An Unanswered Health Disparity: Tuberculosis Among
Correctional Inmates, 1993 Through 2003
Jessica R, MacNeil, MPH, Mark N, Lobato, MD, Marisa Moore, MD, MPH

Tuberculosis (TB) is an importeint health
problem in correctional systems in many
parts of the United States, Although the incident TB case rate for the general population
has remained at fewer than tO cases per
100000 persons since 1993,' substantially
higher case rates, some as high as 10 times
that of the general population, have been reported in correctional populations,^""* The
TB case rate reported from 1 urbcin jail was
72,1 cases per 100000 inmates, representing
10% of the county's cases,^ Furthennore,
studies have foimd the prevalence of latent
TB infection (LTBI) among inmates to be as
high as 25%,®"'° Other studies have shown a
correlation between length of incarceration
and positive tuberculin skin test responses, indicating transmission may have occurred in
these fadiities,"'^
A disproportionately high percentage of TB
cases in the United States occur among persons incarcerated in correctional fadiities. In
2003, 3,2% of all TB cases nationwide occurred among residents of correctional faciKties,' In contrast, 0,7% of the total US population were confined in prisons and jails in 2003,
a population that was increasing at an average annual rate of 3,7% from 1995 through
2003,'^ One notable reason for the high rates
of TB in correctional institutions is the greater
proportion of persons who are at high risk for
TB but who can not access standard public
health interventions. Transmission risks particulcir to correctional institutions include
close living quarters, poor ventilation, and
overcrowding,^''*'^
Owing to the occurrence of TB outbreaks
and the documentation of high rates of TB in
correctioned systems, the Centers for Disease
Control and Prevention (CDC), in 1993,
began asking state health departments to report whether those newly diagnosed with TB
were residents of correctional fadiities. We
analyzed data reported to the national TB
surveillance system from 1993 through 2003

Objectives: y\le sought to describe disparities and trends in tuberculosis (TB)
risk factors and treatment outcomes between correctional inmate and noninmate
populations.
Methods: We analyzed data reported to the national TB surveillance system
from 1993 through 2003, We compared characteristics between inmate and noninmate men aged 15-64 years.
Results: OUhe 210976 total US TB cases, 3,8% (7820) were reported from correctional systems. Federal and state prison case rates were 29.4 and 24,2 cases
per 100000 inmates, respectively, which were considerably higher than those in
the noninmate population (6,7 per 100000 people). Inmates with TB were more
likely to have at least 1 TB risk factor compared with noninmates (60,1% vs 42,0%,
respectively) and to receive directly observed therapy (65,0% vs 41,0%, respectively); however, they were less likely to complete treatment (76,8% vs 89.4%,
respectively). Among inmates, 58.9% completed treatment within 12 months
compared with 73,2% of noninmates,
Conc/us/ons; Tuberculosis case rates in prison systems remain higher than in
the general population. Inmates with TB are less likely than noninmates to complete treatment, (Am J Public Health. 2005;95:1800-1805, doi:10,2105/AJPH,2004,
055442)
to define trends in correctional TB cases and
describe characteristics of individuals with TB
who are residents of correctional facilities.

An inmate TB patient was defined as a person who was incarcerated in a correctioned facility at the time TB was diagnosed. We analyzed data from TB cases reported to the
national TB surveillance system from 1993
through 2003 among inmates of correctional
systems (including federal and state prisons,
local jails, and juvenile fadiities, and other facilities such as immigration detention centers)
in the 50 states and the District of Columbia,
For comparative purposes, all calculations and
comparisons for risk-factor characteristics,
clinical presentation, drug resistance, and
treatment outcomes were performed only for
males aged 15 to 64 years, a group that comprised 85,5% of inmate cases.
Variables in the nationtd TB case report
are collected uniformly throughout the
country with the exception of humem immunodeficiency vims (HIV) status, Califomia

