Ajnerican Journal of Epidemiology Copyright O 1991 by The Johns Hopkins Urtversrty School of Hyp^ene and Pubic Health Al rights reserved

Vol. 133. No. 3 Printed in US A

Risk Factors for Carriage of Meningococcus in the Los Angeles County Men's Jail System

Ten cases of meningococcaJ meningitis in the Los Angeles County men's jail system in 1986 were the first known reported cases in this population. New cases have continued into 1990. Nineteen of 21 symptomatic cases identified by serogroup from the men's jail occurring through 1988 had serogroup C. The prevalence of meningococcal carriage and potential risk factors were studied in 1988 among 150 men booked to enter the jail, 350 inmates being released, and 100 jail staff. The prevalence of meningococcal carriage among releases, bookings, and staff were 25.4%, 18.7%, and 5.0%, respectively. Among releases, imprisonment longer than a threshold of 28 days increased carriage of serogroup C 10.0 times (95% confidence interval (Cl) 4.6-21.6). Among bookings, household crowding increased serogroup C carriage 8.2 times (95% Cl 1.5-45.3). Direct and passive smoking at home increased carriage of any serogroup 5.2 (95% Cl 1.2-47.5) and 2.5 (95% Cl 1.1-5.8) times, respectively. Feasible potential interventions include banning smoking in the jail and immunization with quadrivalent meningococcal vaccine of booked men sentenced for one month or more. Am J Epidemiol 1991 ;133:286-95. meningitis, meningococcaJ; primary prevention; prisoners; risk factors

The annual incidence of meningococcal disease in Los Angeles County increased in 1987 to 3.9 cases per 100,000 person-years, a rate nearlyfivetimes greater than the mean rate for 1981-1985 (0.8 cases/100,000 person-years). Focal transmission in neighborhoods or institutions was not evident except in the Los Angeles County jail system. Meningococcal disease in the Los Angeles County jail preceded the sharp increase in

community incidence which began in December 1986. A study of meningococcal carriage among inmates and staff in the men's jail system was performed to identify risk factors for carriage, and potential means of preventing future cases. MATERIALS AND METHODS

Data on cases of meningococcal disease identified through passive surveillance in the Los Angeles County jail population were reviewed. Isolates obtained from jail cases were classified by serogroup in the Los Angeles County bacteriology laboratory. Only those cases with symptoms arising after 5 days in the jail were considered to have been acquired in the jail and were thus counted in the surveillance. Contacts of all cases were administered prophylactic doses of the antibiotic Rifampin. In 1988, approximately 700-800 men were booked into, and the same number

Received for publication January 8,1990, and in final form August 28, 1990. Abbreviations: Cl, confidence Interval; N. meningttldis, Nelsseria meningttidls; OR, odds ratio. 1 Department of Epidemiology, School of Public Health, University of North Carolina, Chape) Hill, NC. 2 Department of Health Services, County of Los Angeles, CA. 3 Food and Drug Administration, Bethesda, MD. 4 Center for Infectious Diseases, Atlanta, GA. 8 Sheriff Services, County of Los Angeles, CA. Reprint requests to Dr. J. Conley Thomas, Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, CB 7400, Rosenau Han, Chape) HiD, NC 27599-7400.

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J. Conley Thomas,1 Nancie S. Bendana,2 Stephen H. Waterman,2 Margaret Rathbun,2 Gayathri Arakere,3 Carl E. Frasch,3 Jay D. Wenger,4 Virgil Magsombol,5 and John H. Clark5

