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Epidemiology of Tuberculosis in Correctional Facilities, United States, 1993-2011


Slide 1: Epidemiology of Tuberculosis in Correctional Facilities, United States, 1993-2011

Surveillance, Epidemiology and Outbreak Investigations Branch
Division of Tuberculosis Elimination
Centers for Disease Control and Prevention (CDC)

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Slide 2: The National Tuberculosis (TB) Surveillance  System

  • Database of all confirmed cases of TB disease reported to CDC
    • A confirmed case is one that is laboratory confirmed, meets the clinical case definition, or is confirmed by the provider (in absence of adequate laboratory or clinical information)
  • Since 1993, CDC has collected demographic, risk factor, clinical, and laboratory information on TB cases residing in correctional facilities at the time of diagnosis

Tuberculosis (TB) is a reportable condition in all United States jurisdictions and TB cases are reported to CDC in a standard format by public health authorities throughout the United States. Data are collected by CDC into the National TB Surveillance System (NTSS). These reports are summarized for TB cases residing in a correctional facility at the time of diagnosis in this slide set, for the years 1993 through 2011.

Reports of TB are counted according to a set of criteria (the “case definition”) which is specific to the United States. Only incident cases that are diagnosed in the United States are included and cases are verified by three levels of certainty, depending on the types of information that are available to healthcare practitioners and public health authorities. Standardized data are collected for each case such as, demographic, clinical, and laboratory information.  Information on TB cases residing in correctional facilities at the time of their TB diagnosis was first collected in 1993.  In 2009, the NTSS began gathering information on Immigrations and Customs Enforcement (ICE) custody. 

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Slide 3: Surveillance Reporting for Residence of a Correctional Facility

  • Resident of correctional facility at the time of TB diagnosis (Yes, No, or Unknown)
  • Types of correctional facilities:
    • Federal Prison
    • State Prison
    • Local Jail
    • Juvenile Correctional Facility
    • Other Correctional Facility
    • Unknown
  • A separate question about  “Immigration and Customs Enforcement” (ICE) custody was added in 2009
    • Persons in ICE custody can be housed in stand-alone ICE detention centers or other correctional facilities.
    • Questions pertaining to TB patients diagnosed in ICE facilities were 80% complete in 2009; 95% complete in 2011.

In order to be classified as a TB case in a correctional facilities, the case must be a resident of a correctional facility at the time of diagnosis.  The correctional facilities variable has six possible values.  The definitions of these facilities for TB-reporting purposes are as follows:

Federal prison:  Confinement facility administered by a federal agency; includes privately operated federal correctional facilities.

State prison:  Confinement facility administered by a state agency; includes privately operated state correctional facilities.

Local jail:  Confinement facility usually administered by a local law enforcement agency, intended for adults but sometimes also containing juveniles; holds persons detained pending adjudication and/or persons committed after adjudication, typically for sentences of 1 year or less.

Juvenile correction facility:  Public or private residential facility; includes juvenile detention centers, reception and diagnostic centers, ranches, camps, farms, boot camps, residential treatment centers, and halfway houses or group homes designated specifically for juveniles.

Other correctional facility:  Includes ICE detention centers, Indian reservation facilities (e.g. tribal jails), military stockades and jails, federal park police facilities, police lockups (temporary holding facilities for persons who have NOT been formally charged in court), or other correctional facilities that are NOT included in the other specific choices.

Unknown:  Inmate when the TB diagnostic evaluation was performed, but the type of correctional facility is NOT known.

The Immigration and Customs Enforcement (ICE) status was phased into the national TB surveillance system starting in 2009 and is recorded (yes/no) separately from the type of correctional facility.

Completeness of the ICE status information is calculated as the percent of non-missing (“Yes” or “No”) responses among all TB patients in correctional facilities.  In 2009, the first year that the ICE information was collected, the data were 80% complete for information on ICE status.  By 2011, ICE status data were available for 95% of all cases residing in a correctional facility.