1800 I Research and Practice I Peer Reviewed I MacNeil et al.

does not report individual HIV test results
but does submit the results of TB and AIDS
registry cross-matches, Califomia TB patients with an AIDS match were clcissified as
HIV-infected; all others were classified as
having an unknown HIV status. All 2003
Cedifomia cases are classified as unknown
HIV status,
Completion-of-therapy calculations were
done for persons who were alive at diagnosis,
had an initial drug regimen of 1 or more antiTB drugs, did not die during therapy, and did
not have an initial Mycobacterium tuberculosis
isolate resistant to rifampin. Timely completion of therapy was defined as completion of
treatment within 12 months. The latest year
for which information on treatment outcomes
is available is 2001,
State and federal prison population case
rates were calculated with data from the US
Bureau of Justice Statistics,'^'^'^ Estimates
of correctional populations are based on
year-end counts of inmates for state and
federal prisons in the 50 states, the District
of Columbia, and the Federal Bureau of
Prisons, Case rates were not calculated for

American Journal of Pubiic Heaith | October 2005, Voi 95, No, 10

Year

Noninmate

Inmate"

Federal Prison

State Prison

Local Jail

mates with TB had increased from 15,5%
in 1993 to 40,3% by 2003; similarly,
30,6% of those with TB in the general
population were foreign-bom in 1993, and
53,6% were foreign-bom in 2003,

1993
1994
1995
1996
1997
1998
1999

23027(96,0)18,51
22330(95,2)18,11
21545(95,8)17,81
20319(96,3)17,31
18951 (96,2) 16,71
17601(96,4)16,2]
16873(96,7)15,91
15707(96,4)15,41
15384(96,7)15,31
14556(96,9)14,91
14355(96,8)14,8]

953 (4,0)
1119 (4,8)
938 (4,2)
784 (3,7)
746 (3,8)
657 (3,6)
577 (3,3)
587 (3,6)
523 (3,3)
461 (3,1)
475 (3,2)

28 (2,9) 131,3]
31 (2,8) 132,61
24 (2,6) |26,8|
28(3,6)129,41
30 (4,0) 129,5]
32 (4,9) 129,8]
33 (5,7) [26,3]
39 (6,6) 129,91
37 (7,1) 125,81
39 (8,5) 126,2)

462 (48,5) 152,31
470 (42,0) 148,9]
332 (35,4) 133,5]
295 (37,6) 128,4]
220 (29,5) [20,5]
188 (28,6) [16,8]
163(28,3)114,4]

407(42,8)
571 (51,1)

Risi<-Factor Characteristics

172 (29,3) [14,6]
141 (27,0) |11,6]
124 (26,9) 110,31

539 (57,5)
409(52,2)
445 (59,7)
382 (57,9)
343 (59,3)
327 (55,6)
281 (53,5)
238 (51,6)

56 (11,8) 135,2]

81 (17,1) |6,6|

254 (53,5)

200648(96,2)16,7]

7820 (3,8)

377 (4,8) 129,41

2648 (33,9) |24,21

4196 (53,7)

TABLE 1-Tuberculosis Cases Among Inmate and Noninmate Populations, by Prison Faciiity
Category and Year: United States, 1993-2003
Cases, No, (%)IRater'''

2000
2001
2002
2003
Total

'Rates are for cases per 100 000 persons per year from estimates of the US resident population,''^
''Inmate denominators include all inmates held in public and private adult federal and state facilities,
'Inmates are residents of federal prisons, state prisons, local jails, juvenile facilities, and other facilities; hence, the national
total exceeds the number of inmates in federal and state prisons and jails.

jail inmates because accurate estimates for
this population were not available, in part
owing to the difficulty of removing recidivists from the population count,
RESULTS

From 1993 through 2003, US jurisdictions
reported 2tO976 cases of TB to the national
TB surveillance system. Information about
residence at a correctional facility at the time
of TB diagnosis was reported for 208468
(98,8%) patients, of whom 7820 (3,8%)
were inmates. The percentage of TB cases in
males aged 15 to 64 years reported as residing in a correctional facility was 9,2% for
those bom in the United States and 4,2% for
those not bom in the United States (odds
ratio [OR]=2,2; 95% confidence interval
[CI]=2,08, 2,33; P<,001),
Trends in Tuberculosis Cases and Rates