Meningococcal Carnage among Jail Inmates

demonstrating necessary growth patterns were identified by serogroup using Wellcome Meningococcus Agglutinating Sera (Burroughs-Wellcome Co., Kansas City, Missouri) or Bacto N. meningitidis antisera (Difco Laboratories, Inc., Detroit, Michigan). Isolates identified as serogroup C were sent to the Centers for Disease Control (CDC) Neisseria and Special Pathogens Laboratory for isoenzyme typing. Four (12 percent) of the serogroup C cultures died or were untypable when received by CDC. Electrophoretic typing was done on strains grown overnight on blood agar at 35°C as described by Selander et al. (1). Migration of the following enzymes on starch gels was examined by enzyme-specific staining: malic enzyme, 6-phosphogluconate dehydrogenase, gluco-6-phosphate dehydrogenase, isocitrate dehydrogenase, alcohol dehydrogenase, glutamate dehydrogenase with NAD, glutamate dehydrogenase with NADP, alkaline phosphatase and phenylalanylleucine peptidase. Enzyme variants were characterized by distance of migration toward the anode, and isoenzyme types were defined in terms of identical patterns of the entire panel of enzymes. Serum samples from bookings were sent to the Center for Biologies Evaluation and Research of the Food and Drug Administration to test for the presence of antibodies to serogroup C meningococcus. Antibodies to the noncapsular outer membrane antigens were measured by enzyme linked immunosorbent assay (ELISA) as described (2). Antibodies to the purified group C polysaccharide were measured by ELISA (2) with some modifications. The polysaccharide was mixed with methylated human serum albumin prepared as described (3), both at 5 ng/ ml (final concentration), then coated on the plates for 6-7 hours at 28°C. The serum dilutions were incubated on the coated plates overnight at 4°C. Seropositivity was defined as a concentration of group C polysaccharide antibodies and anti-protein antibodies greater than or equal to the lowest values for serogroup C culture-positive inmates.

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were released from, the Los Angeles County Men's Central Jail daily. The men's jail system consists of five separate facilities in the county, but all bookings and releases are processed through the Men's Central Jail. Jail staff assigned to work with the investigators were instructed by the investigators to obtain advised consent from participants and express that nonparticipation would not affect their treatment in the jail. For 10 consecutive weekday evenings in May 1988, after the study's interview station was set up, 15 men among the first entering the jail ("bookings") and 35 men among the first leaving the jail ("releases") volunteered to participate in the study, for a total sample of 500 men. One hundred jail guards and staff at the Men's Central Jail were also randomly selected for the study. Because of the complex movements of inmates through the Los Angeles County jail system, repeat testing of an entering cohort of prisoners was not possible. A throat swab was taken and a questionnaire regarding potential risk factors was administered to each participant. Duplicate swabs were taken on 23 (4.6 percent) of the participants to assess the reliability of swabbing and culturing techniques. Blood samples were obtained from bookings; obtaining blood samples from releases was not feasible. Throat specimens were plated at the time of acquisition on modified Thayer-Martin pill pocket plates and stored in an incubator in the jail within 2 hours of plating. After transfer to the Los Angeles County Department of Health Services Public Health Laboratories, the plates were incubated for 24 hours at 35°C in a 5-10 percent CO2 atmosphere with 50-70 percent humidity. The plates were then tested for the presence of oxidase-positive (N,N-Dimethyl-P-Phenylene Diamine Dihydrochloride) colonies and Gram stained. Negative cultures were incubated for an additional 24 hours and then discarded if still negative. Colonies of oxidase-positive, gram-negative diplococci were subcultured on chocolate agar plates for biochemical confirmation using the Minitek Differentiation System. Isolates biochemically resembling Neisseria meningitidis and

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Variables with an association identified through stratified analysis and requiring control of one or more confounders were included in a logistic regression model. An alpha level of 0.05 for a two-tailed test was used in testing statistical significance. Fisher's exact confidence intervals are reported where necessary.

RESULTS Meningococcal disease surveillance data

A total of 28 cases of meningococcal disease occurred in the Los Angeles County jail system during 1986-1988 (figure 1). The first case in 1986 was the first recorded case in the jail system. One case occurred among the men's jail guards during 1987, and two cases occurred among inmates in the women's jail in 1988. The 1986-1988 mean jail rate of 45 cases per 100,000 person-years in jail was 50 times greater than the rate among nonjailed men in Los Angeles County aged 18 years or older. The mean age of cases was 27 years. Ten (42 percent) of the cases were Hispanic, 10 were black, and the remainder were white. Five cases were septicemic along with meningitis, and two cases (8.3 percent) were fatal. The mean length of time in the jail prior to onset was 30 days, with the shortest period being 6 days. Of 20 samples from male inmate cases of meningococcal disease successfully identified by serogroup, two (10 percent) were serogroup B and the remainder (90 percent) were serogroup C. All serogroup C organisms isoenzyme typed, including those of the two fatal cases, were of the epidemic isoenzyme type (designated ET22 by the Centers for Disease Control) identified among carriers in this study. The seasonal incidence of jail cases coincided roughly with the incidence of cases of meningococcal disease in the community, with the highest incidence during the months of December through March. Following the completion of this study, nine cases occurred in 1989, and three in 1990 by mid-July.

