The crowded conditions that exist in many of the world's jails and prisons create an ideal environment for the transmission of contagious diseases. Restrictions on the availability of clean laundry, soap, water, condoms and needle exchange increase the probability that infectious diseases will be transmitted from one person to another. Furthermore, the transient status of inmates who are frequently moved from one location to another can complicate the diagnosis of infection, recognition of an outbreak, performance of a contact investigation, interruption of ongoing transmission, and eradication of disease.
Infection Control Program and Infection Control Committee
All correctional facilities should have an infection control program. Typical activities to prevent and control communicable diseases (CD) include:
Educating staff and inmates,
Establishing a written exposure control plan that minimizes the potential for employee exposure to blood borne pathogens,
Encouraging staff and inmates to be vaccinated,
Monitoring the incidence of selected CD among staff and inmates,
Ensuring that inmates receive prompt and appropriate treatment and monitoring adherence,
Establishing and enforcing isolation policies,
Ensuring that personal protective equipment is available to and utilized by staff,
Evaluating and making available sharps devices that are least likely to cause injury,
Overseeing an effective post-exposure program, and
Ensuring that reports are completed and submitted as required by local, state and federal laws and regulations.
The infection control program should be managed by an infection control committee that includes physicians, representatives from custody, administration, nursing, dental, housekeeping, food services, unions if applicable, and other clinical areas at the facility such as laboratory, surgery, dialysis, respiratory therapy, and physical therapy. Although smaller facilities may not require the complex program necessary in a facility with a large medical mission, the basic elements remain the same.
Personal Protective Equipment (PPE)
Personal protective equipment (PPE) applies to clothing and equipment intended to protect employees from coming into contact with blood, other body fluids and contaminated air. PPE includes masks, respirators, gloves, goggles, face shields, gowns, hoods, and foot coverings. PPE should be readily accessible in all patient care areas, housing units, transportation vehicles, the laundry, and anywhere that employees are likely to come into contact with inmates. PPE should be inventoried on a regular basis and replaced as needed. Staff should be encouraged to carry gloves with them at all times so that they are prepared to protect themselves when responding to altercations, self mutilators, suicide attempts, and other medical emergencies. Making gloves available at areas where custody staff sign in each day may facilitate their use of PPE by correctional employees.
Personal respiratory protection should be used by staff whenever they enter a room in which a person with known or suspected pathogen that can be transmitted via the air. Those who are in the area of cough- inducing procedures should also wear respiratory protection. Although no respiratory protective device will be 100% protective, when used consistently and correctly, respirators are highly reliable in the prevention of acquisition of respiratory pathogens. Respirators should be rated at least N-95 efficiency, be able to be fit-tested, and be available in several sizes to accommodate different facial sizes and characteristics.
Blood Borne Pathogen (BBP) Exposures
Needlestick and other sharps injuries can occur during a variety of activities, including:
Replacing the cap on used needles,
Disposing of needles,
Passing sharps devices from one person to another,
Handling trash and dirty linens,
Intentional use of sharps as a weapon, and
Cell search or body search.
Inmates are at risk for BBP exposures during injection drug use, tattooing, fights, and unprotected sexual activity. Correctional employees also face a rather unique risk of being intentionally exposed to blood borne pathogens by inmates who throw body fluids at them (known as "gassing" or "chunking").
Decreasing the risk of BBP exposure can be accomplished by vaccination of at-risk staff and inmates, education concerning the appropriate use of PPE, harm reduction education to inmates, implementation of policies and procedures to decrease the likelihood of sharps injuries, and operation of an effective post-exposure management program.
Safer sharps devices that have built-in features such as sheathing devices, blunted surgical needles, and retractable needles and blades are available. These devices have been shown to significantly reduce exposure to blood borne pathogens by decreasing the incidence of accidental needlesticks. Additionally, many injuries can be avoided by decreasing the use of needles (needleless intravenous connectors, using oral medications instead of injectables, consolidating diagnostic blood draws, and using urine or oral fluid tests instead of blood tests).
Many of the currently available safety syringes utilize a spring-loaded system. All safety syringes can be disassembled with minimal effort, and the springs in some of them are made of sturdy gauge wire that may pose security concerns.
For an excellent review of this topic, the reader is referred to the following resources:
HEPP Report July/Aug. 2003: Hepatitis B, C, and HIV Post-exposure Prophylaxis in Correctional Settings. Available at www.hivcorrections.org/archives/julyaug03/mainarticle.html.
MMWR Vol 50, No RR11; 1 06/29/2001: Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis
Standard precautions merge essential components from both universal precautions and body substance isolation, and are to be used for all patients.