From 1993 through 2003, the percentage
of TB cases among local jail inmates increased from 42,8% of all inmates with TB
to 53,5% (z^ for trend= 57,8; P<,001),
whereas cases among federal inmates increased from 2,9% to 11,8% (Table 1), Case
rates for the 11 years studied were 29,4 per

100000 for federal prisons and 24,2 for
state prisons. In contrast, federal prisons in
1993 and in 2003 had nearly level TB case
rates. In state prisons, case rates decreased
from 52,3 in 1993 to 6,6 in 2003, a decline
of 87,4%,
Two states, California and Texas, accounted
for 42,7% of the 7820 reported TB cases
among inmates from 1993 through 2003,
and another 4 states (Florida, Georgia, Illinois,
and New York) accounted for an additional
28,6% of reported TB cases. These same 6
states accounted for 56,9% of the 200648
reported TB cases among noninmates.
Demographic Characteristics

The characteristics of individuals with TB
in correctional facilities differed from those
with TB who did not reside in correctioncd
facilities; inmates with TB were more likely
to be male (89,4% vs 61,9%, respectively),
US bom (77,0% vs 58,3%, respectively),
younger (median; 37 vs 45 years of age,
respectively), and from racial and ethnic
minority groups (81,7% vs 75,5%, respectively). Over time, an increasing proportion
of TB cases were among foreign-bom persons in both inmate and noninmate populations. The proportion of foreign-bom in-

October 2005, Vol 95, No, 10 | American Journal of Public Health

Excess alcohol use, injection drug use, noninjection drug use, and homelessness within 1
year prior to TB diagnosis in adult males aged
15 to 64 years were cill more frequent in inmates with TB than in noninmates with TB
(Table 2), Additionally, inmates were more
likely than noninmates to report at least 1 TB
risk factor including HlV-infection (60,1% vs
42,0%, respectively).
Inmates with TB were also more likely
than noninmates with TB to be HIV infected.
From 1993 through 2003, HIV infection was
documented in 35,8% of inmates with TB in
state prisons, in 20,7% of those in jail, and in
13,2% of those in federal prisons. Overall, of
males with TB aged 15 to 64 years, 25,2%
who were inmates were known to be HFV infected versus 18,0% of those who were noninmates, A positive finding, however, is that
HIV prevalence is declining in this setting.
Among those with TB in state prisons, the
prevalence of HIV infection decreased from
43,1% in 1993 to 11,6% in 2003, In federal
prisons, the prevalence of HIV infection decreased from 23,8% in 1993 to 9,3% in
2003, In local jails in 1993, 22,8% of inmates with TB also were infected with HIV,
whereas in 2003, 12,4% of inmates with TB
were HIV infected,
Ciinical Presentation and Drug
Resistance

A higher proportion of inmates (90,3%)
than noninmates (84,4%) had pulmonary TB,
Results of sputum smears for acid-fast bacilli
and sputum cultures were reported more
often for inmates than for noninmates. Inmates compared with noninmates were less
likely to have extrapulmonary TB (OR=0,60;
95% CI=0,55, 0,66; PK.OOl).
Table 3 presents the frequency of drug resistance of M tuberculosis isolates among inmate and noninmate patients. In general,
drug-resistance levels were higher in those
with a prior history of TB, those not bom in
the United States, those with HIV infection.

MacNeil et al. | Peer Reviewed | Research and Practice | 1801

TABLE 2-Risk-Factor Characteristics of Inmate and Noninmate Populations (iVIales Aged
15-64 Years) With Tubercuiosis, by Year: United States, 1994-2003
Cases, No. (%)
Noninmate

Inmate
1994

2003

1994-2003

1994

2003

1994-2003

214(21.4)
505(50.6)
279(28.0)

140(33.6)
245(58.8)
32(7.7)

1762(29.2)
3249(53.8)
1033(17.1)

2113(21.0)
5357(53.1)
2616(25.9)

1489(23,1)
4727(73.4)
226(3.5)

18682(23.7)
51915(65.8)
8366(10.6)

