's one. Symptom screening and testing

Yeah.

Tara Rhodes: I like that word.

Chad Garrett: Yes. Chest x-ray.

Tara Rhodes: Good.

Okay.

Chad Garrett: Risk assessment.

Tara Rhodes: We're getting a farther. Good. Okay. Let's go with our first one. You're you're

yeah, I don't want you to have the whole presentation yet. So we're gonna start with the symptom screen. That's the

kind of the very first thing that we look at when we're looking to screen for TB, right? So um from

the last ones, what are our symptoms? What are we looking for for TB? Throw some of those in the chat.

Chad Garrett: We have

fever, cough, homoptosis, weight loss, night

sweats

Poor appetite.

Tara Rhodes: Good. Chest pain, fatigue. Those things can also be good So

now that we did our symptom screen, then what is our our second step after a

symptom screen? I heard some of them in the in the first go round. So for us

in the in the BOP, we use a TST, right?

So we want to plant that TST. because we have 48 to 72 hours after that

that it needs drawn. So for per all policy, it has to be done within 24 hours of arrival

of admission to any of our institutions. So we're going to plant that TST.

Some of you, um, oh so how do we remember I just gave you the answer.

I was gonna ask you when do we read it, but I gave you the answer. Never mind. Um so then

if you don't do TST, some institutions or some places may draw blood for an IGRA.

That's not routine in the Bureau of Prisons for us.

a few different reasons, but

one of them that we would use is if they have an allergen to the PPD solution, then

and they can't get a TST, we would do a blood draw for an IGRA. Um, so I'm gonna let you know

in this case the symptom screen is negative

for uh this female who just came in So now that we did our symptom screen, we planted our TST

, how do we know that we can send them to the unit, right? Because they're going to go to this congregate setting.

So how do we know we can send them?

Some places do test x-ray on ache, which is um very helpful.

We don't do that in our system. No

Chad Garrett: simple. So we have to do

Tara Rhodes: the TST. So

in general, if um you don't have

If you don't have chest x-ray in your intake, then

you're going to pretty much go by that symptom screen, right?

So if they're clear from the symptom screen, they've had their testing either their

IGRA or their TST, then that's usually how they get sent to the unit.

Ideally, chest x-ray would be great, but that's not possible in in most situations. And so

Our scenario continues where Nurse Rhodes she reads Mrs.

Smith's uh TST at 53 hours

and it is 15 millimeters. So

Is um is this the correct time frame? Is this okay because it I read it at 53 hours

Chad Garrett: Yes, yes, yes, yes, yes, yes, yes, yes, yes, yes.

Tara Rhodes: Perfect, right? I'm in I'm in that 48 to 72. So perfect. I'm in No

am in the right time frame, so that answer is yes

So I've heard some of them, so let's let's remind ourselves after we have

now we have a positive TST. So what's our next step going to be?

I'm sure it's popping up.

Chad Garrett: Chest x-ray, chest x-ray, chest x-ray.

Tara Rhodes: Yeah.

Thank you. And so in our policy, if there's a positive TST,

we always order the chest x-ray and an HIV test at the same time because as

hopefully you know or you may not know that HIV testing can affect um

your status for TB. It's um they're more susceptible to TB about 10 times. And also chest x-rays

can um look different in HIV positive inmates that have TB. Sometimes

people don't realize that and so when there's not as many changes on the chest x-ray and they're HIV positive

Um that doesn't mean that we don't have uh TB. So good. Yeah. And then I also

Chad Garrett: Okay. So it's I thought it was a good question. So what happens if the inmate refuses screening?

Tara Rhodes: So in our institutions, because we um have

the ability, it's in our policy, we force testing.

Um, we don't like to do it, but we will force testing. And so um

if it takes a team to hold them down and give them a TST or um

in IGRA, then that's how we do it because it's such a

it's such a big deal for us to have TB clearance that the inmate is not allowed to refuse.

So that's our answer in our system.

Chad Garrett: Okay.

