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Epidemiologic Notes and Reports Outbreak of Invasive Pneumococcal Disease in a Jail -- Texas, 1989

Between September 6 and October 2, 1989, invasive pneumococcal disease--including bacteremic pneumonia, meningitis, and primary septicemia--occurred in 12 inmates at a county jail in Texas. Two patients died. Five additional inmates with pneumonia had Streptococcus pneumoniae isolated from sputum specimens. All isolates from the 17 patients were serotype 12. Fourteen patients had underlying conditions including alcoholism and intravenous-drug abuse, cirrhosis, and asplenia. One person reported having previously received pneumococcal vaccine. All patients were male; their mean age was 30 (range: 19-53) years.

The jail is in a 13-story building that was constructed to hold 3500 inmates but houses a daily average of 6900 inmates (84% male). Cases occurred on seven of 10 floors used to house inmates. No cases occurred among 950 staff members.

Immunization with the 23-valent pneumococcal polysaccharide vaccine was recommended for all inmates and staff; 79% of inmates accepted vaccination. In addition, inmates with underlying medical conditions received a 1-week course of penicillin or erythromycin prophylaxis following vaccination.

An ongoing investigation is focusing on risk factors for disease, mechanisms of transmission, further characterization of the isolates, and distribution of serotypes of invasive pneumococcal isolates from patients in the surrounding community. Active surveillance for pneumococcal disease has been initiated within the jail. Reported by: J Pappas, JE Arradondo, MD, KH Sullivan, PhD, City of Houston Dept of Health and Human Svcs; MA Canfield, MS, T Hyslop, MD, Harris County Health Dept, Houston; KA Hendricks, MD, D Simpson, MD, State Epidemiologist, Texas Dept of Health. Respiratory Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: In the pre-antibiotic period, epidemic pneumococcal disease was observed in a variety of settings including military training centers, psychiatric hospitals, and correctional institutions (1,2). Pneumococcal outbreaks are rarely reported now, although two epidemics have occurred in shelters for homeless men (3,4).

Crowding and the medical status of the inmates may have been contributing factors in the jail outbreak in Texas. Underlying conditions that increase the risk for pneumococcal disease in adults include chronic cardiovascular and pulmonary diseases, diabetes mellitus, alcoholism, cirrhosis, asplenia, Hodgkin disease, lymphoma, multiple myeloma, chronic renal failure, nephrotic syndrome, organ transplantation, human immunodeficiency virus (HIV) infection, age greater than or equal to 65 years, and other conditions associated with immunosuppression (5). Of these factors, alcoholism and trauma (possibly predisposing to splenectomy) are common among inmates of correctional facilities (6). In addition, HIV seroprevalence rates among inmates of correctional facilities are higher than in the general population (7). The epidemiology of pneumococcal disease in institutional settings is poorly understood. However, because this disease has been associated with overcrowding (2,3), overcrowded correctional facilities may be at risk for pneumococcal outbreaks.

Correctional facilities' staff have the opportunity to immunize high-risk inmates for pneumococcal disease during medical screening at time of incarceration. However, in facilities with high rates of recidivism among inmates, a policy of routine immunization may increase the likelihood of early revaccination. To prevent unnecessary revaccination, immunization programs in correctional facilities need to include a means of identifying inmates vaccinated during a previous incarceration.

Further efforts are needed to delineate the epidemiology of pneumococcal infections in institutional environments such as jails and prisons. State health departments are requested to notify the Respiratory Diseases Branch (RDB), Division of Bacterial Diseases, Center for Infectious Diseases, CDC, of clusters of cases of pneumococcal disease in these and other settings. Information on pneumococcal disease is available from RDB at (404) 639-3021.

References

  1. Hodges RG, MacLeod CM, Bernhard WG. Epidemic pneumococcal pneumonia. Am J Hyg 1946;44:183-236.

  2. Heffron R. Pneumonia with special reference to pneumococcus lobar pneumonia. Cambridge, Massachusetts: Harvard University Press, 1939, 1979.

  3. DeMaria A Jr, Browne K, Berk SL, Sherwood EJ, McCabe WR. An outbreak of type 1 pneu mococcal pneumonia in a men's shelter. JAMA 1980;244:1446-9.

  4. Nguyen J, Grosset J, Dautzenberg B, Hubert B, Vaccarie M, Geslin P. Type 1 pneumococcal diseases: two successive outbreaks in men's shelters in Paris, France (Abstract). In: Program and abstracts of the 29th Interscience Conference on Antimicrobial Agents and Chemotherapy. Houston: American Society for Microbiology, 1989:145.

  5. ACIP. Pneumococcal polysaccharide vaccine. MMWR 1989;38:64-8,73-6.

  6. Salive ME, Brewer TF. Medical care behind bars: Maryland prison system. Maryland Med J 1989;38:246-9.7. CDC. AIDS and human immunodeficiency virus infection in the United States: 1988 update. MMWR 1989;38(no.S-4). *The ISRA was a cooperative effort by many hospital personnel and by the study's sponsors, the Iowa Governor's Traffic Safety Bureau (supported by the National Highway Traffic Safety Administration) and the Iowa Traffic Safety Now.



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