United States Marshals Service's Prisoner Medical Care
Report No. 04-14
Office of the Inspector General
Communicable diseases are more prevalent among prisoner populations than the general public. This is particularly true of TB,27 where, according to the World Health Organization, prisoner populations are among the groups most at risk because their overall health status tends to be poor, and because they live in a densely populated environment conducive to the spread of airborne diseases, such as TB. According to the National Commission on Correctional Health Care (NCCHC) report to Congress, dated May 2002, there were an estimated 1,400 cases of active TB in the U.S. prisoner population during 1997, with the infection rate in jails (versus prisons) being about 17 times that of the general U.S. population. In addition, an estimated 566,000 inmates with latent TB infection were released in 1996, the overwhelming majority from jails.28
Rates of infection for both hepatitis C and HIV/AIDS, for which there are no known cures, were similarly skewed. The most recent data available indicated prisoner infection rates of 18.6 percent for hepatitis C were over 9 times that of the U.S. population. Prisoner infection rates of .5 percent for AIDS were more than 5 times the prevalence in the U.S. population. The rates for HIV infection were about the same as AIDS in jail populations at four to six times the prevalence, and slightly more in prison populations at eight to ten times the prevalence in the U.S. population.
In 1998, the USMS implemented its policy on the control of TB in the prisoner population. The purpose of the policy is to ensure that USMS prisoners who have active TB are identified as soon as possible and isolated from other prisoners, deputies, and other staff to prevent the spread of the disease. The policy outlines procedures for identifying and isolating prison detainees who have active TB disease, to prevent the disease from spreading to fellow prisoners, law enforcement officials, or others at risk of exposure.
TB is the only infectious disease addressed by USMS policy. However, this is not to say that the USMS does not concern itself with other infectious diseases. On April 16, 2003, for instance, the USMS issued an advisory notice with guidance on Severe Acute Respiratory Syndrome (SARS) to all of the USMS districts. Further, the USMS provides guidance to staff on reducing the risk of exposure to blood borne diseases, such as hepatitis C and HIV/AIDS. However, with regard to tracking and monitoring, TB remains the only communicable disease specifically addressed in written USMS policy.
Initial Screening for TB
USMS policy requires that prisoners be visually screened for symptoms of TB when taken into custody by the USMS. The policy further states that if a prisoner is suspected of having or has been diagnosed with TB, the district should immediately report the case to the OIMS, which monitors each case of active TB and works with the districts and courts to safeguard prisoner and public health during any prisoner transfers.
We determined that although some districts perform an initial cursory screening of prisoners for TB, there was no supporting evidence to indicate that any of the districts were actually conducting initial TB screenings. In fact, district officials at four of the districts reviewed stated that they did not screen for TB, but instead relied on the local detention facility for initial screening. Another five stated that they do some form of initial intake screening for TB, but nothing was done to document this on district intake forms.
Furthermore, we determined that at least four of the districts reviewed failed to notify the OIMS of prisoners that had been diagnosed with TB. As a central contact point the OIMS plays an important role monitoring TB and the potential for an epidemic among the federal prison population. To do so, however, the OIMS must be properly notified of active TB cases.
Documenting TB Results
USMS policy and procedures require that TB test results be documented in the PTS and on the USM Form 553.29 Once completed, copies of the Form 553 are provided to: 1) the district office, 2) JPATS, 3) the local jail, and 4) the OIMS. Standard use of this form ensures that TB clearances are verifiable and also reduces the potential for duplicate testing of USMS prisoners. The form must be signed and dated by a health care professional.
To determine whether USMS personnel adequately screened prisoners for communicable diseases, such as TB, hepatitis, and HIV/AIDS, we interviewed officials at USMS PSD, the OIMS, select USMS districts, and local jails. In each of the districts reviewed, we selected 25 inmates listed as currently in USMS custody in order to determine whether TB testing procedures were in compliance with USMS policy. We examined USMS district prisoner files for evidence of documentation of TB screening, testing and status. We also reviewed printouts from the PTS for information on TB test date and results, and current or past TB diagnosis and treatment.
We found documentation on prisoners' TB status almost non-existent. The USM Form 553, used to document TB clearance, was either entirely missing from case files, if there were case files, or the form did not contain TB results and thus was incomplete. In the D.C. District Court, for example, the auditors could not locate the Form USM 553 in the prisoner files. District officials stated that the district office did not retain a copy in the prisoner files. We then requested that the local jail fax the original Form 553 to the district office, which they did. Upon reviewing the documents, however, we noted that all of the forms were signed on the same day that they were faxed, which suggests that the forms were not accurate.