Tara Rhodes: Okay. Thank you. Um so you're welcome. So after our

Uh chest x-ray and HIV test. I would also like somebody to get a symptom screen

because when you read that TST you should have had a symptom screen.

So not only at intake, you know, kind of every time we encounter them,

we want to make sure that no new symptoms have developed. And so

Now we want to kind of see uh

a history of treatment, right? So Does the patient have a history of TB infection

and did they get treated for that? Does the patient have a history of active TB?

Because those things are going to make a difference once we get these results.

Then we're going to offer treatment. So this all isn't going to happen on the same day, right?

We're going to have to get our chest x-ray back and our HIV test. Do we remember from our

previous presentation, if anybody was on that one, what is usually our first choice for

uh to treat TB infection?

White treatment option.

Chad Garrett: RIPE I N H R P D RIPE. Four

Rice Famplin Daily for 120 doses or three H B

Tara Rhodes: Okay. Some of those are good. Um RIPE. I wouldn't start RIPE, but the others um I agree with.

In our system, we use 3HP. Although for HIV and pregnant patients,

we usually need alternate regimens for them. Some HIV can use

3HP, which is the rifapentine INH and B6. depends on their

uh HIV regimen, which a lot of them are uh they interact and so you can't

You can't use 3 HP. After that, our choice is usually

for those patients, then we have to go to the six months of INH.

So if we can, we always choose 3HP first.

We have done the 4R, the four months of RIFAMPIN.

But it's always recommended to try to use the shorter course therapy

over the six to nine months of INH if possible. And then

we have education, right? So we want to educate these inmates about

what latent or what TB infection is

and about the medication that they're going to receive. Hopefully your EMAR has

the same capability as ours and you can actually print off information

about those medications for them so they have it with them. One thing

the ordering of of baseline labs. This depends on your state. This depends on um

your kind of uh institution or who you work for, but in our system

we like to have standing orders for our nurses and so if

The patient comes back and they have

a positive TST, those standing orders are there for them to order the chest x-ray and the HIV test.

And then if the patient

decides that they want to take um treatment for TB infection, then we also have standing orders where our nurses and and our protocols

also can order those baseline labs.

So they're able to order the CBC, the LFTs, those liver function tests, hepatitis testing, and then HIV testing if it wasn't ordered

previously. So that's just an idea to think about if you haven't considered it

is to get those standing orders to make it easier. If you don't have a physician on site

all of the time, the nurses can get a lot of this done

and then they can see the provider on maybe the one day a week that they come in if you're in some of those small jails.

Chad Garrett: I had just a couple quick questions that came up. Uh one is

do you recommend that you get a pregnancy test for those of childbearing age? Absolutely. Uh

why three HP instead of four R Or uh do you still prefer 3HP

with the price of NIH being higher? I

Tara Rhodes: NH, yeah. So it it's it's kind of on availability too, right?

So it's it's what works. Three H B is always um

We've been lucky enough to be able to always have INH um available.

I know we get rifapentine shortage, sometimes we get rifampin shortages. So um

We prefer the 3HP just as

two drugs in case we have some resistance that we're not aware of, then we kind of have another drug on board.

But that can be a problem if INH is too costly for your institution or facility

or if there is a rifapentine shortage. So you do have a few of those options.

That's just the preference that we use. Hopefully that answers it.

Chad Garrett: One last question is can a patient refuse uh treatment?

Tara Rhodes: Yes, they can. And I believe I have some slides a little further.

If I don't, remind me and we'll talk about what we do for refusals. But I think I put that. in there. Okay?

Okay.

So the next thing is that we want to schedule them so the nurses have been able to talk to the patient, provide them education.

And so now we wanted to schedule them to see a provider. So that may be an NP, a PA,

a physician, whoever you guys have at your facilities. And so Inmate Smith

arrives to health services for her appointment with a provider

and she told the nurse when they met that she would like treatment for latent TB, TB infection.

So what should the provider do?

What's what's their their kind of role now?

