Correctional healthcare practitioners turned their attention to a number of issues over the last year ranging from the treatment of diseases that commonly afflict inmates to the prevention of the spread of those diseases to staff. The field also tackled other health-related issues including the rise in the number of prisoners with mental health problems and technologies that can simplify the provision of health care. The Corrections Connection covered all these issues and more during 2001; we have tried to summarize the highlights of the year below.
Mental Health
Disease Prevention
HIV
HEP
Staff health/safety
Telemedicine
Mental Health
Estimates of the number of inmates with mental health problems are staggering. This has caused correctional practitioners to realize that a deeper understanding of the issue can help provide proper treatment, help these individuals become easier to manage and be more productive behind bars.
About one-fifth of the estimated 191,000 inmates in state prisons who were identified as mentally ill were not getting therapy or counseling, according to a recent Justice Department study. A study based on 2000 data also showed that only 70 percent of state prison facilities screen inmates for mental illness as a matter of policy.
Mentally ill inmates account for 16 percent of the state prison population, and 79 percent of those identified as mentally ill were receiving therapy or counseling, the report said. Female inmates are treated for mental illness at a higher rate than male prisoners. One in four women gets therapy and one in five takes medication for mental illness. Only 10 percent of male inmates receive any treatment.
But some believe that more in-depth screening needs to be done in order to truly understand the types of mental health problems these offenders have.
'When most places screen for mental health issues they are screening for bi-polar disorders or schizophrenia; those kinds of things. We know that we are going to hit 10 to 20 percent of the folks in the agency who have those kinds of problems. [But] we have 80 to 90 percent of the folks who we don't know about,' said John Stoner, PhD, Mental Health Coordinator for the Colorado State Penitentiary, Colorado Department of Corrections.
Stoner suggests that in addition to screening for the typical 'Axis 1' disorders of bi-polar and schizophrenia, corrections agencies also begin to screen for personality disorders, which are much more prevalent in a correctional population than in general society. Axis 2 issues include character and personality disorders that can cause problems that lead to incarceration and management problems once they are there.
A related issue that correctional health care providers are facing is continuity of care once these individuals return to society. Without care that follows them into the community offenders will recidivate and end up back in the system. In order to break this cycle, numerous states, including Texas, are initiating collaborations between corrections and community-based providers so that upon release, these offenders can continue treatment and stay out of jail.
'Felons in general have a hard time reentering [the community] with difficulties in finding a job, for example,' says Dee Kifowit, Director of the Texas Council on Offenders with Mental Impairments (TCOMI). 'Now couple that with being a felon with a serious mental illness and more times than not substance abuse issues. That makes re-entry very hard. So it is common sense not to open the door and say 'you're on your own' to these individuals, because you are setting them up for failure.'
Created over a decade ago by legislative mandate, TCOMI is made up of twenty-one agencies with an interest in special needs offenders, including the Texas Department of Criminal Justice and Texas Department of Mental Health and Mental Retardation.
TCOMI's Continuity of Care program includes both pre and post release care for mentally ill offenders in every state facility. Six months prior to release, counselors develop an aftercare plan and coordinate with service providers in the area the individual is returning to. For offenders with a history of noncompliance with such services, the Parole Board may require mandatory participation in treatment and rehabilitation programs as a condition of release.
According to Kifowit, no matter the level of compliance, case managers are vigilant in checking up on those recently released to ensure that they are acclimating to the community.
'We work hand in hand [with all of our partners] to make sure these people see someone everyday, whether it be a counselor, treatment provider, probation officer, whoever,' she says. 'These people have constant contact and are there for support, not to catch them doing bad things. For some offenders, they have no family structure, so the only people in their lives are paid to be there, so we try to make that as positive as possible.'
Corrections professionals also discussed this issue at a major conference in Boston last summer with the hope of making headway.
The National Corrections Conference on Mental Illness, sponsored by the Corrections Program Office (CPO) of the U.S. Department of Justice Office of Justice Programs, gathered teams of representatives from corrections, mental health, the legislature, the judiciary and others from each state as well as Guam, Micronesia and the Virgin Islands to come together, initiate discussion and develop solutions on the problem.
'This gives them an opportunity for people to get together and have a conversation around a topic like this and it allows them to get away from the hype, get away from the sensational headlines, get away from the people who are sort of watching [in their own state] and have a conversation that is very open, very candid and then to say, 'if we have a problem, we need to have a strategy to deal with it,'' says Larry Meachum, Director of the CPO.