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The questionnaire, administered by staff of the Los Angeles County Acute Communicable Disease Control Unit, was used to obtain information pertaining to the inmate's jail experience and home environment. Jail information included the booking charge, where and how long the inmate had been in the jail, the largest number of cellmates during incarceration, exposure to an inmate diagnosed with meningococcal disease, and previous incarceration (for those being booked). Potential risk factors related to the home included crowding (number of people per bedroom); cigarette, cigar, or pipe smoking by the inmate and others in the home; recent (during the 30 days prior to answering the questionnaire) flu-like illness in the inmate; exposure to children in day care; and occupation prior to booking. Except when referring explicitly to meningococcal disease, a case was defined as an inmate with a throat culture positive for meningococcus. Since meningococcal disease in the jail was due primarily to a serogroup C meningococcus, analysis focused on the epidemiology of this serogroup. A positive culture for serogroup C was used to approximate the isoenzyme typing of the epidemic strain because not all cultures were isoenzyme typed and the large majority of those typed were of the same strain. The jail staff data were not assessed for potential risk factors because of the small number of positive cultures. Prevalence comparisons reflect differences in duration of bacterial carriage as well as the incidence. The duration of meningococcal carriage varies by serogroup (4). To minimize issues of carriage duration, inmates who were culture-positive for serogroup C were compared only with those who were culture-negative (not culture-positive for another serogroup) when assessing for risk factors. Odds ratios obtained from prevalence data estimate the incidence rate ratio when the risk factor being analyzed does not affect the duration of carriage. Under the assumption that duration of carriage is unaffected by a given exposure, the results reflect increases in the risk of becoming a carrier, rather than being a carrier.

Meningococcal Carriage among Jail Inmates

Carriage data

that among bookings and jail staff, respectively. Serogroup B predominated in each group of men. Carriage of serogroup B was 57 percent higher among releases than bookings, while serogroup C was 30 percent higher arnong releases. Of the 22 pairs of swabs cultured, none were discordant. Twenty pairs were negative and two pairs were serogroup B. The absence of false negatives and positives among the duplicate throat cultures does not indicate that the identification of carriers lacked sensitivity or specificity.

Number of Cases I

I Female Inmate

\H2

Male Guard Fatal Male Inmate Male Inmate

3-

2-

1-

II

3

5

7 9 1986

11

1U 1

3

I

5

7 9 1987

11

1 I

3

5 7 9 11 1988

Month of Onset FIGURE 1. Onset of cases of meningococcal disease among male and female inmates and staff of the Los Angetes County jafl system, 1986-1988.

TABLE 1. Number and serogroup of positive N. meningitidis throat cultures arnong male inmates and staff in the Los Angeles County Men's Central Jail, March 1988 No. (%) of positive cultures SOfOQTDUp

Bookings (n-150)

Releases (n-350)

Staff (n = 100)

A B C W135 Y Z Untypable Total

2 (1.3) 15(10.0) 8 (5.3) 1 (0.7) 0 1 (0.7) 1 (0.7) 28(18.7)

3 (0.9) 55 (5.7) 24 (6.9) 1 (0.3) 1 (0.3) 2 (0.6) 3 (0.9) 89 (25.4)

0 2 (2.0) 2 (2.0) 0 0 1 (1.0) 0 5 (5.0)

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The jail staff solicited participation from inmates in a room or hallway apart from the investigators, thus an unknown number of inmates chose not to participate in the study. Two inmates refused to have blood drawn, and none refused the questionnaire. Eightynine (25.4 percent) releases had positive throat cultures for N. meningitidis (table 1). The odds of carriage among these men was 1.5 (95 percent confidence interval (CI) 0.92.4) and 6.5 (95 percent CI 2.5-16.4) times