That they've already met with a nurse, they've already ordered baseline labs, they've already had their chest x-ray done.

What do we expect the provider to do at this time?

Chad Garrett: Review labs, I N

Tara Rhodes: Hacker Medications, yep. So

medical history, right? So nursing can get some of the medical history. Um

That provider should also get a good medical history, make sure that there aren't any other pre-existing conditions that may complicate treatment, like HIV, like we said, is one of them.

Sometimes diabetes can cause um slower absorption of medications and things.

And then we also want to make sure that they do

current medication reconciliation.

paying attention to any potential drug interactions because rifapentine um

does have some significant drug interactions. Well I know that the

anticonvulsants is kind of a class that has some contraindications with rifapentine.

So get a good medication history.

After that medication history, we want them to do a medical exam. And this really can be

a targeted medical exam, really looking for symptoms of active TB

and any signs of hepatitis or other liver disease that might preclude treatment.

And then somebody said INH or 3HP, then we want the provider to order that medication.

And when they do, we want to also give education to the inmates at that time of this is when

you know, you're gonna come for pill line. So if you're doing three HP, we know that that's gonna be once a week.

And so we want to let them know we do uh three HP on Tuesday.

So next Tuesday, your medication's going to start, be here.

If we don't tell the inmates when to show up, then you know we start to have no shows for a 12-week course.

And then the last thing we want to do is they can order any additional labs if they need more frequent monitoring.

So that's going to be

usually at week four that we order additional labs

and that would be from the provider reviewing those labs, seeing if the AST

ALT are elevated at the beginning of treatment. Then we will want to do additional labs.

If they come back positive for hepatitis, we would want to do additional lab monitoring for these patients

Okay, so now we've started them on treatment. They're either on their their

4R, their 3HP, but they're taking some medication, maybe their six months if they have HIV.

So now what do we do while they're on treatment? What are some of the things we need to do?

Any answers?

Chad Garrett: So uh we have from before follow-up appropriately, assuming the labs are available already, uh

educate, symptom check, side effect. Modern name for side effects.

Tara Rhodes: Yes, that's what I'm looking for. Some of those. Good. So we want to monitor Pill Line

because this is only a 12-week course, and so we want to make sure that we don't have no shows.

We've had some situations where the patient has shown up and has missed a week and and nobody really uh

paid attention and then

they get to their under their treatment and the provider thinks they're done and they only had 10 doses.

Well, 10 doses is not a complete treatment for 3 HP. C says You have to have at least 11 doses.

12 is always optimal. So we want to monitor that pill

line, make sure our our inmates are showing up when they're supposed to be showing up and getting their medications.

Maybe they they weren't told when they were supposed to come. So monitor that pill line

We want to document any side effects. The way that I used to do it when

I was in the institution, I would inform my patients when I did the teaching that

If they had any side effects that were mild side effects

to let the nurses know on the next pill line when they came to get their medications

And then we could address those if we needed to.

If they had severe side effects, then they should just come directly to um a

sick call or come to health services if they're having those don't wait until the next week.

But if they're having some mild symptoms, they can usually let you know at the next

pill line and then your whoever's ordering or or the IP and C nurse if you guys have one

can kind of talk to them a little bit further about those side effects And then

we want to get extra labs if we need. For us, that's usually around week four.

We monitor, see how they're doing, making sure LFTs aren't aren't um skyrocketing.

And if those labs are becoming

too high or patients become symptomatic then we want to know when to hold medications

and we need to refer to the provider if they're having those severe side effects. We don't want to

keep giving the medication if they're having severe side effects. So make sure that you hold those medications.

And then

at the end we want a final appointment that's going to be making sure that everybody has had all 12 doses, has had all

four months of their um rifampin has had all six months or nine months of their INH did they

did they meet the the amount of doses they needed to to be considered complete?

At that final appointment, we also want to let them know kind of

you've now had this treatment, you shouldn't need this treatment again. This is

unless you've had a, you know, a

another exposure down the line that's really bad, you know, this should decrease your um your

risk of getting TB from this becoming active from this um kind of infection state that it's in now.