As a commissioner of corrections in Massachusetts, Oklahoma and Connecticut, Meachum knows first-hand how prison administrators can feel isolated from others in managing mentally ill offenders.
'Many times it felt like it was my problem and that everybody left it as my problem,' he said. 'A conference like this can bring other people to the table to see that corrections is a player, but it is not just them - it's not just their problem. All components represented here have a vested interest in persons with mental illness captured by the criminal justice system, so it gives company and support for the corrections people.'
Disease Prevention
Many correctional systems are working hard to find the right combination of testing and treatment to eliminate the spread of the most common infectious diseases among inmate populations - HIV, TB, Hepatitis C and STDs.
In some circumstances, state law dictates the rules that correctional agencies must abide by and other times it is the agency itself that determines how an inmate receives treatment and testing. Either way it is incumbent upon an agency to provide the community standard of care and keep up with the latest treatments for these diseases.
New information from the CDC about a new two-drug treatment for TB gave correctional healthcare practitioners new ammunition. The treatment lasts for 2 months may help solve some of the treatment problems that arise from overcrowding and other corrections-specific issues according to a recent CDC study.
According to a CDC study that was released last year, the treatment, 2RZ, appears to be a promising regimen for improving completion of treatment of (latent tuberculosis infection) among the inmate population. Furthermore, its expanded use could contribute to our goal to eliminate tuberculosis in the United States, according to Dr. Naomi N. Bock, of the Centers for Disease Control and Prevention, and colleagues.
In the CDC's year-long study, the investigators found that 1,360 of the more than 234,000 new inmates admitted to Fulton County Jail in Georgia tested positive for TB. Of that group, 168 were eligible for the 2RZ drug treatment, which includes daily doses of rifampin and pyrazinamide, the authors report in the March issue of Chest. The ineligible group included inmates who were released before being interviewed by the 2RZ drug treatment coordinator as well as those who said they were previously treated for TB. These findings show an almost fourfold increase in the number of inmates who completed 2RZ treatment in comparison to the number of inmates who completed isoniazid therapy during the previous year.
Preventing the spread of STDs is also in the forefront of correctional healthcare practitioners minds. A small syphilis outbreak at three Alabama state men's prisons in 1999 prompted investigation into transmission and raised a number of issues about what works to prevent transmission. Investigators, who released information last year, found that neither partner notification nor routine triennial screening was sufficient to prevent or control the outbreaks, as evidenced by the large percentage of cases (26 percent) that were detected by mass screening. Condom distribution should be used for STD control, the researchers recommended. But, like most state prison systems, the Alabama Department of Corrections prohibits the distribution of condoms in prison. Improved health care provider and prison education about STDs could greatly 'fortify correctional STD control,' according to the authors.
Finally, the authors emphasized that in the United States and perhaps in other parts of the world, correctional STD control affects the health of the general population.
HIV
The connection between corrections and public health agencies is becoming more common as both entities realize the need to partner to prevent the spread of disease. HIV is one area where this is more commonly seen.
In Florida, these parties are working together to prevent the spread of HIV. Dr. David Thomas, Chief of Health Services for the Florida Department of Corrections helped create the Interagency Advisory Committee Taskforce, which is collaboration between jail, prison, county health departments and community HIV providers.
The taskforce's main goal is to bridge any gaps between services for HIV infected inmates and support a continuity of care. The collaborative effort is taking place in Broward, Palm Beach and Dade counties so far and is in its early stages. Thomas and others believe that collaborations such as this one will become more commonplace in correctional healthcare.
Collaborations such as this one have been supported by the CDC's National Center for HIV, STD and TB Prevention for years and a long-time leader in this arena, John Miles. Last year Miles left the CDC to become a senior associate with the health consultation and health care management firm Management Assistance Corporation, where he hopes to continue working in the corrections arena.
One popular way to encourage safe behaviors among offenders behind bars and when they are released is inmate peer education. One example is in Texas. Community and public health officials in Houston, Texas have initiated a peer counseling component in one prison to enhance the positive benefits of HIV peer education.
'[After] we started the first peer education program in the Texas Department of Criminal Justice, we were approached by them to start a pilot program [for peer education.]. As we continued to do evaluations, we kept hearing from a lot of the offenders that maybe the next step might be a prevention counseling program that could be an adjunct. They were just eating it up, so why not develop additional programs to augment peer-based prevention,' said Mike Mizwa, CEO of AIDS Foundation Houston, Inc., which started the peer program with inmates at TDCJ's Gatesville Women's Prison.