121(12.1)
570(57.1)
307(30.8)

49(11.8)
327(78.4)
41(9.8)

733(12.1)
4169(69.0)
1142(18.9)

529(5.3)
6806(67.5)
2751(27.3)

175(2.7)
6012(93.3)
255(4.0)

3197(4.1)
66837(84.6)
8929(11.3)

211(21.1)
480(48.1)
307(30.8)

127(30.5)
251(60.2)
39(9.4)

1523(25.2)
3349(55.4)
1172(19.4)

825(8.2)
6326(62.7)
2935(29.1)

671(10.4)
5498(85.4)
273(4.2)

7754(9.8)
61681(78.1)
9528(12.1)

126(12.6)
726(72.8)
146(14.6)

65(15.6)
326(78.2)
26(6.2)

906(15.0)
4605(76.2)
533(8.8)

1005(10.0)
8165(81.0)
916(9.0)

676(10.5)
5615(87.2)
151(2.3)

8359(10.6)
67 528(85.5)
3076(3.9)

321(32.2)
182(18.2)
495(49.6)

47(11.3)
229(54.9)
141(33.8)

1454(24.1)
2261(37.4)
2329(38.5)

2455(24.3)
2114(21.0)
5517(54.7)

720(11.2)
3243(50.3)
2479(38.5)

13635(17.3)
30678(38.9)
34650(43.9)

Excess alcohol use'
Yes
No
tJnknown
Injecting drug use*
Yes
No
Unknown
Noninjecting drug use'
Yes
No
Unknown
Homelessness'
Yes
No
Unknown
HIV status"
Infected
Noninfected
Unicnown

Wote. The proportions of inmates and noninmates have 1994 as the baseline year owing to a substantially high proportion of
missing data for 1993.
' Reported in the year prior to diagnosis.
"All 2003 Caiifornia cases are classified as unknown HIV status.

and inmates. From 1993 through 2003, declines in drug resistance were greater for inmates than for noninmates; isoniazid resistance decreased (inmates, from 10.9% to
6.7%; noninmates, from 9.9% to 8.8%), as
did levels of multidrug-resistemt TB (inmates,
from 3.3% to 0.6%; noninmates, from 3.4%
to 1.1%), and resistance to any drug (inmates,
from 15.2% to 11.5%; noninmates, from
14.9% to 13.6%).
Treatment Outcomes

In 1993, among patients for whom extended treatment was not warranted, treatment was completed within 12 months in
47.9% of inmates compared to 60.4% of
noninmates. In 2001, rates of completion of
therapy had improved to 63.6% and 80.1%,
respectively. Rates of completion of therapy
within 12 months were lower in persons

with TB risk factors and lowest for those
who had HIV infection at the time of TB
diagnosis, in both inmates and noninmates,
but lower among inmates (Table 4).
Inmates were more likely to receive directly
observed therapy for at least part of their therapy than were noninmates (Table 4); however,
inmates were less likely to complete therapy.
Lower completion rates among inmates compared with noninmates reflect higher levels of
"incomplete treatment" categories (moved,
lost, other, or unknown). A higher percentage
of federal inmates (27.9%) were classified as
"treatment incomplete" owing to a reported
treatment outcome of "moved out of jurisdiction" compared with other inmates (9.0%)
and noninmates (4.4%). In addition, 11.0% of
local jail inmates had a reported treatment
outcome of "lost," compared with 7.1% of
other inmates and 3.9% of noninmates.

