Co$t-effective methods for managing contagious diseases in the jail setting.

The Centers for Disease Control and Prevention has determined that jails currently house what it refers to as its "target population." According to CDC studies, the jail inmate population includes a disproportionate percentage of people with hepatitis, sexually transmitted diseases (such as syphilis and HIV) and a variety of other contagious diseases.

Local jail systems have a transient population, and the same inmates the CDC has identified as its target population are returned to U.S. communities every day. Consider the following questions: How many inmates does a typical jail book and release every day? Do these released inmates pose a health risk to the community? Has everything been done to identify and treat them before they return to their neighborhoods?

Some jails have a policy mandating that unless inmates are symptomatic, the testing, treatment and vaccination of the inmate population are the responsibility of the local health department. After all, with all of the demands placed on jails, why should the sheriff or jail administrator deal with an issue that is someone else's responsibility?

The fact that local jails house the CDC's target population may be perceived two ways by corrections: as an additional burden or as an opportunity to better serve the community. For a jail considering a proactive approach to addressing the health care needs of this population, the questions are "How much does it cost," and "How can the jail pay for it?" The answer is that testing, treatment and vaccination programs can be much less expensive than expected and can be successfully administered inside any jail system in a cost-effective manner. The key to successfully developing and administering a cost-effective approach to addressing contagious diseases is developing partnerships among the jail's health care provider and the local and state health departments responsible for the jail's jurisdiction.

How Broward County Did It

In 2003, Broward County, Fla., Sheriff Ken Jenne directed his jail administration to develop and implement a comprehensive approach to managing contagious diseases in the jail system. The jail has an average daily population of 5,600 inmates and books more than 70,000 people each year. Recognizing the potential to positively impact the community's health, the sheriff's office entered into a partnership with the Broward County Health Department and the State of Florida Health Department--and thus began to take advantage of the opportunity the target population presented.

The process began with a meeting in Atlanta with CDC officials to discuss the vaccination and treatment of inmates with hepatitis. In January 2003, the CDC issued a Morbidity and Mortality Weekly Report titled "Prevention and Control of Infections with Hepatitis Viruses in Correctional Settings." The report indicated that between 12 percent and 39 percent of all Americans with hepatitis B or hepatitis C had been released from custody the previous year. Although focused primarily on prisons, the report made the following recommendations for all correctional institutions, including jails:

* All adults entering the jail should be medically evaluated, and if they are determined to be high risk, they should be vaccinated for both hepatitis A and hepatitis B. The estimated cost for a combination A and B vaccine is approximately $78 for a series of three vaccinations over a six-month period.

* Inmates identified as high risk during entry medical evaluations should be tested for hepatitis C. If positive, further testing should be done. Treatment would be at the discretion of the health care provider.

* The jail should develop and maintain a database to track all vaccination-related data.

In reviewing the full report, Broward County jail officials clearly saw that the recommendations would not be easily implemented in any local jail environment. Broward County's average length of stay, as in most jails, was no more than 28 days, not nearly enough time to complete the three vaccinations recommended during a six-month period. Because of that, the development of a database for the county's transient population would be useless if maintained in the jail.

To address these concerns, the jail's health care provider along with administrators of the Broward County Health Department and the jail director met to discuss the potential of the jail partnering with the health agencies to both create the database and administer vaccinations. The discussion generated ideas on how to develop a comprehensive approach to not only hepatitis but also a variety of contagious diseases. Ideas were exchanged on testing, vaccination and treatment of the inmate population. Plans were made that included not only the average daily population of 5,600 inmates, but all 70,000 inmates who were booked each year.

The jail director offered health officials full access to the inmate population. Further, the health department was offered office space in each of the five jail facilities to allow its staff daily interaction with the target population. As the discussions progressed it was apparent that the health department representatives were surprised by the open access they were offered in each of the jails.

After a discussion about funding and staff to administer the program, the health department, for most of the initiatives, offered to cover vaccination and lab costs if the health care provider agreed to draw blood for testing and administer the vaccine. The health care provider agreed to provide medication to treat identified diseases only as part of its contract for services. Gaps between the two health agencies were addressed by the jail administration, and as different programs for treatment were discussed, it became clear that the cost was not as significant as first anticipated by the director. Money from the inmate welfare fund was offered as a short-term solution while sources of grant funding were explored.