So I'll let you read that while I take a sip.

And feel free to use Laffy emojis, even though I can't see them because I find my memes quite hilarious.

Feel free to use those.

Okay, so what would we need to do differently if when we started off our lab showed that Ms.

Smith had hepatitis, right? We just want to do a a few things to And I've already already talked about those.

That was pretty much the extra monitoring, right, for the hepatitis. So

Continuing our scenario, Mrs. Smith, she reports to Pill Line and she's complaining of nausea and abdominal pain

and her eyes are also slightly yellow. Not too bad, but you can definitely see

that they have a yellow tint. So what's our next step here when she comes to Pilline and

lets us know that she's having these symptoms?

I hate not being able to see comments.

Chad Garrett: Stop the meds. Hold the meds. Hold the meds and draw some labs.

Tara Rhodes: Perfect. Toll medications, right? And we're going to call that provider.

So this is going to be acute hepatitis. This can happen in patients without an underlying chronic hepatitis.

to these medications that we use. So you could have acute on chronic hepatitis

or you could just have an acute hepatitis that that comes on from the medications. And so

in this scenario, we have

that the lab results come back as the ALT is 170, the normal range is 7 to

55, and the AST is 150.

and the normal range is 8 to 48. So this is

three times the upper limit, these results are. So if they're three times the upper limit, then

we are definitely going to continue to hold those medications until those LFTs go down.

And usually we wait about a week to draw those labs

to see if if they're they're trending downward. If they're asymptomatic, then the threshold

is usually around five times the upper limit if you're just drawing labs on possibly, you know, your four-week check on these guys that had

increased risks. We're usually, okay, five times upper limit

you need to hold if they're asymptomatic, but this one, since she has these symptoms, definitely hold this medication because she's three times the upper limit.

If it's bad enough, you may have to send the patient out to the hospital if the hepatitis is

bad enough and the LFTs are are high enough. We did have that scenario before.

And like you said, draw laps. Okay, so once these

return to normal, we want to continue treatment, and then we want to watch those patients really closely for symptoms and we want to draw those labs

more frequently.

For our public health partners that are on, that's a good time that you can consult with your local health department.

They can help you make those decisions on

when to start treatment back and how often to draw those labs on those patients that

you had to hold medications on. So they're a great um resource for you guys in those kind of situations.

Okay, so that was kind of our quick rundown on

and our time is is going, so this is good. We're going to move on to active TB. So we had our first choice of no

infection. And then we had the second choice of

we could have TB infection, and that could go straight into active TB, or we could have a latent

infection that then turns into activates into this active TB. disease, right?

So we've got those those couple options for active TB.

So our second scenario is we're going to have a male inmate this time and you're the new

nurse on duty when a bus comes into receiving and discharge. That's what we call our kind of

intake area.

The RD staff call you over because an inmate has been coughing since he got off the bus

So you arrive in RD and you observe that the RD staff have done a great job.

They've already separated this inmate away from the others.

They took them out of this nice big cell that they have here full of everyone and put them by themselves.

And so kind of some thoughts of those that you work in institutions ,

where can you separate an inmate in your facility

Chad Garrett: Airborne isolation room, negative pressure sale

Tara Rhodes: Those are perfect if you have them. What if you don't have an AI room? You're a small facility.

Could be. But you gotta be careful. Sometimes like our shoe has um

shared ventilation between the cells, and so shoe is not the best place

for our patients to go if we don't have an isolation room. And those are so if you have like an Go ahead.

Chad Garrett: I was going to say put a surgical mask on them and place them in airborne isolation if possible. If not a single

cell without shared air handling.