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Personal and home-related factors for carriage

The racial distribution for bookings and releases, alike, was 42 percent black, 37 percent Hispanic, and 18 percent white. Among bookings, whites were much more likely than nonwhites to carry serogroup C meningococcus (table 2). Their association with a positive test for serogroup C antibodies, however, was not as strong (odds ratio (OR) = 2.0, 95 percent CI 0.6-6.7). The prevalence of carriage among whites had de-

creased by the time of release from the jail, while among nonwhites carriage had increased by the time of release. This resulted in a lower apparent risk of carriage due to white race among releases (OR = 1.3, 95 percent CI 0.5-3.7). Bookings and releases ("inmates") ranged from 17 to 66 years of age, averaging 29 years old. Carriage was not associated with age. Seventy-five percent of the bookings and 81 percent of the releases were smokers. An increased risk of carriage was associated with smoking and passive exposure to smoke (i.e., inhaling others' smoke) at home. Among bookings, there were no nonsmoking carriers of serogroup C. Carriage of any serogroup of meningococcus was 5.2 (95 percent CI 1.2-47.5) times greater among bookings who smoked. Controlling for smoking, exposure to a smoker at home increased the carriage rate of any serogroup 2.5 (95 percent CI 1.1-5.8) times. The associations for carriage of any serogroup were smaller among the releases, with odds ratios of 3.5 (95 percent CI 1.6-7.7) and 1.3 (95 percent CI 0.8-2.2), respectively. For serogroup C carriage, the odds ratios (95 percent CIs) were 1.5 (0.5-4.5) and 1.1 (0.5-2.6), respectively, among releases. Cold or flu-like symptoms within the previous 30 days showed no consistent associ-

TABLE 2. Associations between non-jail-related factors and carriage of N. menlngltldl* serogroup C among male Inmates in Los Angeles County jails, 1988 Odds ratio (95% confidence interval) Factor

Bookings (n = 130)

Releases (n - 285)

Race (white) >2 people per home bedroom* Smoking Passive smoking}; Alcohol or drug-related charge§ Unemployment Recent flu-like symptoms | Children at home? Child in day care**

15.3(2.5-106.0) 8.2(1.5-45.3) Undeflnedt 1.8 (0.4-7.9) 0.6(0.01-12.1) 1.1 (0.1-6.7) 0.4(0.1-2.3) 0.2 (0.03-1.3) 0.0(0.0-146.2)

1.3 (0.5-3.7) 1.9 (0.4-8.4) 1.5(0.5-6.2) 1.1 (0.5-2.5) 1.5 (0.5-4.3) 0.8 (0.3-2.4) 2.1 (0.9-5.2) 1.3 (0.5-3.0) 4.1 (0.7-27.6)

* Controlled for race. t Zero in denominator; lower 95% exact confidencefcrrit,0.6. j ControOed for smoking. § Compared wttti inmates charged with traffic violations or jaywalking. | Controlled for household crowding and the presence of children aged 0-6 years. 1 Controled for household crowding. •* Among those with children aged 0-6 years Bving at home (n = 38 for bookings and n • 101 for releases).

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Four isoenzyme types were identified among the 30 typable samples from inmates who were group C carriers. Twenty-two (73 percent) of the samples were the same isoenzyme type, referred to here as the epidemic type. No single isoenzyme type predominated among the bookings. Two of seven (29 percent) serogroup C bookings were of the epidemic type, while 18 of 21 (86 percent) releases were of the epidemic type. Thus, among the inmate serogroup C carriers tested, releases were 15 times (95 percent CI 1.4-200.0) more likely to carry the epidemic isoenzyme type than bookings. Both of the serogroup C-positive jail staff carried the epidemic isoenzyme type. All of the previous symptomatic serogroup C jail cases were of this same type.

