Vaccination in the county jail as a strategy to reach high risk adults during a community-based hepatitis A outbreak among methamphetamine drug users

doi:10.1016/j.vaccine.2004.07.038

Vaccine

Volume 23, Issue 8, 11 January 2005, Pages 1021-1028

https://doi.org/10.1016/j.vaccine.2004.07.038 Get rights and content

Abstract

Illicit drug use (IDU) is an important risk factor for hepatitis A, but implementing vaccination programs among drug users is difficult. During January 2001–July 2002, 403 hepatitis A cases were reported in Polk County, Florida; 48% were drug users and of these, 80% were recently in jail. To assess the county jail as a potential vaccination venue, we interviewed 280 inmates and conducted a serologic survey during July–August 2002. Of these, 227 (81%) reported a past IDU history. Previous HAV infection was found in 33%. In communities with illicit drug users at risk for hepatitis A and who are frequently jailed, vaccination programs in jails could be an important component of a community-based strategy to control hepatitis A outbreaks among illicit drug users.

Introduction

Hepatitis A is one of the most frequently reported vaccine-preventable diseases in the United States [1]. Since 1999, hepatitis A incidence has decreased to historic lows [1]. Outbreaks of hepatitis A have been reported among illicit drug users in the United States and other countries [2], [3], [4], [5], including among users of methamphetamine [6], [7], [8]. Between 1990 and 2000, 5% of cases reported to the National Notifiable Diseases Surveillance System were identified as injection drug users; in some years the proportion of cases with this risk factor was as high as 14% (CDC unpublished data).

The Advisory Committee on Immunization Practices (ACIP) recommends that injection and non-injection illicit drug users receive hepatitis A vaccine [3], and vaccination of adult high-risk groups early in the course of an epidemic might prevent extension to the entire community [2]. However, the cost of adult vaccination programs and difficulties in accessing the illicit drug user community have posed substantial challenges to health departments that have attempted to implement vaccination programs in this high-risk group [8], [9], [10]. Alternative strategies to provide hepatitis A vaccine to adults in high-risk groups are needed.

Between 1991 and 2000, the mean number of reported cases of hepatitis A in Polk County, Florida (estimated 2002 population 496,112) was 36 cases per year (median: 33; range: 15–69 cases per year). An increase in incidence was recognized in 2001 and from September 2001 through July 2002 the number of reported cases increased dramatically with 20–60 cases reported per month (2001 incidence rate 30.9/100,000). Interviews with case-patients and preliminary analysis of surveillance data by Polk County and Florida state public health authorities indicated that illicit drug use, specifically methamphetamine use, was a common risk factor among cases. In addition, many had previously been arrested and booked into the Polk County Jail, although there was no indication that transmission was occurring in the jail.

Several hepatitis A prevention activities were conducted in Polk County, including providing immune globulin and vaccination for contacts of cases in public health clinics and in their residences, and providing vaccination services at the Polk County Jail. Vaccination efforts also included mobile outreach clinics and vaccination in some drug rehabilitation centers, but these were limited due to resource and personnel constraints. To better focus prevention efforts, we analyzed hepatitis A surveillance data and determined risk factors for hepatitis A among Polk County residents. These results led us to conduct a seroprevalence survey among incarcerated persons to assess whether a strategy of routine vaccination within the Polk County Jail would reach adults at risk for hepatitis A and provide vaccination to illicit drug users who were still susceptible to hepatitis A virus (HAV) infection. The specific purposes of the current study were to determine the proportion of incarcerated persons who remained susceptible to HAV infection and identify risk factors for previous HAV infection among the jailed population.

Section snippets

Epidemiologic investigation

A hepatitis A case was defined as an acute illness with: (a) discrete onset of symptoms; (b) jaundice or elevated serum aminotransferase levels; and (c) the presence of immunoglobulin M antibody to HAV [IgM anti-HAV]. The incubation period was defined as the 2–6 weeks before onset of symptoms. The Polk County Health Department interviewed case-patients using a case investigation form that was revised as the outbreak progressed to include specific questions about illicit drug use. Arrest

Epidemiologic investigation

Between 1 January 2001 and 21 July 2002 (study period), 403 hepatitis A cases were reported in Polk County (Fig. 1). The annualized incidence rate was 51.3 cases/100,000 persons. The median age of case-patients was 32 years (range: 1–87 years), 86% were 16 years or older, 55% were male, 98% were white and 7% were Hispanic. Current or previous illicit drug use was reported by 48%, including 11% who reported injecting drug use (Fig. 2). Among the 62 case-patients who provided specific drug use

Discussion

The prolonged hepatitis A outbreak in Polk County Florida during 2001–2002 was primarily among illicit drug users and their contacts, and most case-patients who provided specific drug use information indicated that they used methamphetamine. The importance of illicit drug use in the Polk County hepatitis A outbreak may even have been underestimated, as some case-patients may not have been willing to admit illicit drug use. Based on our jail survey, most inmates reported using or had used

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However to our knowledge, our intervention is the first example of a rapid response by an ED to help stem a hepatitis A outbreak. The profile of HAV-infected individuals in our city—homeless, substance abuse, incarcerated—is similar to that of other studies from the United States (11,12). An HAV outbreak in Oregon peaked at 400 cases per 100,000 population and approximately 50% of cases were intravenous injecting drug users (12).
In 2004, a hepatitis A outbreak occurred in Boston, Massachusetts with an incident rate of 14.8 per 100,000, compared to 4.2 in 2003. The majority of cases had risk factors of homelessness, injection drug use, or incarceration. In September 2004, the Boston Public Health Commission began an immunization campaign partnering with health centers, detoxification centers, homeless shelters, and our Emergency Department (ED) to increase the number of hepatitis A vaccinations and stem the epidemic. The ED rapidly developed (within days) a vaccination protocol. Hepatitis A vaccinations were offered to patients over age 21 years who were homeless, substance users, or incarcerated. From October 2004 through January 2005, the ED vaccinated 122 patients notable for 64% male, 61% homeless, 28% substance users, and 11% incarcerated. No reported vaccination reactions occurred. There was a 51% decrease in the number of cases of Hepatitis A in Boston in the first 4 months of 2005. As a partner, the ED helped stem the epidemic by rapidly providing vaccinations to those most vulnerable. This project provides a model for future collaborations between EDs and local, state, and federal organizations to address epidemics.

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Vaccination in the county jail as a strategy to reach high risk adults during a community-based hepatitis A outbreak among methamphetamine drug users

Abstract

Introduction

Section snippets

Epidemiologic investigation

Epidemiologic investigation

Discussion

J Virol Methods

The diverse patterns of hepatitis A epidemiology in the United States—implications for vaccination strategies

J Infect Dis

Outbreak of hepatitis A among illicit drug users in southeast Sydney

Med J Aust

Hepatitis A outbreaks among illicit drug users and their contacts in Queensland, 1997

Med J Aust

Hepatitis A outbreak amongst intravenous amphetamine abusers in Finland

Scand J Infect Dis

Multiple modes of hepatitis A virus transmission among methamphetamine users

Am J Epidemiol