Hepatitis A Exposure Response and Outbreak Prevention in a Large Urban Jail - Los Angeles County, California, May-July 2023.

Correctional settings provide a high-risk environment for hepatitis A transmission because of the high proportion of homelessness and injection drug use among persons who are incarcerated. On May 30, 2023, Los Angeles County Department of Public Health informed the Communicable Disease Surveillance and Control (CDSC) unit of the Los Angeles County Jail system that a symptomatic incarcerated person had received a positive test result for acute hepatitis A. Upon learning the next day that the patient was a food handler, CDSC staff members identified 5,830 potential contacts of the index patient, 1,702 of whom had been released from the jail. During June 1-12, a total of 2,766 contacts who did not have a documented history of hepatitis A serology or vaccination that could be confirmed from the electronic health record or state immunization registry were identified. These persons were offered hepatitis A vaccination as postexposure prophylaxis; 1,510 (54.6%) accepted vaccination. Contacts who were food handlers without confirmed evidence of immunity and who declined vaccination were removed from food-handling duties for the duration of their potential incubation period. No additional cases were identified. Identifying contacts promptly and using immunization and serology records to ensure rapid delivery of postexposure prophylactic vaccine can help prevent hepatitis A transmission during exposures among incarcerated populations.

Characterizing predictors of COVID-19 vaccine refusal in an urban southern California jail population.

BACKGROUND: Correctional populations have been disproportionately affected by COVID-19, and many large outbreaks have occurred in jails and prisons. Vaccination is a key strategy to reduce the SARS-CoV-2 transmission in carceral settings. Although implementation can be challenging due to vaccine hesitancy and medical mistrust, correctional settings provide largely equitable healthcare access and present a unique opportunity to identify potential predictors of vaccine hesitancy independent of access issues. METHODS: We retrospectively analyzed electronic health record data for individuals offered COVID-19 vaccination at the Los Angeles County Jail between January 19, 2021, and January 31, 2023, and used multivariable logistic regression to determine predictors of COVID-19 vaccine refusal. RESULTS: Of the 21,424 individuals offered COVID-19 vaccination, 2,060 (9.6 %) refused. Refusal was associated with male sex ([aOR] = 2.3, 95 % CI (1.9, 2.8)), age 18-34 ([aOR] = 1.2, 95 % CI (1.1, 1.4), referent group: age 45-54), Black race ([aOR] = 1.2, 95 % CI (1.1, 1.4)), reporting ever being houseless ([aOR] = 1.2, 95 % CI (1.1, 1.3)), and having a history of not receiving influenza vaccination while incarcerated ([aOR] = 2.4, 95 % CI (2.0, 2.8)). When analyzing male and female populations separately, male-specific trends reflected those seen in the overall population, whereas the only significant predictor of vaccine refusal in the female population was not receiving influenza vaccination while in custody ([aOR] = 6.5, 95 % CI (2.4, 17.6)). CONCLUSION: Identifying predictors of vaccine refusal in correctional populations is an essential first step in the development and implementation of targeted interventions to mitigate vaccine hesitancy.

Risk factors for alcohol withdrawal-related hospital transfer in a correctional setting.

