Receipt of A(H1N1)pdm09 Vaccine by Prisons and Jails — United States, 2009–10 Influenza Season

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Approximately 2.3 million inmates were confined to U.S. prisons and jails on any given day in 2009 (1,2). However, over the course of a year, approximately 10 million persons spend time in a correctional facility (3). To determine to what extent correctional facility populations were included in the national vaccine response to the influenza A (H1N1)pdm09 pandemic, staff members at the Emory University Preparedness and Emergency Response Research Center, aided by the National Commission on Correctional Health Care (NCCHC), conducted a survey to document whether jails and prisons received A(H1N1)pdm09 vaccine during the 2009–10 pandemic period. This report summarizes the results of that survey, which found that 55% of jails did not receive A(H1N1)pdm09 vaccine during the pandemic period, whereas only 14% of federal prisons and 11% of state prisons did not receive the vaccine. Greater inclusion of correctional facilities, especially smaller facilities, in pandemic preparedness planning might better protect correctional facility populations and the community as a whole in the event of future influenza pandemics.

U.S. institutions run by state or federal governments that house persons sentenced to >1 year are referred to as prisons. Those run by city or county governments in which persons are detained before trial or are incarcerated for sentences of ≤1 year generally are referred to as jails. Most jail inmates are released in a matter of days, contributing to a high ratio of releasees mixed in with the public. Strengthening correctional facility pandemic preparedness efforts can enhance pandemic preparedness in the surrounding community, the first stop for releasees (4).

A national survey* was conducted of medical authorities in a representative sample of U.S. prisons and jails. To select the sample, both the Bureau of Justice Statistics ranking of the 50 largest jails by population in 2009 and other jail census data for 2006† were analyzed. To sample one third of each stratum, 17 (34.0%) of the 50 largest jails were chosen randomly to be surveyed, as were 968 (33.4%) of the 2,899 smaller jails (Figure 1). In addition, 34 of the 102 (33.3%) federal prisons and 573 (33.3%) of 1,719 state prisons listed in Bureau of Justice Statistics 2005 prison census data§ were selected.

Because of facility closures, consolidations, and outdated information, NCCHC was able to provide valid contact information for medical authorities at only 1,008 (63.3%) of the 1,592 randomly selected facilities. To supplement these 1,008 facilities, the NCCHC mailing list was used to add convenience samples of 114 jails and 64 state prisons. This resulted in a total final sample of 1,186 facilities: 814 jails (of which 114 [14.0%] had been selected for convenience), 341 state prisons (of which 64 [18.8%] had been selected for convenience), and 31 federal prisons (all randomly selected) (Figure 1). The 37-question survey was distributed by fax and e-mail during July–November 2010. Follow-up requests were sent to nonresponders 1 week after distribution of the survey. Three successive rounds of reminder calls were made to nonresponders. Facilities whose fax numbers or e-mail addresses were incorrect also were called to correct that contact information. Three months after the survey was first distributed, an option of a 10-question telephone version of the survey was offered to facilities that had not yet responded.

To estimate the proportions of inmates in jails that responded to the survey, the average daily population (ADP) was used. For jails with a capacity of fewer than 3,145 inmates, ADP listings from the 2009–2010 American Correctional Association National Jail and Adult Detention Directory were used; when ADP was not available, the population was estimated using the legal capacity of the facility (5). ADPs for the largest jails were taken from Bureau of Justice Statistics data (2). Responding jails housed 50% of the number of inmates in all sampled jail facilities.

Medical authorities in 38% of facilities responded (447 of 1,186), including 94% (29 of 31) of those in federal prisons, 39% (132 of 341) in state prisons, and 35% (286 of 814) in jails. Overall, during the A(H1N1)pdm09 pandemic, 39% of responding facilities reported not receiving any A(H1N1)pdm09 vaccine. However, proportions of vaccine distribution differed with respect to facility type. Only 14% of federal prisons and 11% of state prisons reported not receiving A(H1N1)pdm09 vaccine during the pandemic period. In contrast, 55% of the sampled U.S. jails did not receive vaccine during the pandemic period.

