Management of Infectious Disease Outbreaks in a Large Jail System

The NYC jail system is the nation's second largest, with approximately 90,000 admissions per year. In the past three years, the NYC Department of Health and Mental Hygiene (DOHMH), which oversees medical care in this system, has managed outbreaks of Legionnaires' disease (LD), H1N1 influenza and Clostridium Difficile-associated diarrhea (CDAD). These three outbreaks each involved between 3 and 141 patients and required disparate interventions to assure proper patient care, screening for undiagnosed infected patients and risk reduction for new infection. In the case of LD, one jail in the NYC jail system was historically associated with sporadic cases of LD until 2010, when three cases were identified in a short period of time. Interventions included transfer out of all patients with risk factors for LD, active screening at all medical encounters for LD symptoms, surveillance in all housing areas for symptoms of LD and short- and long-term efforts to purify the water system. The H1N1 outbreak was first recorded in the NYC area in the spring of 2009 and cases of Influenza-like illness (ILI), and confirmed H1N1 infection were recorded in the NYC jail system in early May. Ultimately, 140 cases of ILI were identified, with 109 cases of confirmed H1N1. Efforts during this time included screening of all persons entering the jail system and re-screening at all subsequent medical encounters and active surveillance of all housing areas with recent ILI or H1N1 cases. Patients with ILI were transferred to respiratory isolation for medical management for 7 days from date of symptom onset, assuming an asymptomatic recovery. Coordination with multiple city agencies was required for this outbreak. The CDAD outbreak occurred in the male infirmary, which houses approximately 100 ill patients who routinely cycle between the jail infirmary and 2 local hospitals. These patients are in dormitory housing with beds approximately 18-24 inches apart. Major interventions included aggressive hand washing program, transfer of symptomatic patients to a contact precaution setting and increased surveillance for diarrhea. While each of these infectious diseases outbreaks presented unique challenges, key lessons learned are; 1. The importance of case definition and tracking, 2. The vital role of screening for disease symptoms in routine medical encounters and 3. The daily and weekly evaluation of changes in location, patient profiles and other risk factors that may require a change in response.