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Slide 4: TB Cases in Correctional Facilities

  • In 2011,  a total of 9,946 TB cases ≥ 15 years old were reported in the United States
    • 9,884 of those (99.4%) had information on residence in correctional facilities
    • 424 (4.3%) cases were reported as residents of correctional facilities at time of TB diagnosis
  • Between 1993 and 2011, 3.8% (n=11,721) of TB cases reported in the U.S. were residents of correctional facilities at the time of diagnosis.

* http://www.cdc.gov/tb/topic/populations/correctional/default.htm

In 2011, 9,946 total TB cases ≥ 15 years old were reported in the U.S.  Among those, over 99% had information on whether or not they were a resident of a correctional facility at the time of diagnosis.  There were 424 cases who were residing in a correctional facility at diagnosis of their TB disease, 4.3% of all the TB cases reported that year.

Between 1993 and 2011, 3.8% (n=11,721) of TB cases reported in the U.S. were residents of correctional facilities at the time of diagnosis.

 

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Slide 5: Counts of TB Cases in Correctional Facilities Compared to All TB cases, 1993-2011

This graphs shows the number of cases of TB decreasing since 1993 to 2011.  Except for an unexpected decline in cases in 2009, the number of cases starting in 1953 with, 25,103 cases, has fallen steadily to a total of 10,528 cases reported in 2011.  The number of cases reported as residents of correctional facilities has also declined since 1993 when 953 cases were reported to a total of 424 in 2011.

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Slide 6: TB Cases in Correctional Facilities, Percentage of All Reported TB Cases, 1993-2011

From 1993 to 2011 there were a total of 11,721 TB cases reported in correctional facilities at the time of their diagnosis.

The percentage of confirmed TB cases in correctional facilities has always been under 10% of total cases reported.  The highest reported proportion occurred in 1993, with 8% (953) of all TB cases reported as residents of correctional facilities.  In 2011, this percentage had dropped to 4% (424).

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Slide 7: Percent of TB Cases in Correctional Facilities by Type of Facility, 1993-2011

Persons in correctional facilities at the time of diagnosis can reside in federal or state prisons, local jails, juvenile correction centers or other facilities.  Other facilities include Immigration and Customs Enforcement (ICE) detention centers, tribal jails operated by an Indian reservations, police lockups (temporary holding facilities for person who have not been formally charged in court), military stockades and jails, or federal park facilities.  Just over 50% of all TB cases reported as residents of correctional facilities were from local jails.  About 30% reside in state prisons, about 10% reside in other facilities (e.g. ICE), and under 1% were in facilities housing juveniles.

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Slide 8: TB Cases in Correctional Facilities in U.S.-born and Foreign-born Persons, 1993-2011

The proportion of foreign-born TB cases in correctional facilities is 30% compared to 46% of foreign-born among all TB cases reported from 1993 to 2011.

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Slide 9: Number of TB Cases in Correctional Facilities in U.S.-born and Foreign-born Persons, 1993-2011

Just as the proportion of foreign-born cases among all reported TB cases has risen over the years, the proportion of foreign-born TB cases in correctional facilities has surpassed those that are U.S.-born.  The number of U.S.-born cases has dropped sharply over the years from a high of 918 reported in 1993, to just 191 reported in 2011. The number of foreign-born has risen gradually from 177 in 1993 to 228 in 2011.  The highest number for any year was in 2010 when 274 foreign-born cases were reported.  The number of foreign-born exceeded the number of U.S.-born among all cases of TB in 2001.  For those in correctional facilities this cross-over occurred in 2008.

For more slides on U.S.-born and foreign-born in the United States see the Surveillance Slide Set “Tuberculosis in the United States, National Tuberculosis Surveillance System Highlights from 2011”, http://www.cdc.gov/tb/statistics/surv/surv2011/default.htm.