1802 I Research and Practice | Peer Reviewed | MacNeil et al.

The success of TB control in the United
States is evident by the steady decline in
cases among incarcerated populations along
with declining rates in the communities from
which inmates are drawn. Yet, our findings
call attention to the epidemiology and healthrelated outcomes in correctional inmates that
demonstrate marked disparities in TB rates,
measures of risk including HIV infection, and
TB treatment outcomes.
Substantially greater case rates in correctional systems are indicative of this disparity,
especially in the federal prison system. In
2003, the TB case rate for federsil prisons
was 6.9 times the case rate in the general US
population (5.1 cases per 100000 population).' Paradoxically, enhanced screening in
federal prisons may have resulted in better
case detection and thus an apparent rise in
the number of TB cases.'* The increasing
proportion of inmates who are bom in countries other than the United States also may be
partly responsible for the increase in TB cases
in federal prisons.'^ Although we did not calculate the case rate cimong jail inmates because of unreliable population estimates, local
studies indicate that case rates in jail populations are also greater than in the general population. In San Francisco, for example, jail inmates had a case rate of 72.1 cases per
100000 inmates compared with a rate of
26.2 cases per 100000 persons in the local
population.^
Inmates, in contrast to noninmates, are
more likely to have multiple risk factors for
infection with M tuberculosis and for progression to TB disease. Inmates are also more
likely to have drug-resistant TB. Special efforts are needed to mitigate the personal
and public health toll created by these risk
factors.^"'^' The concentration of these factors
in a congregate population has resulted in explosive outbreaks of TB, as demonstrated in
a North Carolina outbreak involving 25
homeless patients, 72% of whom had a history of incarceration in the local county jail.^^
Tuberculosis outbreaks and ongoing transmission have occurred even after inmates were
screened for jg^''"^^ and also have been attributed to failure to complete treatment by
inmates known to have
^'^^'

American Journal of Public Health | October 2005. Vol 95. No. 10

TABLE 3-Characterlstics of Persons Reported to Have Anti-Tuberculosis (TB)
Drug-Resistance, by Inmate and Noninmate Populations (Maies Aged 15-64 Years):
United States, 1993-2003
Cases, No. (%)
Inmate

Noninmate

No Prior TB

Prior TB

No Prior TB

Prior TB

Isoniazid resistance'
US born

301 (8.1)

26(11.7)

2235 (5.8)

178(8.2)

HIV infected

108(9.5)

13 (18.6)

782 (8.4)

47 (9.5)

HIV noninfected

100 (7.6)

5(6.0)

728 (4.8)

73(8.2)

136 (11.0)

23 (34.2)

3319 (11.9)

308 (23.1)

Foreign born
Multidrug resistance'
US born

75(2.0)

14 (6.3)

589 (1.5)

80(3.7)

HiV infected

46 (4.0)

6(8.6)

330 (3.5)

33(6.7)

HIV noninfected

15(1.1)

2(2.4)

107 (0.7)

19(2.1)

16(1.5)

7 (9.2)

457 (1.6)

135 (10.2)

453(12.1)

37 (16.6)

3875 (10.0)

289 (13.3)

155 (13.6)

20 (28.6)

1294 (13.8)

89 (18.1)

Foreign born
Resistance to at least 1 first-line drug
US born
HIV infected
HIV noninfected
Foreign born

145 (10.9)

8(9.5)

1218 (8.0)

109 (12.2)

234 (18.9)

31 (40.8)

5114 (18.2)

407 (30.5)

/Vote. HIV=human immunodeficiency virus.
'Resistance to at least the drug(s) indicated, but also may have resistance to additional first-line drugs.
'Resistance to isoniazid and rifampin.

TABLE 4-Tubercuiosis (TB) Treatment Outcomes for Inmate and Noninmate Popuiations
(iVIalesAged 15-64 Years): United States, 1993-2001
Cases, No. (%)
Inmate

Noninmate

Yes, total direct

3499 (65.0)

27 320(41.0)

Yes, direct and self

1018(18.9)

16761(25.1)

No, self-administered

654(12.2)

21200(31.8)

Unknown

211 (3.9)

1374 (2.1)

Directly observed therapy

Completion of therapy
Completed therapy

4133 (76.8)

59629(89.4)

Moved

550 (10.2)

2917 (4.4)

Lost

514 (9.6)

2621 (3.9)

Refused
Other/Unknown

36 (0.7)

540 (0.8)

149 (2.8)

998 (1.5)

Completion of TB therapy within 12 months by risk factor (%)
Injecting drug use°

57.9

62.9

Noninjecting drug use'

61.8

69.6

Excess alcohol use'

63.8

73.4

Homelessness'

59.1

67.7

HIV-infected at TB diagnosis

44.8

54.5

'Reported in the year prior toTB diagnosis.