Issues of access for HIV positive inmates were also addressed by corrections agencies last year. In March of 2001, a task force appointed by the Mississippi DOC Commissioner Robert J. Johnson presented a list of 11 specific recommendations that would increase HIV-positive inmates' access to education, treatment and job skills programs. Among the recommendations was the appointment of an HIV Training Advisory Committee to oversee and review increased HIV training of both staff and inmates, train selected inmates to be peer educators for use in all DOC units and ask the University of Mississippi Medical Center to perform a hazard analysis review of vocational programs available at two facilities.
Two months after their submittal, Commissioner Johnson accepted the Task Force's recommendations, opening the way for HIV-positive inmates to have equal access to valuable treatment and programming, which left Alabama as the only state to fully segregate prisoners with HIV from the general prison population.
According to Johnson, the decision against creating separate programs for HIV-positive inmates was twofold. 'The bottom line was that to recreate or duplicate existing programs just doesn't make sense,' he said. 'Also, it goes back to the 'separate but equal' theory, which was not the case here. Typically, with separate programming that is called equal, they don't work and something gets shorted - we know our offerings [for HIV-positive inmates] were unequal.'
HEP
Much like HIV a decade ago, hepatitis C, its treatment and the costs associated with it is on the lips of correctional healthcare providers. But hepatitis C differs in that treatment may not be helpful for certain patients depending on their health, mental health status, age and other factors.
'Seventy-five to 80 percent of people with hepatitis C (HCV) live their lives without any sign of hep C other than a positive lab test. Some of our [inmates] are diagnosed when they have end-stage liver disease, some are diagnosed early, before they have signs of end-stage liver disease. There is no way to tell if they have had it for one year or 10 years,' said Michael Kelley, Director of Preventative Medicine for the Texas Department of Criminal Justice.
The Centers for Disease Control provides guidelines for the management of hepatitis C that includes offering screening for all those who are at high risk for the disease, such as intravenous drug users, but does not provide specific guidance about when to treat for the disease or how.
'The tipping point has been around hep C; there's so much we don't know. If we offer screening how many will take it?' said Rob Lyerla, Epidemiologist for the Hepatitis Branch at the CDC. Lyerla said educating inmates about their status through screening is an important step because those individuals can begin to take better care of themselves and take precautions to prevent infecting others.
The CDC's MMWR (Morbidity and Mortality Weekly report) on HCV from 1998 states that those with chronic hepatitis C who are at greatest risk for progression to cirrhosis should be treated. For all others, treatment benefits are less well known. (See MMWR at http://www.cdc.gov/mmwr/preview/mmwrhtml/00055154.htm) Corrections agencies are awaiting revision to these guidelines, which are expected in a few months.
A CDC investigation following an outbreak at a long-term state correctional facility in 2000 helped show how the disease can be spread. The outbreak in an undisclosed state involved 11 patients who had been incarcerated for more than six months and had acute (recent-onset) infection--indicating that transmission had occurred within the prison. An additional 10 inmates had previously unrecognized chronic hepatitis B infection.
The investigation started in May 2000, after a 34-year-old man who had been in the prison for more than 2 years developed jaundice. The man reported having had unprotected sex with his cellmate, who also tested positive for HBV.
Testing was done on inmates in the same dormitory, as well as inmates in other dormitories. About half of the 907 inmates who completed a questionnaire reported participating in behaviors that could cause HBV. Twenty-one reported injecting drugs, 26 reported having sex with another man, 73 reported using another inmate's razor, and 429 reported receiving a tattoo. 'Sex with another man accounted for only 20% of the new infections in this investigation. However, this and other behaviors prohibited by the correctional facility (e.g. injecting drugs) probably are underreported by inmates,' the researchers wrote in the June 29th issue of the CDC's Morbidity and Mortality Weekly Report.
Staff health/safety
Many jurisdictions have implemented new methods to help keep their staff safe in a potentially dangerous environment. On example is a partnership between the Correctional Service of Canada and Health Canada has resulted in a surveillance system for offenders and staff that actively detects and treats TB at the earliest stages in order to keep those in the prison environment safe.
The CSC's Tuberculosis Tracking System (TBTS) was developed to capture information on reported TB screening results from both inmates and staff. Any offender entering into the Canadian federal corrections system is screened upon reception for TB through either a skin test or chest x-ray.
Those with negative results are offered a second test one to three weeks later to provide a two-step baseline. Those suspected of having active TB are isolated until further diagnosis and risk can be determined. Furthermore, ongoing assessment in the form of annual testing occurs while inmates are incarcerated to additionally monitor their TB status. Staff are also screened by nurses from the Occupational Health and Safety Agency (OSHA). If negative, they too are offered testing one to three weeks later and if positive are referred to their physician for further investigation, including a chest x-ray. Annual screening is also available to staff. In the cases of both inmates and staff, participation in screening and treatment is voluntary.