Meningococcal Carnage among Jail Inmates

meningococcus as those with traffic or jaywalking charges. The relation of this exposure with serogroup C carriage among bookings is uncertain because of sparse data. However, the corresponding odds ratios (95 percent CIs) for carriage of any serogroup among bookings and releases were 2.3 (0.77.7) and 2.0 (1.1-3.8), respectively. Jail-related factors for carriage

A total of 119 (79 percent) of the bookings has been incarcerated in the Los Angeles County jail system before. The mean and median times since the last release from the jail were 21 and 9 months, respectively. Bookings who had been jailed in Los Angeles County before the current incarceration may have been less likely to carry serogroup C meningococcus than first time bookings (OR = 0.7, 95 percent CI 0.1-7.9) (table 3). Of the two bookings positive for the epidemic isoenzyme type of serogroup C meningococcus, one had been booked in the jail before, having been released 30 days before the current booking. Previous incarceration was not associated with race. Sixteen (13.6 percent) of the 118 bookings for whom data were available tested positive for antibodies to serogroup C. Ten of these had negative throat cultures, suggesting seroconversion from a previous infection. Thirteen (81 percent) of the serogroup C seropositive men had been incarcerated in the jail before. Three (12.5 percent) of those not previously incarcerated were antibody positive. In contrast to the carriage data, the point estimate of the odds of seropositivity was greater than unity for those previously

TABLE 3. Associations between jail-related factors and carriage of N. menlngHldls serogroup C among male Inmates In Los Angeles County jails, 1988 Factor

Bookings (n = 130) Incarcerated before in Los Angeles County jail Releases (n = 285) Incarceration >28 days Transfer to another facility* Fewer than 10 cellmates at one time ' Controied for Incarceration £28 days.

Odds ratio (95% confidence Interval)

0.7(0.1-7.9) 10.0(4.6-21.6) 2.3 (0.8-7.0) 0.7(0.1-3.0)

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ation with carriage of serogroup C meningococcus among bookings and releases after controlling for crowding in the household and the presence of young children. Forty percent of the inmates had children less than 6 years old living in their home, but the association with serogroup C meningococcal carriage was inconsistent among bookings and releases after controlling for household crowding. Among those with young children, having one or more of them in day care may have been associated with a slightly increased rate of serogroup C carriage among releases. Data were sparse on carriage of serogroup C among bookings, but the carriage rate of any serogroup was 3.6 (95 percent CI 0.2-55.3) times greater among those with a young child in day care. Having more than two people per bedroom (i.e., household crowding) in the home was strongly associated with carriage of serogroup C among bookings, but less so among releases. The median numbers of people per bedroom among bookings and releases were 1.7 and 1.6, respectively. Unemployment showed no association with carriage, and there was no geographic clustering of cases by community of residence within the county. Among both bookings and releases, 30 percent had been charged with traffic violations or jaywalking (with inability or refusal to pay a fee), and 39 percent had been charged with alcohol or drug-related crimes. The remaining inmates were charged with crimes of violence or other miscellaneous offenses. Releases charged with alcohol or drug-related crimes were 1.5 (95 percent CI 0.5-4.3) times as likely to carry serogroup C

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70

Uarnage iper cenu Serogroup C

60

Other Serogroups

Bookings

1

2

3

4-7

Weeks in Jail FIGURE 2. Prevalence of colonization by serogroup C and other serogroups of meningococcus among men entering the Los Angeles County jail system and reteases by the number of weeks spent in the jaB, 1988.

incarcerated (OR = 1.6, 95 percent Fisher's exact CI 0.4-9.4), though both interval estimates included unity. The length of time in the jail was associated with carriage among the releases (figure 2). Carriage of serogroup C meningococcus increased moderately after 21 days in the jail, and dramatically after 28 days (OR = 10.0, 95 percent CI 4.6-21.6). Transfer from the Men's Central Jail to any of the other jail facilities may have been associated with a slight increase in carriage after controlling for the time spent in jail (OR = 2.3, 95 percent CI 0.8-7.0). No single facility stood out as a focus of exposure or infection. The vast majority of inmates are kept in dormitory-like situations, sharing a room with dozens of other men. A small number of men are kept separate in holding cells alone or with only a few other men, because of violent behavior or other reasons. Sharing a cell with no more than nine other inmates may have been protective against carriage of serogroup C meningococcus (OR = 0.7, 95 percent CI 0.2-3.0), but the men in these cells were also qualitatively different from men in more populated cells. Eleven men

reported exposure to a case of meningococcal disease in the jail. Perhaps because they had received prophylactic doses of antibiotic following exposure, they did not appear more likely to carry meningococcus (OR 0.7, 95 percent CIO. 1-3.3). Four of the bookings in the study were also among the releases sampled. All four were culture-negative on booking and release. Three of the men were in the jail only one day, and the fourth was in for 3 days. Three were antibody negative for serogroup C on booking, and blood was unavailable for testing on the fourth. DISCUSSION