INTRODUCTION: A major health concern among individuals with alcohol use disorder is alcohol withdrawal syndrome (AWS), where individuals with physical dependence on alcohol may experience withdrawal signs and symptoms upon stopping or reducing alcohol use. AWS has a range of severity, with the most severe cases referred to as complicated AWS, presenting as seizure or signs and symptoms indicative of delirium or new onset of hallucinations. In the general community, risk factors or predictors of complicated AWS among hospitalized patients have been described, but there is no literature that examines such risk factors in a correctional population. The Los Angeles County Jail (LACJ) is the nation's largest jail system and manages 10-15 new patients per day for AWS. Here we aim to identify the risk factors associated with alcohol withdrawal-related hospital transfers among incarcerated patients being managed for AWS in the LACJ. METHODS: From January 1, 2019, to December 31, 2020, data were gathered about LACJ patients who required transfer to an acute care facility for alcohol withdrawal-related concerns while on the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) protocol. Log regression analysis was performed to generate an odds ratio for acute care facility transfer for the following variables: race, sex assigned at birth, age, CIWA-Ar scores, highest systolic blood pressure (SBP), and highest heart rate (HR). RESULTS: Out of 15,658 patients on CIWA-Ar protocol during this 2-year time frame, a total of 269 (1.7%) were transferred to an acute care facility for alcohol withdrawal-related concerns. Of those 269 patients, significant risk factors associated with withdrawal-related hospital transfer included: Other race (OR 2.9, 95% CI 1.5-5.5), male sex assigned at birth (OR 1.6, 95% CI 1.0-2.5), age ≥55 years (OR 2.3, 95% 1.1-4.9), CIWA-Ar score 9-14 (OR 4.1, 95% CI 3.1-5.3), CIWA-Ar score ≥15 (OR 21.0, 95% CI 12.0-36.6), highest SBP ≥150 mmHg (OR 2.3, 95% CI 1.8-3.0), highest HR ≥ 110 bpm (OR 2.8, 95% CI 2.2-3.8). CONCLUSION: Among patients studied, the higher CIWA-Ar score was the most significant risk factor associated with alcohol withdrawal-related hospital transfer. Other significant risk factors identified are race other than Hispanic, white, and African American; male sex assigned at birth; age ≥55 years; highest SBP ≥150 mmHg; and highest HR ≥ 110 bpm.

Characterizing and combating the opioid epidemic in the Los Angeles County jail system.

INTRODUCTION: Opioid overdose-related morbidity and mortality is a pressing public health crisis. Successful overdose reversal through bystander administration of naloxone is well documented, but there is an absence of literature on the implementation and impact of widespread naloxone access in a correctional setting during incarceration. The objective of this study was to describe our efforts to combat opioid overdose, prevent deaths, and examine and identify opioid use and predictors of opioid use through factors including age, sex assigned at birth, and ethnicity among the incarcerated population within the Los Angeles County jail system. METHODS: We retrospectively analyzed self-reported substance use information from all newly incarcerated persons from September 2018 to December 2020 to characterize opioid use in the Los Angeles County Jail system and used multivariable logistic regression analysis to determine predictors of substance use. We analyzed data on all cases of naloxone administration by custody personnel (i.e., all correctional officers) during the same period by examining patient demographic information, hospital discharge diagnosis, and patient outcome information. To describe naloxone training and access for incarcerated persons as an overdose prevention strategy, we reviewed electronic health record data on patient health outcomes for all cases of naloxone administration by an incarcerated person. RESULTS: A total of 6.4 % (11,881 of 187,528) of incarcerated persons reported opioid use. In the multivariable analysis, reported substance use was most significantly associated with any ethnicity other than Black (aOR for White =11.2; 95 % CI 10.4, 12.0, aOR for Hispanic/Latinx 3.0; 95 % CI 2.8, 3.2, aOR for All Others; 5.2 95 % CI 4.6, 5.8) and being <65 years old. Naloxone was administered by custody personnel to a total of 129 patients, where 122 (94.6 %) survived and 7 (5.4 %) died. After the deployment of naloxone in jail housing units, there were two instances of bystander naloxone administration by incarcerated persons that led to successful opioid overdose reversal and survival. CONCLUSIONS: The expansion of naloxone availability to both custody personnel and incarcerated persons is an effective and warranted method to ensure timely naloxone administration and successful overdose reversal in a correctional setting.

Implementation of a COVID-19 Infection Control Plan in a Large Urban Jail System.