Most of the facilities that received vaccine did so during October 2009–January 2010, when vaccine was allocated to persons at high risk. Some facilities in each of the category types began receiving vaccine before all the vaccine became available to the general population in January 2010 (Figure 2). A(H1N1)pdm09 vaccine distribution was begun earlier for federal prisons (median: October 30, 2009) than for either state prisons (median: November 15) or jails (median: November 14). When facilities that reported receipt of vaccine but did not report a receipt date were excluded, the proportions receiving vaccine by April 2010 were 71% for federal prisons, 55% for state prisons, and 28% for jails (Figure 2).

Reported by

Alice S. Lee, MPH, David M. Berendes, MPH, Katherine G. Seib, MSPH, Ellen A.S. Whitney, MPH, Ruth L. Berkelman, MD, Saad B. Omer, PhD, Anne C. Spaulding, MD, Emory Univ, Atlanta, Georgia. R. Scott Chavez, PhD, National Commission on Correctional Health Care, Chicago, Illinois. Patricia Lynn Meyer, Correctional Medical Svcs, St. Louis, Missouri. Corresponding contributor: Anne C. Spaulding, aspauld@emory.edu, 404-727-3369.

Editorial Note

Inmates of jails and prisons have high rates of chronic and infectious diseases (4); 5.2% of women entering jails are pregnant (5). Persons dwelling in jails and prisons are at increased risk for exposure to infectious agents because new entrants can constantly introduce new pathogens, and close confinement can facilitate disease transmission (6). For some inmates, incarceration is their first contact with the health-care system as an adult. Improving the health of inmates, especially controlling communicable disease among them, is important not only for their health and that of their fellow inmates, but for the health of the public at large (7).

The findings in this report indicate that, although some correctional facilities were able to obtain A(H1N1)pdm09 vaccine in a timely manner after it became available, 55% of jails in the United States did not receive any vaccine during the 2009 influenza pandemic period. Inmate populations include groups in the highest risk categories for A(H1N1)pdm09 influenza (e.g., pregnant women). The distribution process for A(H1N1)pdm09 influenza vaccine was a state-directed process, in which states received population-based allocations and determined the best way to use those allocations. Some states might need to reexamine their priorities in dispensing vaccine so that they can protect persons in jails who might otherwise be missed during vaccination efforts and pandemic influenza planning.

The findings in this report are subject to at least three limitations. First, the study focused on delivery of vaccine to facilities and not on vaccination coverage among inmates and staff members. For facilities reporting receipt of vaccine, coverage rates varied. Second, because contact information for a number of facilities could not be found, a convenience sample was added to the random sample. These insertions were selected arbitrarily. A retrospective sensitivity analysis determined that the convenience sample did not bias the estimates in the study.¶ Finally, response rates were below 50% for jails and state prisons and differed by strata and selection method. Among the randomly selected facilities, response rates were 38% for jails, 94% for federal prisons, and 39% for state prisons. Among the convenience samples, response rates were 36% for jails and 45% for state prisons. However, surveys of correctional health-care personnel often have low response rates (10), in part because of a reluctance to engage in any form of health research. As a result, many correctional health studies have resorted to using convenience samples. The overall correctional facility response rate of 40% is comparable with other surveys that have been conducted within the context of correctional health care (10).

Failing to address the vaccination needs of incarcerated populations affects inmate populations and correctional workers, including health-care workers, because of their persistent contact with inmates. As inmates are released, this cycle has the potential to influence the health of the public in nearby communities as well. Because a large proportion of the inmate population is apt to be medically underserved before incarceration as a result of factors such as lack of insurance coverage or inadequate access to primary health care (9), entry into incarceration might be an inmate's first contact with the health care system as an adult. Consequently, correctional health-care workers need adequate resources and vaccine to protect these populations.

The United States undoubtedly will experience future pandemics, some of which might be more severe than the 2009 influenza pandemic. Meeting the need for adequate vaccine delivery to jails can affect the health of inmates and the general population. The experience of vaccine distribution for the A(H1N1)pdm09 influenza pandemic highlights the importance of including correctional health-care leaders in emergency pandemic planning.

Acknowledgments

Sarah Bur, MPH, Federal Bureau of Prisons. Paul Weiss, MS, Jessica Cook, Koo Chung, MPH, Meghan Donohue, Alexandra Fehr, MPH, Meghan Griffin, MPH, Neema Iyer, MPH, Christopher Simpson, Colleen Spellen, Emory Preparedness and Emergency Response Research Center, Rollins School of Public Health, Emory Univ, Atlanta, Georgia.

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