An Outbreak of Syphilis in Alabama Prisons: Correctional Health Policy and Communicable Disease Control

Disease control in incarcerated persons is of great public health concern. The United States has the second highest reported incarceration rate in the world, behind the former Soviet Union. At the end of 1998, approximately one in every 149 US residents (1,852,400 persons) was incarcerated in state or federal prisons or in local jails.

Syphilis rates in the United States are the lowest ever reported. Despite the overall decline, some urban areas and areas of the Southeastern United States contain foci of endemic syphilis. High syphilis rates have been found at entry into jails and prisons, attributed mainly to the aggregation of persons at high risk for STDs in correctional institutions -- socially and economically disadvantaged and medically indigent persons -- and the fact that many persons have been previously incarcerated.

After syphilis outbreaks were reported at three Alabama state men's prisons in 1999, the investigators evaluated the risk factors for infection and outlined the patterns of syphilis transmission. The investigators reviewed medical, patient interview and prison transfer records and documented sexual networks. Presumptive source cases were identified by the authors, and the odds of exposure for unscreened jail populations and transfer from other prisons were calculated for case patients at one prison. In addition, all outbreak case patients were tested for antibody to HIV-1.

From 1995 to 1997, a mean of 3.7 cases of early syphilis was reported at the three outbreak prisons. The annualized incidence rate was 8.9 times higher than the previous three-year average for the outbreak prisons. Prisons A and B house 1,000 to 2,000 inmates who live in dormitory-style rooms; each room contains about 100 bunk beds. Prison C-HIV, an HIV-dedicated facility, houses about 275 inmates who sleep mainly in bunk beds.

A total of 39 patients with early syphilis were identified. At the time of the outbreak, the mean length for case patients was 66 months. Nearly one-third (28 percent) of case patients were classified as having primary or secondary syphilis. Thirty-six percent were detected through partner notification, 26 percent through routine triennial or annual screening and 26 percent through mass screening. Recent jail exposure and prison transfer were associated with being a case patient. Thirteen percent of case patients, two of whom were from Prison A, were transferred to a local jail and back to prison. At prison A, source case patients were eight times more likely than nonsource case patients to have been transferred to jail during the interview period. There were no new cases of HIV found in case patients.

Treatment delays included follow-up or delayed receipt of laboratory tests, as well as weeks of delay once penile lesions were found and tests performed. Case patients named a median of two sex partners (range 0-18) during the interview period. Only one case patient named no sex partners during this period. At prison A, 81 percent of the case patients named another outbreak case patient as a sex partner. The remaining 19 percent named only uninfected partners but were themselves named as partners of other case patients.

The investigators included a long discussion of their findings. Major points included the fact that neither partner notification nor routine triennial screening was sufficient to prevent or control the outbreaks, as evidenced by the large percentage of cases (26 percent) that were detected by mass screening. Condom distribution should be used for STD control, the researchers recommended. "It has been shown that inmates with no access to condoms make ersatz condoms with latex from rubber gloves and used plastic wrap." Like most state prison systems, the Alabama Department of Corrections prohibits the distribution of condoms in prison. In contrast, the authors point out; "condoms are available to inmates in all Canadian federal prisons and some provincial prisons. Few problems related to the perceived risk of condom distribution have been reported from these systems." Improved health care provider and prison education about STDs could greatly "fortify correctional STD control," according to the authors. "This investigation found that some prisoners presenting with signs of syphilis did not receive proper testing and that reports to the health department were not made in a timely manner or at all."

Finally, the authors emphasized that in the United States and perhaps in other parts of the world, correctional STD control affects the health of the general population. "Inmates in correction facilities are not isolated but are 'inescapably part of the American community,'" the authors said. "Most inmates eventually return to the community, bringing with them infectious diseases."

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