The prevalence ofN. meningitidis carriage among inmates was greater than the estimated prevalence in the general population (5-10 percent), but less than the prevalence among military recruits (40-80 percent) (57). The exposure of inmates to crowded conditions at home (as expected in a low socioeconomic population) and in the jail is a likely reason for the relatively high prevalence of carriage. The lower prevalence com-

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50

Meningococcal Carriage among Jail Inmates

ment also may have been responsible for the lower observed effect of household crowding among releases than among bookings. Crowded conditions in the jail would alter the exposure level of those not reporting crowding at home. While the risk of serogroup C carriage was highest among whites in the jail, the incidence of meningococcal disease in Los Angeles County in 1988 was highest among blacks and Hispanics (unpublished data). Carriage rates of meningococcus, however, are not necessarily associated with the incidence of meningococcal disease; additional factors are often required to cause symptoms (4, 13). Some of the inconsistent associations may have biologic explanations. The inconsistent associations of recent flu-like illness with carriage may have resulted from sparse data and a small (if any) biologic effect, and/or the use of an inappropriate recall period (30 days). Associations have been observed with current respiratory infections and meningococcal disease (14, 15). Possibly since current infection with influenza virus is more likely in the crowded jail conditions than in the community, a positive association between flu-like symptoms and carriage was more evident among releases than bookings. The prevalences among bookings who had been jailed before which were potentially lower for carriage and higher for antibody to serogroup C may reflect immunity acquired from previous exposure and colonization with meningococcus (8). The most fundamental factors leading to opportunities for contact with a carrier and subsequent transmission are crowding and the amount of time spent in the jail. The men's jail system is designed to house 11,134 inmates. The actual number of inmates incarcerated has increased from around 8,000 in the late 1970s to 19,783 on one arbitrarily selected day in November 1987. This number of inmates is 80 percent over capacity. Sharing a cell with no more than nine other men may have been protective against carriage. Based on this finding, but primarily on the biology of person-to-person transmission, the elimination of crowding in the Los

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pared with military recruits probably reflects the shorter time that inmates spend in crowded conditions (a mean of 5 days) relative to military recruits. The bookings and releases were similar in composition by race, age, smoking status, and booking charge. The different prevalences of carriage among bookings and releases, therefore, are not likely to be attributable to biases in the sampling of inmates. The lower rate among the staff may be due to distancing of the jail staff (including guards) from the inmates with physical barriers, and/or acquired immunity to meningococcus after repeated exposures (8). The epidemic isoenzyme type of serogroup C was the most transmissible meningococcus in the jail, even though mean serogroup B transmission was greater than the mean transmission rate of serogroup C. The large proportion of jail cases and the two deaths due to this isoenzyme type indicate that it is the most pathogenic strain in the jail and one that is highly virulent. Alternatively, this strain may be one with which this population has had little experience and to which they are more susceptible. Excessive alcohol consumption or use of illicit drugs, and cigarette smoke may affect the natural and acquired resistance of pharyngeal epithelial cells to colonization with meningococcus. Griffis (9) found that alcoholism interfered with clearance of immunoglobulin A, and thus decreased immunity to meningococcus. Associations have been observed elsewhere between exposure to cigarette smoke and meningococcal disease (10), as well as carriage (11). The associations of smoking and passive exposure to cigarette smoke at home with carriage were weaker among releases than bookings. Nonsmoking inmates were exposed to considerable amounts of cigarette smoke in the jail, and therefore were not truly unexposed to smoke. This would result in a lower apparent risk of carriage from reported smoking amongreleases.(San Diego County, California, recently banned all smoking in its jails in anticipation of lawsuits by inmates and employees claiming unhealthful effects from secondhand smoke (12).) The jail environ-