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Slide 10: TB Cases in Correctional Facilities by Race/Ethnicity and Percent of Foreign Born, 1993–2011

The largest number of cases reported in a correctional facility at the time of TB diagnosis are blacks (4933), followed by Hispanics (4251), whites (1966), Asians (325) and persons of other race/ethnicities or unknown race (191).  Among those the highest proportion of foreign-born were among Asians (95%) followed by Hispanics (74%).  The highest proportions of U.S.-born were among whites and blacks, both reporting 96% U.S.-born.

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Slide 11: Percent of TB Cases in Correctional Facilities by Immigration and Customs Enforcement (ICE) Status, 2011

Ninety-five percent of all TB cases in correctional facilities had information reported on whether or not they were in Immigrations and Customs Enforcement (ICE) custody.  Among those, 37% were in ICE custody.

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Slide 12: TB Cases in Correctional Facilities by Type of Facility and Immigration and Customs Enforcement (ICE) Status, 2011

TB cases reported to be in ICE custody in 2011 can be a resident of any facility type.  The category of other facility* housed the highest number (84 of 98 cases, 86%) of the TB cases in ICE custody, which include ICE detention centers.

*Other facilities include ICE detention centers, tribal jails operated by an Indian reservations, police lockups (temporary holding facilities for person who have not been formally charged in court), military stockades and jails, or federal park facilities.

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Slide 13: TB Cases in Correctional Facilities by Age Group and Percent in Immigration and Customs Enforcement (ICE), 2011

TB cases are also reported by age at time of diagnosis.  The age group with the majority of cases in ICE custody were among those 15 to 24 years of age (59% of cases in ICE custody).  This was followed by 47% in ICE custody among 25 to 44 year olds and  and 16% among 45 to 64 year olds.  There were no reported cases in ICE custody among those TB cases aged 65 years and older.

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Slide 14: TB Cases in Correctional Facilities by Age Group, 1993-2011

Among all TB cases reported in correctional facilities from 1993 to 2011 those 25 to 44 years old formed the largest proportion of cases (62.7%) followed by those 45 to 64 years of age (23.2%) and 15 to 24 years of age (12.5%).  Only 0.1% of all TB cases in correctional facilities were under age 15 and 1.5% age 65 years and older.

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Slide 15: TB Cases ≥ Age 15 in Correctional Facilities by Age Group, 1993-2011

The proportion of age groups reported in correctional facilities over the 19 years of data collection has remained relatively stable.  One exception is the 25 to 44 age group. In the early years, 1993 to 1996, proportions for this age group ranged from 70% to 72% of all TB cases reported in correctional facilities.  By 2011, the 25 to 44 age group still reported more TB cases (230 out of 424) than other age groups but the percentage had dropped to 54%.

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Slide 16: TB Cases < Age 15 in Correctional Facilities by Correctional Facility Type, 1993-2011

Very few TB cases reported in correctional facilities are under age 15.  From 1993 to 2011, only 11 TB cases were reported as residents of correctional facilities.  Of these, 9 (82%) were in a juvenile correctional facility.

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Slide 17: Number of TB Cases in Correctional Facilities by Sex, 1993-2011

Ninety percent of TB cases reported to reside in a correctional facility are male.  From 1993 to 2011, the number of males ranged from 1013 in 1997, to 390 in 2011.

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Slide 18: TB Cases in Correction Facilities by Race/Ethnicity, 1993-2011

Among racial/ethnic groups of TB cases residing in correctional facilities, non-Hispanic blacks form the highest percentage (42.2%), followed by Hispanics (36.6%), whites (16.8%), and Asians (2.8%).

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Slide 19: TB Cases in Correctional Facilities by Race/Ethnicity, 1993-2011

As the overall number of TB cases reported in the United States has dropped from 1993 to 2011 so has the number of TB cases in correctional facilities dropped.  With this decline the number of cases in each race/ethnic group has also declined each year with the exception of Hispanics, whose numbers of TB cases over the years has fluctuated slightly (161 to 291 cases) but the percentage of Hispanics among all TB cases in correctional facilities has risen from 29% in 1993 to 54% in 2011.