A study by researchers at Columbia University's Mailman School of Public Health revealed last year that correctional health care workers are frequently being exposed to infectious disease and may not be doing all they can to prevent those exposures.
The study, funded by the National Institute for Occupational Safety and Health (NIOSH), surveyed correctional health care workers in Rhode Island, Maryland and Texas - representing low, medium and high risk for exposure from inmate patients.
'We found 7 percent reporting an exposure in the last six months. This corresponds with our hospital data [for heath care worker exposures.] We wouldn't have thought they would have had as much of a risk because they are not doing as many procedures [as hospitals],' said Robyn Gershon, Dr.PH, MHS of the Mailman School of Public Health at Columbia University, who lead the study. The survey showed that 4 percent of participants were carriers of Hepatitis B and none of those who were infected knew they were infected. 'It is almost a public health implication,' said Gershon. For Hepatitis C, 3 percent of participants said they knew they had a past positive test and in fact 3 percent were infected.
In addition, 7 percent of respondents said they had at least one needle stick, 4 percent had at least one splash to the eyes and 2 percent had been cut with sharps. The study, which is the first to focus solely on correctional health care workers, also showed that 32 percent of those surveyed never reported an accidental exposure.
The reason many gave is they didn't know who to give the information to, Gershon said. But Gershon also believes that many health care workers perceive they would 'get in trouble' if they reported an accidental exposure. 'They know [what they should do] but a lot of them are in denial,' she said.
Despite improved safety measures, such as requirements to use safe needles that do not need to be recapped, there are still some issues. The results of the study show the problems: 42 percent lack protective clothing, 46 percent lack eye protection, and 27 percent participate in improper sharps disposal.
The reasons for placing an emphasis on staff health safety are many. 'The whole issue of keeping our staff safe makes sense. We have been working to find the safest equipment to do that,' said Lester Wright, Director of Health Services for the New York State Department of Correctional Services.
The recent data is hard to ignore. According to a recent federal Government Accounting Office report, there are 236,000 injuries each year in hospital settings from needle sticks. Since hospital workers make up only 40 percent of the health care workers in the U.S., - with the remaining 60 percent in non-hospital settings, the actual number of injuries is likely to be much higher.
In addition, the GAO report suggested that the adoption of safety needles and other prevention measures could significantly reduce the number of those injuries. This information combined with the passage in 2000 of the federal Needlestick Safety and Prevention Act has prompted correctional agencies to take notice.
The act ordered OSHA to revise its bloodbourne pathogens standard to require all employers, including corrections, to take measures to eliminate sharps in juries. The standard addresses:
*devices - employers are obligated to consider safety devices in their annual review of their exposure control plan,
*employee input - employees who will be using sharps and other devices must take part in selecting them,
*injury tracking - employers must maintain a log of all injuries from contaminated sharps - not just those that actually lead to illness.
Telemedicine
The use of telemedicine in corrections has become more common as it provides the means to connect physicians to inmates who are miles away. While the technology does not replace all face-to-face visits, it has given facilities the ability to provide effective health care for inmates, while also maintaining security by reducing inmate transports.
'There has been a tremendous growth in the correctional application of telemedicine and we've seen both states and local correctional facilities become more interested,' says Don McBeath, Director of Telemedicine, Rural Health and Special Projects for the Texas Tech University Health Sciences Center. 'Part of the [reason for this growth] has been a learning curve for folks not familiar with telemedicine in the correctional environment to hear about, learn and study - which takes a number of years. [The other reason] is that the cost of equipment has dropped over the years, so telemedicine applications that were not of sound business principals [in the past] may be now because of reduced cost.'
The state of Arizona has found that the investment in telemedicine has produced a larger savings in the long run. According to Richard McNeely, Co-Director of the Arizona Telemedicine Program, their first study in 1996/97 showed that it cost about $850 for one standard medical visit from a local facility, whereas with telemedicine, the same case would cost $470. By using technology, the prison can save money by eliminating the need for of two officers to accompany the inmate as well as the cost of transportation to the medical site.
Beyond cost, another benefit McNeely has seen is reduced litigation from inmates on health care matters. These kinds of results are what attract other agencies to this technology.
With
2001 behind us, correctional healthcare practitioners are bound to embrace and
discover even more innovations in 2002.
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