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estimates do not include the costs incurred from the salaries of jail staff administering the vaccine, and costs saved from preventing long-term care for cases who develop permanent sequelae, prevention of community cases attributed to jail exposure, and relatively high inflation of treatment costs compared with vaccine cost over the duration of the vaccination program. Others (16, 17) have suggested similar programs of selective vaccination of inmates against infection with hepatitis B virus and pneumococcus. Though a vaccination program may lower the meningococcal carriage rate for several weeks, antibiotic chemoprophylaxis may be required to prevent or eliminate carriage of meningococcus for longer periods (18, 19). (The mean duration of carriage for serogroup C is estimated to be between 3 and 9 months (6, 20).) A program of chemoprophylaxis, however, would be logistically difficult, expensive, and biologically unsound. A full course consists of two doses over 24 hours, and locating inmates on their second day in the jail would be difficult. Many inmates would be released within 24 hours. The cost of one course of antibiotic is the same as for vaccine (about $2.00/person). But the need to administer antibiotic to repeat bookings would keep the cost of a prophylaxis program high. The current standard prophylactic antibiotic (Rifampin) can cause adverse reactions and interact with other medications. Also, it is likely to develop resistant strains of meningococcus (21). Administration to large numbers of inmates, many of whom return to the jail, would soon render the antibiotic ineffective in this population. Continuation of the hyperendemic rate of cases in the jail depends on the continuing presence of a critical number of susceptible men. The high rate of recidivism among inmates should quicken the advent of herd immunity in the jail. However, one cannot predict when this will occur. Many of the conditions in the jail favoring transmission and infection will remain unchanged or even worsen. The potential thus exists for continued transmission of the current strain and for outbreaks caused by other strains. An

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Angeles County jail facilities would decrease opportunities for transmission of N. meningitidis. Decreasing crowding in the jail would mean either fewer men booked, shorter sentences, and/or a larger jail capacity. Though current trends are toward stricter sentencing, Los Angeles County is planning expansion of its jail capacity by approximately 50 percent in the next 4 years. Duration of time in the jail has been shown in Los Angeles County to predispose to meningococcal disease as well as carriage. An unpublished case-control study of the 1987 jail cases found that cases were 10.9 (95 percent CI 1.7-71.4) times more likely than controls to have been in the jail for 28 days or more (Los Angeles County Department of Health Services, unpublished data). Administration of quadrivalent meningococcal vaccine to bookings would protect them against meningococcal disease. The US military obtains the vaccine at an estimated cost of $2.00 per dose to vaccinate recruits (retail cost is $10.00/dose). With a mean of 750 bookings per day, it would cost $547,500 per year to vaccinate all bookings at the military price. About 80 percent of bookings have been incarcerated in the Los Angeles County jail system before, however. If repeat bookings can be identified, then eventually (in approximately 2 years), only 20 percent of bookings would require vaccination. A vaccination program could focus even more narrowly on those who are sentenced to 28 days or more and thus are at high risk of colonization and infection. Twenty percent of the releases had spent 28 days or more in the jail. Thus, only 30 bookings a day would require vaccination, at an annual cost of $21,900. The mean cost to Los Angeles County of treating an inmate for meningococcal disease was $ 12,375. For 10 potential serogroup C cases per year, vaccination of new bookings sentenced to 28 days or more would prevent five cases (54 percent of serogroup C cases had been incarcerated for 28 days or more before symptoms) and would save Los Angeles County $61,875 from not having to treat these cases. The net savings after paying for the vaccine would be $39,975. These

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11. 12. 13. 14.