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Slide 20: Percent of TB Cases in Correctional Facilities by Whether HIV Test Results Known*, 1993-2011

Sixty-five percent of TB cases reported in correctional facilities have known HIV status compared to 50% for all TB cases reported from 1993 to 2011.  The HIV infection status reported for TB cases has improved over the years.  In 1993, less than 30% (29.7%) of all reported TB cases had known HIV status and in 2011, 82.5% had known HIV status.

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Slide 21: Percent of TB Cases by HIV Status and Correctional Facility Status, 1993–2011

TB cases in correctional facilities had over twice the percentage of HIV positive cases (20.9%) than among all TB cases in the United States (9.5%).  Yet, there was a higher percentage of TB patients with a negative HIV status and fewer with unknown categories for HIV status (indeterminate, refused, not offered, and unknown and missing) among the TB cases in correctional facilities than for all TB cases reported in the United States.

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Slide 22: Treatment of TB Cases in Correctional Facilities by Use of Directly Observed Therapy (DOT), 1993-2009

The American Thoracic Society and CDC strongly recommend directly observed therapy (DOT) for all TB patients. DOT means that the ingestion of each dose of medication is observed by a trained health worker. The majority (71%) of TB cases residing in a correctional facility at the time of diagnosis are completely on DOT (totally directly observed), compared to 47% of total DOT used for all TB cases reported in the United States. Some TB patients in correctional facilities may continue therapy using DOT or self-administered therapy or a combination of both after they are released from a corrections facility. 

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Slide 23: Percent of TB Cases in Correctional Facilities at the Time of Diagnosis by Treatment Completion, 1993-2009

Most TB cases in correctional facilities complete treatment for TB (73%) either during their stay in the correctional facility or after they are released.  Most TB patients complete treatment within a year, but for some, treatment can take years.  The data shown here are based on TB patients having ever completed treatment.  Five percent die during treatment from any cause and a total of 22% are reported as lost, having moved, other outcome, or refused treatment.  Those who are lost or moved during treatment were most likely released from a correctional facility before treatment was completed.

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Slide 24: Percent of TB Cases by Treatment Completion Status and Correctional Facility Status, 1993-2009

TB cases in correctional facilities are a little less likely to complete therapy.  It is believed that this is due to patients not reporting to their local health department after discharge from a correctional facility.  More TB cases who are living in a correctional facility at the time of diagnosis are reported as lost or having moved during treatment.

NOTE:  Data for  “Adverse Treatment Event” and “Unknown” each accounted for <0.1% of outcomes.


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Slide 25: Percent of TB Cases in Correctional Facilities by Reported History of Excess Alcohol Use Status, 1993-2011

The majority (57%) of TB cases in correctional facilities are reported as not having a history of excess alcohol use in the year prior to their TB diagnosis.  Twenty-seven percent do report excess alcohol use.

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Slide 26: Percent of TB Cases in Correctional Facilities by Reported History of Injection Drug Use, 1993-2011

The majority (73%) of TB cases in correctional facilities do not report a history of injection drug use in the year prior to their TB diagnosis. Eleven percent do report a history of injection drug use.

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Slide 27: TB Cases in Correctional Facilities by Reported History of Non-Injection Drug Use Status, 1993-2011

The majority (57%) of TB cases in correctional facilities do not report a history of non-injection drug use in the year prior to their TB diagnosis. Twenty-six percent do report a history of non-injection drug use.

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Slide 28: For More Information

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta,  GA  30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail:  cdcinfo@cdc.gov   Web:  http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for HIV/AIDS, Viral Hepatitis, STD , and TB Prevention
Division of Tuberculosis Elimination

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