In addition to utilizing standard precautions for all patient contacts, transmission-based precautions are to be used in situations in which patients are known or suspected to have a particular CD. There are three categories of transmission-based precautions, airborne, droplet and contact, and each relates to a method of transmission.
Airborne precautions are intended to decrease the likelihood of transmission of organisms that can be carried in small sized (less than 5 µm) dust particles or droplet nuclei and should be used for patients who are known or suspected to be infected with Mycobacterium tuberculosis (MTB), measles, chicken pox (VZV), and disseminated shingles (VZV). Airborne precautions require isolation in a private room that has negative pressure relative to the hallway and at least six air exchanges per hour. The air from the room should either be vented directly to the outside or passed through a high efficiency filter prior to being recirculated. The door to the room should remain closed at all times. While in use, the room should be evaluated each day to ensure that it maintains negative pressure relative to the corridor. All those who enter the room must wear a respirator that meets the National Institute for Occupational Safety and Health's (NIOSH) N-95 standard, with an ability to filter 1 µm particles with an efficiency of at least 95%. Movement of the inmate/patient from the isolation room should be minimized. While out of the room, the patient must wear a surgical mask.
Droplet precautions are intended to decrease the likelihood of transmission of organisms that can be carried in particles that are larger than 5 µm. Droplets of this size can be created when a person talks, coughs, sings, or sneezes. Procedures such as suctioning and bronchoscopy can also create droplets of this size. These larger droplets do not remain suspended in the air and usually will travel no more than three feet. Examples of illnesses that require droplet precautions include meningitis and epiglottitis caused by Haemophilus influenza, and infections caused by N. Meningitidis, influenza, and Mycoplasma pneumonia. Patients confirmed or suspected to have these conditions should be placed in a single cell or cohorted with other inmates who are infected with the same organism. Negative pressure respiratory isolation is not required. Staff should wear a mask when they are within three feet of the infected person. If the inmate/patient must leave the room, s/he should wear a mask.
Contact precautions should be used for persons known or suspected to be infected or colonized with organisms that commonly cause disease and can be transmitted by direct or indirect contact. These organisms can be acquired by direct contact with an infected or colonized person or indirectly by contact with inanimate objects. Examples include Clostridium difficile, Herpes simplex virus, Hepatitis A virus, VZV, staphylococci including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, lice, and scabies.
Staff should wear gloves when entering the patient's room, and remove gloves and wash their hands when leaving. Gowns should be worn while in the patient's room and removed prior to leaving. Face shields and eye protection should be worn during procedures that are likely to cause splashes of body fluids. Patient care items should remain in the room and not be reused on other patients unless they are disinfected.
Culinary Services and Food Handlers
All persons being considered for a position in the culinary department should be screened for health conditions that would preclude them from working in food services. Potential workers should be excluded if they have open sores on their hands or arms, an active respiratory infection, or an illness characterized by vomiting or diarrhea. Those who have had recent positive cultures for enteric pathogens should not be approved for food handling until cleared by infection control. Individuals with poorly controlled mental illness and those who lack the intellectual ability to adhere to appropriate standards of hygiene should not be utilized as culinary workers. HIV, hepatitis B, and hepatitis C are not transmitted through food, and the presence of these infections should NOT preclude otherwise qualified individuals from working in food services.
Prior to beginning work in culinary services, all staff should receive an orientation concerning the importance of good hygiene. Comprehension of basic cleanliness and disease prevention concepts should be assured through testing. This education should be repeated at least annually. Supervisors should perform daily inspections of workers to ensure that they do not have active respiratory illnesses, open sores on their hands or arms, or an active gastrointestinal illness. Those who are ill should be removed from food services until cleared by infection control.
Insufficient access to clean clothes and linen is associated with acquisition of body lice and methicillin-resistant Staphylococcus aureus among those housed in congregate living environments.
In the correctional environment, there are legitimate custody concerns regarding laundry distribution. Clothing and linen are often hoarded, and can be cut up to make non-approved clothing, curtains, and escape items such as ropes and altered clothing. These concerns notwithstanding, inmates should be provided an adequate supply of clothing and linens, and these items should be exchanged on a frequent and regular basis.
Those who handle contaminated laundry should be provided gloves, gowns, masks, and face shields for use while handling and sorting contaminated laundry. Thick utility gloves may provide workers with additional protection, and can be decontaminated and reused if they are not cracked, torn, or punctured.