Documentation of TB results in the PTS was also sparse to non-existent. Only two of the districts reviewed were utilizing the PTS, and they were doing so only partially. One of those districts had entered only 9 of the 25 inmates selected, and the other had entered only one prisoner out of the 25 selected.
Timeliness of TB Testing
USMS TB policy requires that prisoners be tested as soon as possible after intake at the local jail or detention facility, unless there is medical documentation stating that the prisoner has already been tested and cleared for TB.30 Our audit testing determined that prisoners were not timely tested for TB -- within the 14-day standard established by the ACA -- in 50 percent of the districts reviewed. Depending on the district, prisoners remained untested an average of three to seven weeks after initial incarceration.
Source: Prisoner records
Untimely testing increases the risk of exposing other prisoners, USMS employees, and other parties involved in the judicial process to TB. In addition, delays in TB testing may impede the judicial process because prisoners cannot be transported without a TB clearance.
Tracking Active TB Cases
We asked each of the districts reviewed to provide us a list of prisoners currently in USMS custody who had been diagnosed with active TB. Of the 14 districts, 6 districts could not provide a list of prisoners with active TB, 3 districts were able to provide a list, and 5 of the districts stated that they had not processed any prisoners with active TB during the review period. However, we later determined that one of the districts claiming not to have processed any prisoners with active TB had paid for treatment of active TB for a USMS prisoner in FY 2002. This lack of awareness was not totally unexpected, given the scarcity of TB-related information in the prisoner files and the PTS. It is, nevertheless, a cause for concern given that prisoners who are suspected of or have been diagnosed with active TB are not to be produced for court or transported (other than to an appropriate local medical facility) by USMS personnel until the prisoner has received the appropriate medical care and is medically cleared by a health professional.
Districts often rely on the local jails or detention facilities to test detainees for TB and keep track of those with active TB. The problem with such reliance is that not all local jails test their prisoners for TB. In 1998 the OIMS conducted a survey of TB testing in jails housing USMS prisoners. At the time about 60 percent of USMS prisoners were housed in local jails under IGAs between the USMS and local jails. The survey revealed that only 74 percent of the local jails tested federal prisoners for TB, most upon intake. Of the remainder, 17 percent did not test for TB, and 9 percent deemed TB testing as optional, provided upon request by the prisoner.
It is the USMS, not local jail facilities, that is responsible for monitoring the health status of federal prisoners. Failure to track active TB cases could endanger the courts, law enforcement officials and the public. In the Western District of Texas, for example, a prisoner was released on bond prior to his TB test results being received. Subsequent receipt of the prisoner's chest x-ray results confirmed that he had active TB. In another incident a deputy marshal was unknowingly exposed to TB when he escorted a prisoner that, unbeknownst to him, had been diagnosed with active TB. According to the deputy, he was not advised of the prisoner's condition until after he had transported the prisoner. The deputy later tested positive for TB and had to be treated.
Hepatitis and HIV/AIDS
Currently the USMS has no formal policies similar to that of its TB policy concerning the tracking and monitoring of HIV/AIDS and hepatitis. This was a cause for concern with regard to HIV/AIDS in particular because its management is inseparable from that of other communicable diseases, such as TB, given the increased opportunity for infection among prisoners with compromised immune systems.
While no formal USMS policies currently exist at the national level we performed audit steps to determine to what extent district offices were tracking and monitoring cases of hepatitis and HIV/AIDS on their own. We found that little was being done at district offices to fill the policy vacuum at the national level regarding hepatitis and HIV/AIDS. When asked, district officials stated that there were no local policies or that they were not aware of them if there were. While some steps were being taken, there was little consistency from district to district in the handling of hepatitis and HIV/AIDS cases.
With regard to screening for HIV/AIDS and hepatitis we noted the following:
With regard to treatment provided at local jails we noted the following:
USMS officials at our exit conference explained that tracking and monitoring of HIV/AIDS was problematic due to privacy issues, which would preclude tracking and monitoring. However, we found evidence of current mandatory HIV testing at both the state and federal level. According to the Bureau of Justice Statistics (BJS) Bulletin, HIV in Prisons, 2000 (October 2002), the BOP tests all federal inmates at the time of release. Further, the BOP tests a random sample of inmates for HIV in alternate years. The BJS Bulletin also listed 19 state prison jurisdictions, including Colorado, Michigan and New Hampshire that test all incoming inmates for HIV.
The USMS needs to take a more active role in monitoring and tracking TB and other infectious diseases, such as HIV/AIDS and hepatitis. Too often the USMS districts place undue reliance on local jails to provide them information on federal prisoners in USMS custody. Failure to effectively track and monitor these communicable diseases endangers not only the health of those involved in the judicial process, but that of the general public as well.
We recommend the USMS: