The overarching goal of this project was to develop a streamlined process for contact investigation and administration of hepatitis A PEP in our local correctional facility (BCDC) within the 14-day PEP window to prevent further spread. This was achieved through four objectives:
- Establish a good working relationship with BCDC by identifying a point of contact for current and future responses;
- Educate jail staff on HAV transmission and disinfection procedures;
- Identify and isolate inmates acutely infected with HAV during their infectious period;
- Administer vaccine to those at risk to prevent further spread within the facility.
Prior to the first identified case of HAV at BCDC, the collaborative partnership between BCDC and the LHD was occasional. The BCDC had utilized the LHD for various clinical services such as family planning and/or lab testing, bringing inmates to the health department. No known outbreaks at BCDC had been reported to or investigated by the LHD prior to this outbreak. Therefore, this response was the first of its kind in our community. Upon consultation with our jailer, BCDC staff was accepting and appreciative of the LHDs recommendations regarding education on isolation and vaccination protocols in response to this outbreak.
The LHD was aware of the additional risks posed by infectious diseases in congregate settings and was immediately concerned about additional spread in the jail following the first confirmed case in February 2018. The inmate population at BCDC is highly transient; many inmates are transferred into and out of the facility per week (mostly to other correctional facilities) and a large number of inmates spend a short amount of time in the facility (less than two weeks). This turnover increased the likelihood of the illness being frequently reintroduced into the facility.
Educational materials were distributed to jailer and medical staff for swift isolation of potential cases and quick contact investigation via both electronic and physical means. These educational materials provided information on HAV case presentation, appropriate isolation of contagious cases, incubation and infectious periods, preventive strategies and proper disinfection guidelines for contaminated surfaces.
BCDC has no physician on staff and currently contracts with a medical service (MS). MS specifically works with corrections and is used by many facilities in the area. No preventive care was provided to inmates by MS; their duties consisted of monitoring inmates for cases of acute illness for referral to outside care and the monitoring and administration of prescription medication. Over the course of the outbreak, BCDC and MS began medical isolation for any inmate reporting jaundice, prior to any confirmed diagnosis, to prevent possible spread.
The LHD has no authority regarding the inspection of county correctional facilities, including food preparation areas. Disinfection of surfaces potentially harboring HAV is very difficult, as it is a hardy virus. Successful disinfection requires a high concentration of bleach or a cleaner that specifically identifies HAV as susceptible. A courtesy facility-wide inspection was provided by environmental health staff and epidemiologists to discuss disinfection and prevention of disease spread. High-risk areas of the facility were identified and many current practices were discouraged. Tables located in congregate areas frequently had inmates sitting on top of them and they would have their feet up on the table surface. This practice was discouraged, as well as a practice known as ‘making cake'. Inmates would collect items from commissary, such as honey buns and other sweets, and mash them up on the surface of the table with bare hands to share with other inmates. This was done to celebrate birthdays and other milestones. Hand hygiene during this practice was questionable at best, and the LHD recommended this practice cease.
Kiosks and phones were also located in the communal areas. These kiosks are touchscreen electronics, and allow inmates to order items from commissary and research items in the library. The inspection by the LHD revealed these were rarely cleaned, and when cleaned, window cleaner was used because of fear of destroying the electronics. An alternative cleaning solution, used by restaurants for touchscreens, was recommended as it is known to kill HAV on these surfaces. Phones and surfaces in the visitation area were also identified as a possible source of contamination. Sleeping mats distributed to inmates, while cleaned between each inmate, were not cleaned using a disinfectant effective against HAV. Inmates were also observed sleeping on these mats without any type of sheet or covering on them. Effective cleaning of restroom facilities was also emphasized with operations staff, as this was a likely source of contamination. The cleaning of each restroom is the responsibility of inmates, so the LHD was concerned about the quality of cleaning. A bleach solution (5000 ppm) was recommended, as the current cleaner was not effective against HAV.
The identification and administration of HAV vaccine to at-risk contacts within the BCDC made up the majority of this response. Upon identification of a suspect acute HAV case, isolation protocols were immediately implemented within the facility. If the inmate was currently hospitalized off site, no immediate isolation was implemented. Upon their return to the facility, they were isolated within the medical unit of the BCDC in a single cell. This single cell did not share restroom facilities with any other inmates. The isolation period was defined as 7 days after the onset of jaundice (if present) or 14 days after onset of symptoms if jaundice was not present.
While in isolation, BCDC operations staff began collecting a list of at-risk contacts at the facility. An at-risk contact was defined as an individual sharing a communal space with the acute case (being housed in the same holding cell or room, sharing a restroom), a laundry worker who may have come in contact with the dirty laundry of the acute case, and inmates who were food workers in the facility. This definition of at-risk contacts was created by the LHD in consultation with the KDPH and neighboring LHDs.