October 2005, Vol 95, No. 10 | American Journal of Public Health

Despite elevated rates of HIV infection—
the strongest risk factor for developing TB
among adults who have LTBI^*-the HIV
status of more than one third of inmates with
TB is unknown. In a study of 20 large city
and county jails, a review of inmate medical
records found that only 48% of 376 inmates
with LTBI had a known HIV status.^" Although the CDC recommends routine HIV
counseling and testing at intake to the correctional facility,'"' the majority of correctional
systems currently do not offer universal HIV
testing, a critical limitation for effective TB
prevention and control and for the medical
management of individual patients.^' Moreover, in HIV-infected persons infected with
M tuberculosis, the progression to TB disease is often rapid and can cause difficultto-control outbreaks.^^
Outbreaks of both multidrug-resistant and
drug-susceptible TB related to HIV coinfecdon have been documented in correctional
facilities.^"'""'^'^^ These outbreaks are often
attributed to the failure to detect TB disease
early after entry into the facility or failure to
complete treatment for LTBI resulting in TB
transmission to other inmates, correctional
facility employees,^'^**'^^ and community
members.''^
Epidemiologic and operational studies have
helped elucidate problem areas for TB prevention and control in correctional systems
and the surrounding community.^'^"^''*'^^'^''"''^
One such study in Memphis, Tenn, showed
that 4 3 % of community residents with TB
had been incarcerated in the same jail at
some time before their diagnosis, and this jail
had experienced a TB outbreak lasting several yecU^." A subsequent study revealed the
strain in question was more prevalent in the
surrounding community than it was pdor to
the jail outbreak.''^ In Maricopa County, Ariz,
24% of persons reported with TB during
1999 and 2000 had been incarcerated in the
county jail prior to their TB diagnosis.'" Additionally, it was discovered that the majority of
persons (83%) who later had TB had not received any TB screening while in jail. These
and other reports have highlighted the need
for implementing infection control measures
in correctional facilities.^''
Our data confirmed that health disparities
in treatment outcomes exist for inmates with

MacNeil et al. \ Peer Reviewed | Research and Practice | 1803

TB. Inmates have lower treatment completion rates; even when individual risk groups
are compared, the discrepancy in treatment
completion for inmates persists (Table 4).
Tuberculosis screening at entry to a correctional facility provides a unique opportunity
for identifying individuals at risk for TB who
might not otherwise have access to medical
care and prevention services.^'^ Correctional
systems, especially jails, offer distinct logistical obstacles to screening and treatment; inmates are moved frequently or are released,
making evaluation eind completion of therapy
difficult at best'"* Inmates are more likely to
have treatment outcomes classified as "incomplete" owing to their moving out of the
jurisdiction or being lost to treatment supervision.^^ Failure to complete treatment for
TB is a cause for concem for the health of
those individuals who did not receive a full
course of curative therapy and for the communities in which they live.
One limitation of our study is that the national surveillance data identified only casepatients diagnosed during incarceration.
Those with TB who may have progressed to
disease before or after incarceration are not
separately defined in our analysis. Standcird
TB-control activities and investigations may
not elicit information about incarceration, resulting in possible underreporting of cases
that are epidemiologiccdiy linked with incarceration.''^''^ Failures to establish these connections hamper the effectiveness of public
health intervendons.^^'^*'^* Another limitation
of the study is the difficulty of tracking outcomes when inmates are transferred within or
between correctional systems. For that reason,
our data may underestimate completion rates
for some prison inmates.
Poor access to TB services and socioeconomic status play a role in the elevated TB
rates among correctional inmates."*^ However, inmates are more likely to receive treatment by directly observed therapy, a patientmanagement practice that generally improves
the success of treatment completion. Our finding of unacceptably low rates for the therapy
completion among inmates is disturbing because of the possibilify that these individuals
may be the cause of future TB outbreaks in
a given community.'"' To better ascertain and
improve treatment completion rates among