Tara Rhodes: Yeah, perfect. If you have got a closed door room, that's always good. So like in our receiving in

our RD area, we have um like a medical room that has a door, we have another room that kind of um

SIS or those people will go in that actually have a closed door without any kind of gate

And that's a place that you could possibly put somebody. So

just trying to get them separated if there's a closed door, that's your best option if you don't have

an AAI room. And so what do we do next? I did hear

my very first and

happy answer is that you're going to mask the inmate, but then you also want to mask yourself if you're going to

talk to the inmate. mate. So yay for whoever put that answer in. After that, what are you going to do?

It's something that I I love from before that we talked about with um

With TB infection.

Chad Garrett: We do have an interesting answer, is that uh

this person at their institution, um if they suspect active TV, they call an ambulance and send them out

with a mask, naturally.

Tara Rhodes: Yep. That's good because um that's eventually what you're gonna have to do um with them. Um

and so just separating them until the ambulance comes is um is a good good idea.

And during that time um

Some of the things you can do is get a symptom screen, right?

So kind of find out what other symptoms this person is having.

You want to know how long have these symptoms persisted. This could just be somebody just

got a cold yesterday, right? There's a whole lot of reasons for coughing.

So we kind of want to get a full symptom screen. And then we want to determine other risk factors.

So does this patient have any immunocompromising conditions or taking any um

immunocompromising medications? Are they from an endemic country?

Do they have IV history of IV drug use? So

any of those risk factors we want to note at the same time because this is going to help us make decisions if

this patient has to go to the hospital, those kinds of things.

Next, we also want to know TB history. So have they been a close contact to a TB case?

Have they had a history of treatment for TB infection or TB disease?

In that previous scenario, we had the female that came from Mexico. A lot of our cases in Texo

in Texaco, we are that close, but we are not Texaco. Um in Texas come from

Mexico and I think that I can tell you almost every single person

that has had a um positive symptom screen that said that they were in a Mexico prison

has had um positive for TB disease. So Mexico Prison

is a very high risk factor for uh in our area for having um active TB.

And then like we said, we want to isolate that person. And if we don't have an airborne isolation,

you can send them out to the hospital, get them into a separate area until you can get

the ambulance there to get them to get worked up in the hospital. Very good. So

an update on this guy.

Okay, so I'm gonna read each paragraph and then we're gonna look for some risk factors in each paragraph

in this scenario. So the first one, Mr.

Jones reveals he was born in Mexico and was released from prison there a month ago.

He doesn't know if he has been exposed to TB, but a lot of people in prison were coughing.

He has never been treated for TB infection or TB, and his TST is red

at 30 millimeters. So what are some of our risk factors here for this?

Chad Garrett: Prior prison, lived in Mexico, positive T S T

Good. Mexico, Mexico, Mexico, Mexico.

Tara Rhodes: Yes, a lot of people were coughing, right? Good. Good. So uh

so then he tells you that he's lost about twenty pounds

and he had a fever and night sweats, but that was about three weeks. weeks ago. And that he has

this new cough though that's been there for about three weeks since he had those night sweats and that.

What what do we see in this one?

All of the above, right?

Chad Garrett: Uh yeah, night sweet, night sweats. High index of suspicion. Eat sweets at night.

I'm just saying right here, it's bad. Just bad.

Yep, right.

It gets worse. It gets worse. No matter what we need

out he goes.

Tara Rhodes: Yep. Okay, why don't I click? Okay. So

one good thing is his HMA test and all of his other base labs are are are negative, which um

You wouldn't necessarily know that though at intake, but that's just some general information for you to have.

So in this paragraph, he says he has diabetes. Um he's got hypertension, psoriasis, and GERD.

And he reports that he takes a shot for his psoriasis, but he doesn't know what it is. Risk

factors from this paragraph

Chad Garrett: Diabetes , use medications, immunocompromise.

Yeah. Biologics.

Tara Rhodes: Yep, he's probably on a biologic, right? If he's got a shot for psoriasis. Good. Got them all.

Okay, so now his chest x-ray showed some small reticular

nodular changes in the right apical lung, and there's a small right pleural effusion.