To solve the problem of completing three shots during a six-month period, the health department offered to provide vouchers to the inmates who were released to encourage them to continue the program, thereby developing a post-release link between the inmate and the health department. To further expand the impact on the overall target population, a plan was developed to include an education component for the inmates and their visitors and families. It was agreed that if the inmate was infected, there was a high probability the visitors and family were infected as well. The health department offered educational materials, and the jail purchased and installed television monitors and DVD players in all visitor waiting areas. In addition to the availability of educational brochures, informational videos are continuously played in all lobby areas, providing information on all contagious diseases.

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Recognizing that this program was voluntary, the jail system developed, as inmate incentive, informational brochures that outline the overall program and emphasize that testing, treatment and vaccinations were at no cost to inmates. Those brochures are distributed to each inmate passing through the system. The inmate handbook was revised, and the information was incorporated into the inmate orientation video. To reinforce the initiative, jail administrators use every opportunity to educate inmates and promote the program.

Program Specifics

The original meeting was the beginning of a successful partnership that has seen the Broward Sheriff's Office fulfill its goal to develop and implement a comprehensive approach to managing contagious diseases in the Broward jail system. Following are brief summaries of the various parts of the program along with the estimated costs for each. The key to the program's success has been the sharing of resources among its partners in providing testing, vaccination and treatment.

HIV RAPID testing. The Reducing AIDS Prevalence in Detention (RAPID) HIV Program offers testing for HIV infection to all inmates on a voluntary basis. In a collaborative effort, the Broward County Health Department has worked closely with the Broward Sheriff's Office to successfully implement this initiative. Information about the RAPID HIV Program is posted at intake and throughout the jail. Most testing is offered during the initial health assessment (within 14 days of incarceration), and results are provided while the inmate is waiting. Pre- and post-counseling is provided for all individuals tested. A counselor is available at each jail site to conduct both the counseling and testing. All positive results are referred to the medical provider for further evaluation and treatment.

The RAPID HIV Program performs approximately 600 tests each month, with a monthly average of four new positive cases. Those newly identified with HIV are seen by the physician and have additional lab tests performed. After completing the evaluation and reviewing laboratory results, the physician and the patient formulate a treatment plan, including a potential medication program. The program is currently funded by the Broward County Health Department, with costs of approximately $160 for each test and treatment at approximately $1,200 per month for each inmate treated.

STD testing and treatment. Most women infected with gonorrhea are unaware of their infection. The majority of men develop symptoms, but they might be unaware of their infection because symptoms may not be present during the first month of infection. Chlamydia infections are more common than gonorrhea and can be present in women and men without symptoms. Early detection and treatment of gonorrhea and chlamydia reduce transmission and the risk of complications, which can include pelvic inflammatory disease, obstetric complications, infertility and systemic illness.

Screening for women can be accomplished by performing a special DNA assay on a urine specimen. Results are available in a few days. Each lab test costs approximately $10, which is paid through a grant from the Broward County Health Department. Screening for males is easier and can be accomplished with a urine dipstick that can detect the presence of white blood cells in the urine within a minute. Test strips cost approximately 40 cents each and are provided by Armor Correctional Health Services, the jail's health care provider. Treatment costs approximately $5 for each positive case, which is also paid by Armor.

Broward County has one of the highest rates of syphilis in the United States. A blood test remains the primary screening mechanism for determining syphilis infection. Many of the signs and symptoms of this disease are similar to those of other diseases, so diagnosing syphilis from signs and symptoms alone is difficult.

Pregnant women with syphilis can pass it to the babies they are carrying. Untreated syphilis may lead to serious health problems for the baby; it can cause death in the womb or shortly after birth. Many people infected with syphilis have no symptoms for years yet remain at risk for late complications if they are not treated.

The Broward County Health Department processes the specimens at the state laboratory at a cost of approximately $5 each. Armor provides treatment for positive tests at a cost of about $50 each.

Hepatitis A and B vaccinations. Most hepatitis A cases occur through person-to-person transmission (by the fecal-oral route) during communitywide outbreaks. Persons at greatest risk for hepatitis A include illicit drug users, men who have sex with men and individuals with chronic liver disease.

The hepatitis B virus is carried by blood and transmitted when skin or mucous membranes are exposed to infected blood or body fluids such as semen. Although prevalence varies geographically, between 15 percent and 30 percent of inmates have been infected with hepatitis B. Injection drug use has been reported among 10 percent to 19 percent of patients infected with hepatitis B. Most hepatitis B infections among inmates are acquired prior to incarceration; the rate of new infection among inmates is approximately 1 percent per year.

Hepatitis A and B vaccination is recommended for all incarcerated adults, including those who lack proof of previous vaccination or previous hepatitis B infection, regardless of the length of incarceration. Because some individuals may be incarcerated only long enough to receive partial series doses, a tracking system should be in place to communicate with the outside public health system and ensure completion of the vaccination series. Even a partial series of vaccine confers significant protection. Vaccinating inmates in prisons and jails is feasible and cost-effective for the community. Among inmates offered a hepatitis vaccine, 60 percent to 80 percent accept vaccination.