1804

inmates, health departments should enhance
their capacity for tracking TB patients diagnosed or treated in correctional systems. To
ensure that TB medical evaluations and therapy are completed for inmates, public heeilth
and corrections officials are obliged to develop
policies that optimize discharge planning and
case management for inmates released during
TB evaluation or treatment.^^'"'" These policies
should be reevaluated periodically to determine whether such practices should be modified to improve outcomes.^"*' •

4.
Braun MM, Truman BI, Maguire B, et al. Increasing incidence of tuberculosis in a prison inmate population: association with HIV infection. fAMA. 1989;261:
393-397.
5.
White MC, Tulsky jP, Portillo CJ, Menendez E,
Cruz E, Goldenson J. Tuberculosis prevalence in an
urban jail: 1994 and 1998. Intf Tuberc Lung Dis.
2001,5:400-404.
6. Spencer SS, Morton AR. Tuberculosis surveillance
in a state prison system. Am f Public Health. 1989:79:
507-509.
7. Alcabes P, Vossenas P, Cohen R, Braslow C,
Michaels D, Zoloth S. Compliance with isoniazid prophylaxis in jail. Am Rev Respir Dis. 1989,140:1194-1197
8. Salive ME, Vlahov D, Brewer TF. Coinfection with
tuberculosis and HIV-1 in male prison inmates. Public
Health Rep. 1990;105:307-310.

About the Authors
At the time of the study, fessica R. MacNeil, Mark N. Lobato,
and Marisa Moore mere with the Division of Tuberculosis
Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Ga.
Requests for reprints should be sent to National Center for HIV STD, and TB Prevention, Office of Communications, Centers for Disease Control and Prevention,
1600 Clifton Road, Mail Stop E-06, Atlanta, GA
30333.
This article was accepted May 20, 2005.

Contrihutors
The authors all conceptualized the study. J. R. MacNeil
conducted analyses. M. Moore supervised the analyses.
M. N. Lobato assisted with the interpretation of the data
analyses and coauthored the article. All authors conceptualized ideas, interpreted findings, and reviewed drafts
of the article.

Acknowledgment

9. Centers for Disease Control and Prevention. Tuberculosis prevention in drug-treatment centers and
correctional facilities-selected US. sites, 1990-1991.
MMWR Morb Mortal Wkly Rep. 1993:42:210-213.
10. Lobato MN, Leary LS, Simone PM. Treatment for
latent TB in correctional facilities: a challenge for TB
elimination. Amf Prev Med 2003:24:249-253.
U. Stead WW Undetected tuberculosis in prison:
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12. Bellin EY, Eletcher DD, Safyer SM. Association of
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13. US Department of Justice. Prison and fail Inmates
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May 2004, NCJ 203947
14. Jones TF, Craig AS, Valway SE. Woodley CL,
Schaffner W Transmission of tuberculosis in a jail. Ann
Intem Med. 1999;131:557-563.

We thank Robert Pratt for his careful scrutiny during
data verification.

15. Koo DT, Baron RC, Rutherford GW Transmission
of Mycobacterium tuberculosis in a Califomia state
prison, 1991. Amf Public Health. 1997:87:279-282.

Human Participation Protection

16. US Department of Justice. Prison and fail Inmates
at Midyear 1996. Bureau of Justice Statistics Bulletin.
June 1997, NCJ 164619.

No protocol approval was needed for this study. The
national surveillance system has been classified by the
CDC as a project not involving human subjects or research because the primary intent is a public health
practice disease control activity, specifically routine disease surveillance. The data are used for disease control
program or policy purposes.

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36. Bur S, Golub JE, Armstrong JA, et al. Evaluation
of an extensive tuberculosis contact investigation in an
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7;S417-423.
37 MacNeil JR, McRill C, Steinhauser G, Weisbuch JB,
Williams E, Wilson ML. Jails, a neglected opportunity
for tuberculosis prevention. Amf Prev Med 2005;28;
225-228.
38. Cummings KC, Mohle-Boetani J, Royce SE, Chin DP.
Movement of tuberculosis patients and the failure to

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