And so if um if you're not familiar with reticular nodular nodular um like

opacities or changes like the reticular and

I have a a slide in a little bit that shows some of it, but there's some uh reticular that um

Reticular is is like a net like is what they call it. And then nodular is like a sounds. It's like a small round.

And if it's opacity, it can be like a shadow.

If it's an actual nodule, then it's uh usually uh more

dense. So uh-oh, right? Like from all of this, what do we have and what do we do, right?

This is a big uh oh like somebody said he goes out if you don't have a room right

So now we need to determine if this is TB or not TB. My very, very

high alerts would be going off for TB on this guy, right? So um

we want to continue him on isolation because of all of his risk factors that he has.

And like y'all said, if you don't have an AI room, you're gonna send him out so he can get worked up for

TB. So what are our first steps in our workup for

TB? We did a chest x-ray, we got that. So what comes next? Uh

Chad Garrett: SPM collection, PCR.

Tara Rhodes: Great. Yep. So we're gonna do at least three acid fast bacilli

um and culture um and then we're going to try to do um at least one NAT

or PCR and then two if possible. We like two if you can get them The NAT

is going to be your nucleic acid amplification test, and that's really, you know, just your

molecular test that's going to show if we've got MTB. uh DNA in there and then some places will

use the polymerase chain reaction the PCR so depending on your lab whatever it reads you would order that

NAT or the PCR however that that goes in your in your area.

And then we really want to make sure that one of those specimens specimens is a morning time specimen.

That's going to be our best bet.

When they wake up in the morning and they're they're kind of coughing and hacking, those are usually your best samples.

So if you can get at least one morning sample and they need to be be eight hours apart.

So you can get two in a day. They just need to be eight hours apart if you do that.

And then we also want to get some baseline labs. And when we do baseline labs, um

The least we usually want to do is going to be a CMB, CMB. Let's put two labs together again.

We want to do a CBC , complete blood count, and a complete metabolic panel.

We like to get uric acid because if they get started on um unripe

then that pyruzinamide can cause some effects in that uric acid and gout-like symptoms.

And then we want to do an HIV if they haven't had one already, and we want to draw hepatitis labs if they haven't gotten them already.

Okay, so on day four of isolation, you get your results back from AFB sample one

and two. So sample one resulted as positive and as a plus four.

Your lab may read them differently.

It may say me, it may say few, you know, it may have numbers.

The ones we see a lot have have numbers, so a plus four And then sample one, that

was also positive, and the organism identified was M tuberculosis. And sample two was

plus two. So what should we do?

Chad Garrett: He is highly infectious.

Tara Rhodes: Matt

Yeah, we don't want to let him out, do we? No. We're going to keep him in isolation. That's not good.

Three positive. All three of his samples are are positive. Um, he's not positive. Um

his third sample also comes back positive. Yes, very good for our public health partners.

We want to make sure that they know that you've got a a uh a TB case.

So we want to start right. And

if you have all three of those labs already drawn and you're getting good results back, you can assume that third result is also going to be

a good sample, you want to start your RIPE.

So the sooner you start the RIPE, the sooner you can get them out of isolation. And so here we've got three

positive sputums. So then we need to do weekly sputums. And why do we need to do weekly sputums

on this guy?

Trying to think how many slides I have. Oh no. For

Chad Garrett: remove isolation, monitor response and get him out of isolation.

Tara Rhodes: Right. So we we need to get three negative smears, right? So they have to be consecutive.

And if we don't draw weekly, then we're we're not going to know uh when he can get out of isolation. So

when can he release from isolation? isolation.

They have they've put out new guidance for community standards. They're trying to be able to

decrease the amount of time that patients have to stay in isolation. People have jobs, they

got to get back to their life. But we are in a congregate setting in corrections and therefore

our standards have not changed. There is no guidance

that has changed on release since 2006 from the CDC. So

for us, they need at least five days of RIPE and three of those consecutive negative sputums.

If this patient had had a cavitation, then that increases to 14 days of RIPE

and three consecutive negative sputums before they can leave isolation. So

Five days non-cavitary, fourteen days cavitary,

three negative sputums consecutively

So sensitivity comes back on this guy and it shows no resistance to medications, so that's good.