When the COVID-19 pandemic hit the United States, the number of people confined in correctional facilities on a single day numbered 1.8 million. Incarcerated people are at an increased risk of contracting and spreading SARS-CoV-2. Recommendations from the Centers for Disease Control and Prevention on case recognition, management, isolation, and contact tracing are particularly challenging in jails because of the high turnover of incarcerated people. Beginning in late February 2020, the Department of Correctional Health Services in the Los Angeles County Jail system implemented a multipronged COVID-19 mitigation plan that was progressively amended in accordance with local and national recommendations. This plan entailed the creation of housing for people under investigation, SARS-CoV-2 screening upon entry, a mass-testing program, and identification and monitoring of medically vulnerable people. After the identification of the first laboratory-confirmed case on March 29, 2020, predictive models were generated to visualize potential disease spread and gain support for mitigation strategy planning, which forecasted approximately 3300-4600 cumulative cases during a 278-day period. From March 7 through December 31, 2020, the percentage positivity among unique people tested for SARS-CoV-2 was 11.6% (3933 of 33 921 tested). Among those screened at intake, the percentage positivity was 2.0% (502 of 25 702 tested). The ethnic distribution among people with a positive SARS-CoV-2 test result was largely representative of the overall jail population, and most people were asymptomatic. A sustainable, multifaceted mitigation plan that relies on collaboration among medical, custodial, and local public health personnel is essential for limiting the spread of SARS-CoV-2 infection in correctional facilities.

Establishing an Epidemiologic Profile of Hepatitis C Virus Infection at the Los Angeles County Jail.

OBJECTIVE: The hepatitis C virus (HCV) is the most common blood-borne infection in the United States. Although 2% to 3% of the global population is estimated to be infected with HCV, an estimated 18% of the US prison population may be infected. The objective of this study was to establish an epidemiologic profile of HCV infection in the largest urban jail system in the United States. METHODS: We retrospectively analyzed 20 years of data on demographic characteristics, risk factors, and HCV positivity among 80 681 individuals incarcerated at the Los Angeles County Jail who were tested for HCV infection from January 1, 2000, through December 31, 2019. We used multivariate logistic regression analysis to determine predictors of HCV positivity. RESULTS: Of the 80 681 individuals tested, 27 881 (34.6%) had positive test results for HCV infection. In the multivariate analysis, HCV positivity was most strongly associated with injection drug use (adjusted odds ratio [aOR] = 34.9; 95% CI, 24.6-49.5) and being born during 1946-1955 (aOR = 13.0; 95% CI, 11.9-14.2). Men were more likely than women to have HCV infection (aOR = 1.4; 95% CI, 1.3-1.5), and Hispanic (aOR = 4.2; 95% CI, 3.9-4.4) and non-Hispanic White (aOR = 3.8; 95% CI, 3.5-4.0) individuals were more likely than non-Hispanic African American individuals to have HCV infection. Noninjection drug use, homelessness, and mental health issues were also significantly associated with HCV positivity. CONCLUSION: Even in the absence of resources for universal screening for HCV infection, the creation of a risk profile and its implementation into a screening program may be a beneficial first step toward improving HCV surveillance and establishing an accurate estimate of HCV infection in the incarcerated population.

Risk-Based HIV Testing at Los Angeles County Men's Central Jail.

Incarcerated populations tend to be disproportionately affected by HIV and sexually transmitted infections (STIs), and men who have sex with men (MSM) are an especially high-risk subset of these populations. Despite the Centers for Disease Control and Prevention's recommendations for universal HIV screening, a lack of resources and high inmate turnover make it difficult to implement such guidelines in jails. From September 2013 to May 2016, the Infection Control Unit of the Los Angeles County Jail used existing resources to implement a voluntary, risk-based HIV educational and screening program targeting MSM inmates during early incarceration. The results revealed a high percentage of previously unknown HIV infections (8.5% = 57 of the 671 tested) and some unknown non-HIV STI cases. In the absence of resources for universal HIV screening, the risk-based approach is a sustainable and cost-effective approach for improving HIV surveillance in the correctional setting.