Abstract
Hennepin County Adult Detention Center (Jail) is Minnesota’s largest jail. In August 2019, the Minnesota Department of Health declared a statewide hepatitis A outbreak. Within three days, Hennepin County Jail Health Services made significant changes to vaccination protocols that increased vaccination rates from 0.6% to 7.1% among detainees, who have a greater risk of contracting hepatitis A. We highlight the opportunity for jails to develop sustainable public health interventions in the setting of community outbreaks.
We describe Hennepin County Adult Detention Center’s (Jail) response to Minnesota’s hepatitis A outbreak that began in August 2019.
INTERVENTION
In response to the declared outbreak, Hennepin County Jail Health Services, in collaboration with county public health officials, adopted significant changes to hepatitis A vaccination protocols for those in detention. The vaccination strategy outlined herein was pursued with the goal of preventing further spread of hepatitis A among high-risk groups in the community who also interfaced with the criminal justice system.
PLACE AND TIME
Hennepin County is Minnesota’s most populous county, with more than 1.2 million residents. From 2010 to 2018, Minnesota averaged 25 total hepatitis A cases per year. From January to May 2019, there were seven total hepatitis A cases across the state, with a steady increase thereafter. The Minnesota Department of Health declared a statewide hepatitis A outbreak on August 8, 2019; at that time there were 3 confirmed cases in Hennepin County and 23 confirmed cases across the state. On August 12, 2019, Hennepin County Jail Health Services successfully implemented sustained changes to their detainee vaccination protocols. To date, the outbreak encompasses 127 total hepatitis A cases, 46 of which occurred in Hennepin County, that have resulted in 88 hospitalizations and one death. Most of the state’s cases, 86 in total, were confirmed between August 31, 2019 and April 18, 2020.1
PERSON
Hennepin County jail averaged 32 000 bookings per year from 2015 to 2018.2 Located in downtown Minneapolis, Minnesota, Hennepin County Jail’s detainee population is composed of both men and women who are awaiting trial. The average length of stay is approximately nine days. Evaluation of the health status and chronic disease risk factors of people experiencing incarceration in the United States has consistently shown this population to possess an increased prevalence of known risk factors for viral hepatitis, including intravenous drug use. Facility data show that approximately 50% of detainees report using illicit drugs. These factors, in addition to general living conditions and barriers to accessing health care after release, create a greater risk of acquiring infectious and chronic diseases for individuals experiencing incarceration.3
PURPOSE
Because of the inherent risk of hepatitis A transmission among populations experiencing incarceration, rapid, effective changes to existing vaccination strategies were a key strategy to prevent transmission. Although significant health disparities exist among those who interface with the criminal justice system,4 jails possess a relatively untapped capacity to meet the basic health care needs of vulnerable individuals and function as an effective public health entity. Hennepin County Jail was well positioned to play a central role in minimizing the spread of hepatitis A for those who were experiencing incarceration. The highly transient nature of this group poses challenges for accessing the traditional medical system but allowed Hennepin County Jail a unique opportunity to provide necessary care to individuals who may otherwise be difficult to reach.5
IMPLEMENTATION
Before Minnesota’s hepatitis A outbreak, the Hennepin County Jail Health Services offered the hepatitis A vaccine at each detainee’s initial nursing health assessment within 14 days of jail admission. Within three days of the outbreak being declared, Jail Health Services effectively modified their strategy to vaccinate detainees against hepatitis A. At that time, protocols were changed to offer the hepatitis A vaccine at the initial intake nursing assessment and were subsequently administered by a nurse circulating to the different housing units daily during weekdays. If a detainee was unavailable, the nurse would attempt to return within 48 hours to reoffer the vaccine. All detainees already in detention were offered vaccination in their housing units during the initial week of the intervention. Vaccinations occurred typically within 48 hours of initial offer. Although vaccinations continued to be offered at the initial health assessment, significant changes to vaccination messaging and education were also employed pertaining specifically to the outbreak. This included educational materials available during the booking process along with signage in the housing units.
EVALUATION
Before the declaration of the hepatitis A outbreak, the initial rate of hepatitis A vaccinations at the Hennepin County Jail for the six months preceding the outbreak was 0.6%, or about 16 vaccinations per month. With the new protocols in place, administration of the hepatitis A vaccine increased to 7.1% (202) in August, 3.3% (90) in September, and 5.4% (137) in October. Although initial rates were significantly higher owing to offering testing to detainees already in custody, monthly rates have stabilized to between 2% and 5%.
Although rates increased significantly, challenges remain in the uptake of vaccination because of the rapid turnover of the jail population. In the initial months of the intervention, 28% to 47% of detainees expressing interest in vaccination were released before receiving the vaccine. Another 15% to 28% declined vaccination after initially expressing interest. Ongoing monitoring of the workflows includes tracking detainees interested in vaccination and reviewing statistics monthly regarding vaccination efforts. Continued collaboration with local public health allows contact tracing and postexposure prophylaxis if needed.
ADVERSE EFFECTS
Hennepin County Jail’s changes to hepatitis A vaccination protocols presented certain challenges. Although incomplete vaccination records are common, repeat hepatitis A vaccination poses no significant risk to the detainee. Other challenges include the need for vaccine education and needles as possible triggers for patients with substance use disorders.
SUSTAINABILITY
Program sustainability is a persistent challenge for many public health programs because of various financial, political, and societal factors. Through thoughtful planning by the Jail Health Services team, the changes made to hepatitis A vaccine administration were achieved by adjusting existing protocols. Neither additional funding nor additional personnel were needed to offer this preventive service more efficiently to all detainees. Moreover, all vaccines provided to individuals by Jail Health Services are made accessible through the Minnesota Department of Health’s Uninsured or Underinsured Adult Vaccine Program. Although a two-part vaccine series is the gold standard for protection against hepatitis A in adults, anti–hepatitis A immunoglobulins have been shown to be present for up to 11 years after a single vaccine dose.6 Although this intervention may not impart lifelong immunity for all detainees, this strategy remains important as a short-term intervention during an outbreak. Additionally, all jail vaccinations are entered into a statewide database, and subsequent vaccination can be performed when accessing care at other facilities to complete the series.
PUBLIC HEALTH SIGNIFICANCE
Disparities among incarcerated populations are numerous and substantial, and they span both clinical and social determinants of health. Each year spent inside prison is associated with a two-year decrease in life expectancy.7 Although the reasons for such gaps are likely multifactorial, pre-8 and postincarceration9 utilization of health care services can contribute to health disparities and limit access to preventive care, such as vaccination.
The response to Minnesota’s hepatitis A outbreak by Hennepin County Jail Health Services showcases the role that jails can play in meeting the health needs of marginalized populations, particularly those with illicit substance use. Changes to vaccination protocols to include immediate education on and offering of the hepatitis A vaccine yielded greater protection at the individual, facility, and community levels. As traditional public health entities struggle to address upstream determinants of health for the communities they serve, jails are uniquely positioned to meet the basic health needs of individuals that interface with the criminal justice system.
ACKNOWLEDGMENTS
This project was funded through existing contracts (contract A23) between Hennepin Healthcare and Hennepin County Sheriff’s Office.
We would like to thank the Hennepin County Sheriff’s Office for supporting our ongoing medical work and David Johnson, Kelzee Tibbetts, and Cameron Bright, Hennepin County Public Health, for their assistance with proofreading the article and providing data.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.
HUMAN PARTICIPANT PROTECTION
Institutional review board approval was not necessary because no human participants were involved in this descriptive work.
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