Dirty linens should be rolled up to confine solid waste and to avoid aerosolization of organisms. Soiled linen should be bagged or put into carts at the location where it was used, and should not be sorted or otherwise excessively handled in any patient-care area. Linen from inmates who are on contact precautions should be handled according to published guidelines. Linen that has been contaminated with blood or other potentially contagious body fluids should be either placed in leak proof bags or containers labeled with the biohazard symbol, or placed in red bags for transportation. Because of the potential for disease transmission during handling of laundry, the sorting process should be minimized. Adequate ventilation should be maintained in the laundry area to decrease the potential for transmission of airborne diseases.
To minimize sharps being disposed of in the laundry stream, staff should be educated to adhere to procedures that detail the appropriate disposal of sharps, and laundry workers should be trained on how to handle sharps that are found in laundry. Needle containers should be readily available in laundry areas.
A temperature of at least 71° C (160° F) for a minimum of twenty-five minutes has commonly been recommended to effectively kill microorganisms. Studies have demonstrated that low temperature washing at 22-50° C can effectively reduce microorganism concentrations when adequate amounts of chlorine bleach are utilized.
In most jails and prisons, inmates perform the majority of haircuts. In many cases, these inmate barbers have had little or no training. Barbering tools may be reused without appropriate disinfection, creating an opportunity for the transmission of bacterial, fungal, or parasitic organisms. All inmates who are to serve as barbers should receive training, undergo post-education testing, and be observed periodically to ensure adherence with infection control practices. Access to necessary disinfection supplies should be facilitated.
Barbers should be provided containers to hold soiled linens. Towels should only be used on one client before being appropriately laundered. Containers should also be provided for the disinfection of combs, brushes, clippers, and scissors. An adequate supply of a disinfectant solution should be provided to allow for the complete immersion of barbering tools between haircuts.
Before each use, all non-electrical instruments should be cleaned with soap and water and then soaked in a disinfectant with known activity against bacteria, viruses, and fungi. This solution should be changed whenever visibly dirty, but at least weekly. Before each use, clippers and other electrical instruments should be brushed to remove all foreign matter and then disinfected by wiping with a disinfectant. Disinfected instruments should be stored in a clean, covered area.
All those who perform barbering activities should thoroughly wash their hands with soap and water and/or an approved hand disinfectant before each client. Barbers who are infected with an organism that is readily transmitted to others during barbering activities should not work until they are no longer contagious. Examples of conditions that can be transmitted during haircutting include purulent conjunctivitis (pink eye), VZV, respiratory illnesses such as colds, influenza, and tuberculosis, bacterial skin infection such as impetigo or cutaneous abcesses, methicillin-resistant staphylococcus infection, and ectoparasites such as scabies and lice. Hepatitis B, Hepatitis C, and HIV are not transmitted during routine barbering activities and should NOT preclude employment as a barber.
General Infection Control Resources
The Occupational Safety and Health Organization (OSHA) is part of the United States Department of Labor, and exists to develop and enforce workplace safety standards (www.osha.gov).
The Centers for Disease Control (CDC) is an advisory body of the federal government. The CDC creates guidelines and provides recommendations concerning health-related issues (www.cdc.gov).
The National Institute for Occupational Safety and Health (NIOSH) is part of the CDC (www.cdc.gov/niosh/homepage.html).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) publishes performance standards and provides certification to health care organizations that meet them (www.jcaho.org).
The Association for Professionals in Infection Control and Epidemiology (APIC) is a professional organization for those involved in Infection Control. APIC collaborates with the CDC to publish infection control guidelines, conducts research, sponsors educational programs, and provides resource materials (www.apic.org).
Herwaldt LA, ed. A Practical Handbook for Hospital Epidemiology. Thorofare, NJ: SlACK Incorporated 1998.
Mayhall CG, ed. Infection Control and Hospital Epidemiology. Baltimore, Maryland: Williams and Wilkins; 1999.
MRSA information: www.cdc.gov/ncidod/hip/aresist/mrsa.htm, Methicillin-Resistant Staphylococcus Aureus Skin or Soft Tissue Infections in a State Prison-Mississippi, 2000. MMWR 2001;50:919-22, Outbreaks of Community-Associated Methicillin-Resistant Staphylococcus Aureus Skin Infections-Los Angeles County, California, 2002--2003. MMWR 2003;52:88., Methicillin-Resistant Staphylocccus Aureus Infections in Correctional Facilities-Georgia, California, and Texas, 2001-2003. MMWR 2003; 52(992-996).
Joseph Bick, M.D., is Chief Medical Officer at California Medical Facility. He has nothing to disclose.