Once a line list of at-risk contacts was compiled, operations staff began determining where those contacts were currently located. Inmates were classified as currently on-site, transferred to another facility, or released. This information was then provided to the LHD. Upon receipt of the line list, the epidemiologist at the LHD began the process of pulling available vaccination records to see which inmates were in need of vaccination. In Kentucky, there is an online vaccination registry which many providers and pharmacies voluntarily submit records to. Metro Corrections in Louisville, a neighboring county where many inmates were transferred from, had also begun administering vaccinations to inmates and tracking them in the registry. This allowed the LHD to eliminate many contacts from the list. If an inmate had a record in the registry demonstrating receipt of two single-antigen hepatitis A vaccines or three TwinRix vaccines, they were determined not to need additional vaccine. If they had started but not completed one of these regimens, they were candidates for vaccine if the correct amount of time had passed since their last dose (based on current CDC vaccination schedule). A final list of vaccine candidates was then created. Inmates who had been transferred to other facilities had their information forwarded to the KDPH for further follow-up, as well as inmates released to other counties. Inmates released in our county were contacted first by phone, if a phone number was available. The majority of inmates did not have a working phone number on file, so certified letters were sent to their last known address. If contact was made with these released inmates, the LHD epidemiologist counseled them on HAV risk, signs and symptoms to watch for, and the need for vaccination. If the contact desired vaccination, this was coordinated either through the LHD or their primary care provider.
Vaccine candidates still at BCDC were offered vaccine by LHD staff at one of our jail clinic events. This list of candidates was sent to BCDC operations staff prior to our arrival. Informed consent was provided and a PEF was signed. At the end of each clinic, these PEFs were used to enter vaccination administration records into the online registry by the LHD.
In terms of vaccination of contacts, the health department coordinated 13 events, including one large scale mass vaccination clinic for all inmates on August 23, 2018. A total of 248 inmates were investigated as close contacts of confirmed cases and 107 received vaccinations from the health department. An additional 195 vaccinations were given at a mass vaccination clinic to all inmates on August 23rd. A total of 302 vaccines were administered to inmates at BCDC between February and October 2018.
The majority of the data collection throughout this outbreak was done by the LHD epidemiologist with the assistance of the internal HAV team and BCDC operations staff. Initial case notifications came from either MS at BCDC or local hospitals upon lab confirmation. BCDC operations would begin collecting information on all possible contacts to create a line list for the LHD. This line list included inmate name, dates of exposure to the confirmed case, and current location (in facility, transferred to other facility, or released). This information was then reviewed by the LHD epidemiologist and compiled into an internal tracking document. This document allowed LHD staff to identify all inmates identified as contacts throughout the outbreak and assisted in determining who was in need of vaccination. After the vaccination clinics at BCDC, LHD epidemiologist calculated throughput for each event.
Throughput for each clinic clearly demonstrates how the process improved over the course of the outbreak. At the first vaccine event on February 22nd, 17 inmates were vaccinated over the course of 120 minutes (7.1 mins/inmate). The vaccination event on April 12th saw 15 inmates in 90 minutes (6.0 mins/inmate). The mass vaccination clinic on August 23rd had the best throughput, with 195 vaccines administered in 150 minutes (45 seconds/inmate).
The internal HAV team met weekly throughout the outbreak, beginning in February 2018. At these weekly meetings, the nurse administrator and epidemiologist would share lessons learned from recent vaccination events at BCDC and solicit feedback from members of the team. KDPH and neighboring LHDs also provided guidance and feedback throughout the outbreak response.
Conversations between BCDC operations and medical staff were ongoing and allowed for improvements to the process. For example, prior to the large-scale mass vaccination clinic, members of the internal HAV team suggested prefilling PEFs with relevant demographic information provided by BCDC, to cut down on the amount of time spent completing these forms on site. With these prefilled forms, inmates were only required to verify their correctness and sign the HIPAA/VIS statements. Following the first clinic in February, the LHD also identified an improvement that could be made to speed up the process once on site. The LHD would now send a final vaccination list to BCDC the day before the clinic, so those inmates in need of vaccination could be pulled and ready for LHD staff when they arrived.
Our four objectives for this program were all achieved. Objective one saw the establishment of a strong, working relationship with our local correctional facility which will benefit the community during this outbreak and in future outbreaks. For objective two, the expertise and knowledge of the LHD was shared with BCDC staff in regards to HAV transmission and disinfection strategies to decrease the spread of HAV within the facility. BCDC staff are now aware of HAV isolation protocols, and this knowledge can easily be applied to other infectious diseases. Contact identification and the creation of a line list will also be beneficial if there is an additional outbreak at the facility and will lead to a speedier response by the LHD and BCDC. For the final objective, vaccine administration to inmates at BCDC has led to no documented secondary spread within the facility. Additionally, the number of cases currently or recently incarcerated at BCDC dropped significantly by late summer 2018.