The complete series of vaccinations costs approximately $78. The vaccine is currently provided by the Broward County Health Department and administered by Armor staff.

MRSA screening and treatment. Methicillin-Resistant Staphylococcus Aureas is an emerging problem in many jail and prison environments throughout the country. Long ago, MRSA was often written off as "spider bites." Today it is well-known how contagious and serious a problem this can become if not identified and treated immediately. In March 2004, the Broward Sheriff's Office developed an aggressive approach to identifying and treating each inmate infection to prevent an epidemic. Not only does the medical staff conduct examinations, but an informational flier with color photos of wounds and sores consistent with the MRSA bacteria was posted in each housing unit to educate the inmates on what to look for. Although the initial focus was on the inmate population, the sheriff's office soon realized that the deputies and staff members appreciated the efforts of the sheriff's office. When the first case of MRSA was identified in May 2004, the staff expressed concern as rumors began about the seriousness of the infection. Fortunately, the education process had been under away for two months before this occurred. And when the first case was positively identified, all employees were fully briefed at roll calls. Statistical data regarding any additional cases is provided to all commands on a weekly basis to keep all staff informed.

Cultures of any suspect MRSA are taken by Armor and positive cultures are treated by a course of antibiotics. The costs are approximately $28 for the culture and $5 for 10 days of antibiotics.

Tuberculosis testing. TB testing is mandatory for all inmates. The cost for the test is $0.68. All TB testing is conducted and paid for by Armor.

Flu and pneumonia vaccinations. Flu and pneumonia vaccinations are offered to inmates who may be at risk, consistent with the guidelines for those offered to the community at large (the elderly, etc.). The costs are $10.40 for the flu vaccine and $25.60 for the pneumonia vaccine.

Health Education

Health education is a critical component to any program that addresses the management of communicable disease. It is important not only for the targeted inmate population but for their visitors as well. Health education for inmates and their visitors is expected to impact the community at large. Below are just a few of the educational opportunities the Broward Sheriff's Office offers.

The POWERR (Providing Our Women Education for Risk Reduction) program is conducted by the Broward County Health Department. A health educator speaks to inmates and their visitors about the prevention of HIV infection.

The health department provides periodic health education seminars to inmates in the Military Training Unit through the RAPID testing program. These are generally youthful first-time offenders who will be returning to the community.

Also through the RAPID testing program, the health department provides periodic health seminars in all programming units. All inmates are provided educational brochures and materials.

Because the sheriff's office knows it can positively impact community health, it continues to stress the importance of managing contagious diseases in the jail population. Managing contagious diseases in the jail environment can be done in both an efficient and cost-effective manner. The first step is deciding whether the target population presents an opportunity or a burden.

Lt. Col. Rick Frey is director of the Department of Detention at Broward Sheriff's Office in Fort Lauderdale, Fla.

Figure 2. Excerpt from Roll Call Training Bulletin--MRSA: Infection
Control, March 5, 2004

  Methicillin Resistant Staphylococcus Aureas (MRSA) in non-medical
terminology is a staph infection that is resistant to penicillin.
Because of such wide use of antibiotics over the years, some strains of
infection have become resistant to antibiotics and that is when it
becomes MRSA.
  MRSA usually develops in hospitalized patients who are elderly or very
sick or who have an open wound (such as a bedsore) or a tube going into
the body such an IV catheter or a urinary catheter. In the community
however, cases of MRSA have been associated with recent antibiotic use,
sharing contaminated items, having active skin diseases, and living in
crowded settings. Clusters of skin infections caused by MRSA have been
described among injecting drug-users, incarcerated persons, players of
close-contact sports and other populations.
  Staph infections can be treated with different antibiotics or by
draining the sore. It is very important to complete the full course of
antibiotic therapy for complete healing.
  Staph bacteria and MRSA can spread among people having close contact
with infected people; MRSA is almost always spread by direct contact,
and not through the air. Spread may also occur through indirect contact
by touching objects (such as towels, sheets, wound dressings, clothes,
workout areas, sports equipment) contaminated by the infected skin of
the person with MRSA or staph bacteria.
  To prevent staph infection or MRSA:
  1. Keep your hands clean by washing thoroughly with soap and water.
  2. Keep cuts and abrasions clean and covered with a proper dressing
     until healed.
  3. Avoid contact with other people's wounds or material contaminated
     from wounds.