15. REFERENCES 1. SelanderRK,CaugantDA, OchmanH.etal. Methods of multilocus enzyme electrophoresis for bacterial population genetics and systematic^. Appl Environ Microbiol 1986;51:873-84. 2. Frasch CE, Zahradnik JM, Wang LY, et al. Antibody response of adults to an aluminum hydroxideadsorbed Neissena meningitidis serotype 2b protein-group B polysaccharide vaccine. J Infect Dis 1988;158:71O-18. 3. Mandell JD, Hershey AD. A fractionating column for analysis of nucleic acids. Anal Biochem 1960; 1:66-77. 4. Schwartz B, Moore P, Broome CV. Global epidemiology of meningococcal disease. Clin Microbiol Rev 1989;2:S 118-24. 5. Fraser PK, Bailey GK, Abbott JD, et al. The meningococcal carrier-rate. Lancet 1973;1:1235-7. 6. Greenfield S, Sheehe PR, Feldman HA. Meningococcal carriage in a population of "normal" families. J Infect Dis 1971;123:67-73. 7. Broome CV. The carrier state: Neissena meningitidis. J Antimicrob ChemotheT 1986; 18 (Suppl A):25-34. 8. DeVoe IW. The meningococcus and mechanisms of pathogenicity. Microbiol Rev 1982;46:162-90. 9. Griffis JMcL. Protective and permissive antibodies in bacterial sepsis. In: Root RK, Sande MA, eds. Septic shock: contemporary issues in infectious diseases. Vol 4. Edinburgh: Churchill Livingstone, 1985:135-46. 10. Hanenburg B, Tonjum T, Rodahl K, et al. Factors preceding the onset of meningococcal disease, with

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21.

22.

special emphasis on passive smoking, stressful events, physical fitness, and general symptoms of ill health. NIPH Ann 1983;6:169-73. Stuart JM, Cartwright KAV, Robinson PM, et al. Effect of smoking on meningococcal carriage. Lancet 1989;2:723-5. Register news services. California briefly. Orange County Register 1989 Jun 30:A4. Wenzel RP, Davies JA, Mitzel JR, et al. Nonusefulness of meningococcal carriage-rates. (Letter.) Lancet 1973;2:205. Olcen P, Kjellander J, Danielsson D, et al. Epidemiology of Neisseria meningitidis: prevalence and symptoms from the upper respiratory tract in family members to patients with meningococcal disease. Scand J Infect Dis 1981; 13:105-9. Moore PS, Hierholzer J, Reeves M, et al. Upperrespiratory-tract infections and increased risk of epidemic group A meningococcal meningitis. Paper presented at the Centers for Disease Control Epidemic Intelligence Service Conference, Atlanta, GA, April 1989. Anda RF, Perlman SB, D'Alessio DJ, et al. Hepatitis B in Wisconsin male prisoners: considerations for serologic screening and vaccination. Am J Public Health 1985;75:1182-5. Centers for Disease Control. Outbreak of invasive pneumococcal disease in a jail—Texas, 1989. MMWR 1989;38:733^. Gotschlich EC, Goldschneider I, Artenstein MS. Human immunity to the meningococcus. V. The effect of immunization with meningococcal Group C polysaccharide on the carrier state. J Exp Med 1969;129:1385-95. Blakebrough IS, Greenwood BM, Whittle HC, et al. Failure of meningococcal vaccination to stop the transmission of meningococci in Nigerian schoolboys. Ann Trop Med Parasitol 1983;77: 175-8. Blakebrough IS, Greenwood BM, Whittle HC, et al. The epidemiology of infections due to Neisseria meningitidis and Neisseria lactamica in a Northern Nigerian Community. J Infect Dis 1982;146: 626-37. Beam WE, Newberg NR, Devine LF, et al. The effect of Rifampin on the nasopharyngeal carriage of Neisseria meningitidis in a military population. J Infect Dis 1971 ;124:39—46. Safyer SM, Alcabes P, Chisolm S. Protecting public health in US jails: a call for the development of guidelines for managing communicable disease outbreaks. Am J Infect Control 1988; 16:267-71.

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outbreak of invasive pneumococcal disease in a Texas jail in 1989 (17) is further evidence of the potential for outbreaks in crowded settings. Plans for controlling outbreaks should be prepared in advance (22). In the meantime, health care providers in crowded jails should strongly consider addressing the health risks from exposure to tobacco smoke in the jail, and initiating a program of selective vaccination against meningococcus.

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Risk factors for carriage of meningococcus in the Los Angeles County men's jail system.

Ten cases of meningococcal meningitis in the Los Angeles County men's jail system in 1986 were the first known reported cases in this population. New ...
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