We've got a pansensitive case and Mr. Jones completes 56 doses of his RIPE without any issues.

So now what do we want to do?

Chad Garrett: Add in H

Tara Rhodes: So we started with INH because we had rifampin in case anybody doesn't know. I'm sorry, I just put in um

acronyms here. We started him on rifampin, um, INH.

uh pyrazinamide and thambutol. So that's what he's been getting for his 56 doses.

So for us, we like to get a chest x-ray after that 50, we know he's he's positive.

We know he's going to have to continue medications. But we like to kind of check where that progress is at

that two month and then we know his sensitivities.

We wouldn't want to switch him if we didn't have sensitivity testing back.

So do not switch to continuation phase, which is just rifampin and INH, if you don't have your sensitivity testing back, because if they're resistant.

We don't want to take away medications if they have an INH or rifampin resistance.

We want to make sure we have that information. So

they take their 56 doses. And then we switch to our continuation phase.

And so that's going to be another 126 doses because he is a lab -confirmed case.

So that's going to give us a total end treatment of 182 doses. Now this is for daily dosing.

Some of you in public health on the outside, you don't do daily dosing.

You do five days and then you give your patients

Two days to take on the weekend, but those don't count because they're not directly observed. So

your dose counts may be a little different for daily therapy.

It's going to be 56 and 126 for us

with a total of 182 doses to finish out that treatment.

One good thing about having them in prison, we can give them meds every day. Okay, so Mr.

Jones has been compliant with his medications, reports that he had no side effects.

He completes his 126 doses of his continuation phase.

So what are our very last steps with this guy?

Chad Garrett: We refer to the TB clinics when released, follow-up

yearly, and as needed, if he remains incarcerated. End of treatment.

Tara Rhodes: Yep. So we always get an end of treatment chest x-ray

because we do have patients that leave our custody, come back in, right, or they go somewhere else.

So at the end of treatment, we want to get that chest x-ray to just kind of see what their new baseline is, right?

Active T can leave some some scarring, it can leave some changes on their chest x-ray.

So we want to make sure when they finished, what did that chest

like. And then we want to have one last provider evaluation, make sure that everything was good.

They can give them their information of what do you need to do. um from now on.

And if they're incarcerated, we just, you know, let them know if you have symptoms come back, if something happens, you know, let us know.

Otherwise they can remove them from that infectious disease clinic usually. And then we have

our coding in our um record that would change to history of respiratory TB instead of

the the active code of respiratory TB. So let's quickly go over culture negative TV

because my little computer issues didn't give me a lot of time from the beginning. So this is what

we used to use Quest. We're now using LabCore. I actually haven't

seen any new LabCore ones, but this is what a Quest um

uh culture report is going to look like. So you can see on the top it's gonna

it's gonna tell you that the order was the correct order. It was this micro bacteria culture with a floor

fluorochrome smear. And then

you're going to be able to see that the smear results were no acid fast bacilli using that fluorochrome method

and then the result was that they didn't find any MTB none was isolated after the six weeks.

So that's what um what a a culture negative or that's what a negative um

lab report could look like. So

in this scenario we have a work supervisor in the kitchen and he calls medical to report he has an inmate, Mr. Koch

that has been coughing for about two weeks. Mitch Sarkoch reports he hasn't been able to go to sit

call because he leaves for work before medical gets to the unit.

He is brought to the medical to see a provider. And on review of the chart, NP Nightingale notices that Mr.

Koch had a 20 millimeter TST last year and refused treatment for TB infection, latent

TV He also has type 1 diabetes that hasn't been well controlled

and he denies any other symptoms. So what do we do?

Here's your answer since we're running out of time. Right? A chest x-ray.

