Rubella Outbreaks in Prisons -- New York City, West Virginia, California

From March to July 1985, three rubella outbreaks were reported among groups of inmates and staff at prisons in New York City, West Virginia, and California. A total of 93 persons were affected.

New York City. The largest outbreak occurred at a correctional institution in New York City, where 50 cases of clinical rubella* were reported from March 14 through June 11. All but three patients had onset of rash on or after April 21 (Figure 1). Ten (20%) of the 50 cases were serologically confirmed as rubella. The prison is located in the same geographic area as a factory with reported rubella activity, but an epidemiologic link could not be documented.

Of the 50 patients, 42 (84%) were prison inmates, and eight (16%) were correctional staff. One 41-year-old female correctional officer in the unit where the majority of cases occurred developed rubella; the remaining 49 patients were males. Patients ranged in age from 19 years to 41 years.

The detention facility confines approximately 8,000 inmates, 600 of whom are women. Four thousand correctional officers and other personnel are employed by the detention facility. Daily admissions into the correctional system range between 150 and 250 persons, including approximately 40 women. The constant movement of inmates and accompanying staff to and from courts and the transfers of inmates to other correctional facilities create substantial potential for spread of illness.

When rubella was first suspected, isolation precautions were initiated for all symptomatic patients. Pregnant female inmates were serologically screened for rubella immunity and housed in the infirmary if found to be susceptible. After rubella infection was serologically confirmed in five inmates on April 25, the New York City Department of Health and the Montefiore Rikers Island Health Services established immunization clinics for inmates and employees at the main detention facility and five satellite facilities from April 27 to May 7. Vaccine was not offered to persons over 45 years of age. A total of 4,107 (51%) inmates and 976 (24%) correctional staff received rubella vaccine at the clinics. In addition, a program to immunize newly admitted inmates on a daily basis continued until 21 days after onset of the last case.

West Virginia. From April 17 to May 6, nine cases of clinical rubella, all of which were serologically confirmed, occurred among inmates at a federal prison in Morgantown, West Virginia. Patients ranged in age from 23 years to 30 years; seven were males, and two were nonpregnant females. Immediately after diagnosing the first case on April 17, the prison physician contacted the West Virginia Immunization Program. After serologic confirmation of the first seven cases was obtained April 22, voluntary immunization of inmates and prison staff began. Three hundred two (96%) of 316 inmates and 78 (55%) of 142 prison employees who lacked written documentation of rubella immunity** were immunized. Rubella did not spread to the surrounding community.

California. The third rubella outbreak occurred at a county prison facility in Santa Clara County, California. Thirty-four cases occurred from April 18 to July 26, 30 among inmates and four among prison employees. One female among each of the two groups was affected. Of the 34 clinical cases, 24 (71%) were serologically confirmed. Patients ranged in age from 19 years to 35 years. The presumed index patient, a 23-year-old female file clerk, was employed in an office adjacent to the prison sick bay where she continued working during her rash illness. Control measures included isolation of active cases and of nonimmune pregnant inmates. Warnings were issued to staff and visitors who might have been pregnant. Rubella immunization of 350 persons on the correctional staff and the 230 female and 2,500 male inmates began June 21. One woman who did not know she was pregnant received rubella vaccine. Two rubella cases in nearby Santa Cruz County were epidemiologically linked to a prisoner with serologically confirmed rubella. No subsequent spread to the surrounding community was documented.

In none of the three outbreaks was any patient known to have been previously immunized against rubella. No pregnant women were known to have contracted rubella during the outbreaks. Reported by S Chisolm, RL Cohen, MD, J Cortesi, MS, Montefiore Hospital and Medical Center, Z Fabrizi, E Leskovac, PA Thomas, MD, S Schultz, MD, Bureau of Preventable Diseases, New York City Dept of Health; JA McDonald, MD, Federal Bureau of Prisons, Morgantown, JD Farris, PF King, Immunization Program, J Brough, PhD, Preventive Health Svcs, DK Heydinger, MD, State Director of Health, West Virginia Dept of Health; B D'Armond, MD, M Fenstersheib, MD, C Fazekas, MJ Wilson, MD, Santa Clara County Health Dept, LG Dales, MD, Immunization Unit, J Chin, MD, State Epidemiologist, California Dept of Health Svcs; Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Before vaccine licensure in 1969, rubella was primarily a disease of young school-aged children, with the highest incidence rate in children 5-9 years old. However, a substantial percentage (23%) of cases was reported among persons older than 14 years (1). Since vaccine licensure, age-specific incidence rates have declined in all age groups. Initially, the decline was less marked for persons older than 15 years (2). Consequently, the occurrence of rubella among adolescents and adults became increasingly prominent as outbreaks among susceptible populations of military recruits (3), hospital personnel (4), office workers (5-7), college students (8), and, most recently, prison inmates and staff were recognized.

The goal of rubella immunization is to prevent rubella infection during pregnancy and the consequent 20%-80% risk of delivering an infant affected by congenital rubella syndrome (CRS). The severe consequences of CRS and the average lifetime cost (in excess of $200,000) incurred by each CRS patient (9) may thus be prevented by vaccine. When rubella vaccine was first licensed, transmission of rubella was greatest among preschool and elementary school children. The initial vaccination strategy adopted by the United States was universal immunization of all young children; vaccination would protect them immediately and subsequently through their childbearing years, while greatly reducing or even interrupting circulation of the virus. By virtually eliminating the risk of exposure, susceptible pregnant women would be protected indirectly (1).

This vaccination strategy reduced the reported incidence rates of rubella in all age groups by more than 90%, but the greatest declines occurred among persons under 15 years old (1). Meanwhile, the proportion of susceptible individuals in the population of childbearing age remained fairly constant (10%-20%) (9). As a result, adolescents and adults began to account for an increasing percentage of reported cases. Since 1981, 37%-62% of rubella cases reported annually have been among persons 15 years of age or older.

The changing age distribution of reported rubella patients has been accompanied by continuing reports of sustained rubella outbreaks in settings where older adolescents and adults congregate. The reports of sustained outbreaks have lead to increased efforts to vaccinate these older populations and thus hasten the elimination of CRS (1,9). However, many gaps still exist in these efforts because of the logistical problems of vaccinating nonschool-based populations.

Although they have not previously been reported, rubella outbreaks in prisons are not unexpected, given the susceptibility of groups within prisons and the closed, confined environment with its increased opportunities for transmission. Rubella outbreaks in prisons lead to disruption of orderly activities, to time lost from work, and, possibly, to breakdowns in security. Rubella outbreaks also pose a risk of infection for pregnant women inmates, staff, and visitors. To control such outbreaks, active identification and confirmation of cases, isolation of patients during the infectious period, isolation or exclusion of nonimmune pregnant women until the end of the outbreak, and vaccination of susceptible individuals are necessary.

Preventing outbreaks is preferable to controlling them. Outbreaks in prisons and other institutions where young adults congregate are likely to occur until those adults are immune. A history of previous infection is unreliable and should not be accepted as proof of immunity (10). Vaccinating susceptible persons in prisons--and the remaining susceptible adult population-- would effectively reduce the risk of outbreaks. Vaccination requirements have virtually eliminated rubella among military recruits (3); similar requirements should be equally effective in other institutions. Vaccination against measles and hepatitis B could also reduce the risk of transmission of these diseases among prison inmates.

References

1. Orenstein WA, Bart KJ, Hinman AR, et al. The opportunity and obligation to eliminate rubella from the United States. JAMA 1984;251:1988-94.

2. CDC. Rubella and congenital rubella syndrome--United States, 1983-1984. MMWR 1984;33:528-31.

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