And he takes this chest x-ray

and it gives us the result of reticular opacities in the lateral left

upper lung along with patchy alveolar opacities. That's a camp rule out TB

for us when we see that. So these are a bunch of different chest x-rays

that just kind of show you can see some of that reticular kind of um netting

like in some of those pictures that we talked about previously. So

What do we think this is and what do we do? We've got this bad chest x-ray and some symptoms, right? So

it's going to be the same workup as we did on our previous case. We're going to

we're going to do sputum, we're going to put them in isolation, we're going to get our sputums ,

and then we're going to see what our results are So uh

the AFB smears and the NAT, one or two of them, they all come back uh negative.

So do we release Mr. Koch from isolation?

Chad Garrett: Not without more information, we don't.

Tara Rhodes: Good. Good answer. He's still sick. Right. So we have no reason.

We have we don't have an explanation for this um for this abnormal chest x-ray and we don't have um

he's had symptoms for a while, right? So as as long as they're

hasn't been um an ammonia and and here's the thing, you y your providers can do this a a couple different ways.

If they think it's a possible pneumonia or a bronchitis or something

while they're in isolation if they want to try those antibiotics um for some other diagnosis

then they need to make sure that they're not given a fluoroquinolone because that can treat TB

and then they need to do a follow-up test x-ray.

And if nothing has changed, symptoms have not improved, and the test x-ray is still not looking

any better, then we need to start RIPE on this patient.

So cultures return negative. So right now we have him on rape.

He's got negative smears, negative cultures. So what is

kind of the difference between what we're going to do with a culture negative case, which we actually see a lot in the Bureau.

We we get these subclinical cases of TB and

we catch them before they start to really produce a lot of bacteria.

Same thing, we're going to repeat that chest x-ray after 56 doses like we we wanted to the first time.

But here's the difference. If there's no improvement, we're going to stop treatment.

If there is improvement, we're going to continue treatment for

what we consider a culture negative TB.

So sometimes if you don't have a really bad chest x-ray and it's kind of iffy and then you

you give them the TB treatment and nothing really changes after 56 doses, um

TB meds are are going to make some some change. So if it's

if there's no change, we just stop that treatment and we consider them treated for um TB infection because uh

fifty-six doses of RIPE is equivalent to um a full treatment for um

plain TB or TB infection. So we continue treatment.

So we're going to do another 56 doses of rifampin and INH. So

it just shortens our continuation phase. So in

Lab

culture, lab positive, we're going to go 56 doses of RIPE and then 126 doses of INH Rifampin.

Here we just shorten it to a total of 56 doses and 56 doses. which

ends up um being four months instead of six months. So at the end of treatment it's going to be the same.

You want to get the the chest x-ray

and that provider appointment to let the patient know what what they need to do.

So the take-home points, um, my take-home point is that I want to live in this house, in this beautiful place, um, someday.

I don't live there now, unfortunately. So treating TB infection or latent

TB reduces the overall TB risk. So in a um situation where we have control

of people for um extended time in some of these prisons, it's uh we want to try to get that done.

Only 12 doses reduces the risk of disease.

Prison is a great setting to treat TB infection. Patients can be [unclear speech]; cultures do not rule out active TB.

And TB can be complicated. So seek assistance. You've got your health departments that can help you.

You have um in the U. S. we have our centers of excellence and that

Um any questions that you have new you talk about um TB. So

that wraps it up for today. Um This is my information at the bottom. That's my email and that is my work

cell. So feel free. I know we had to kind of um End this quickly.

If you have any questions that we didn't answer, if you just have questions about how we do it, if you're from

outside of the US, then feel free to email me or give me a call.

I'd be more than happy to answer any questions.

Chad Garrett: And can you slip one more slide so we can get to the post-course survey? Sweet, thank you.

Um I would appreciate it very much if you guys would take just a minute there, follow that survey to SurveyMonkey, and complete a survey for us.

We would greatly appreciate any feedback that you have for us. And

Captain Rhodes, would you be willing to stay on another couple minutes if anyone has a question?

Tara Rhodes: Sure, of course. So

Chad Garrett: if you want to stay with us for