key: cord-0745364-gv1zf071 authors: Zawitz, Chad; Welbel, Sharon; Ghinai, Isaac; Mennella, Connie; Levin, Rebecca; Samala, Usha; Smith, Michelle Bryant; Gubser, Jane; Jones, Bridgette; Varela, Kate; Kirbiyik, Uzay; Rafinski, Josh; Fitzgerald, Anne; Orris, Peter; Bahls, Alex; Black, Stephanie R.; Binder, Alison M.; Armstrong, Paige A. title: Outbreak of COVID-19 and Interventions in a Large Jail — Cook County, IL, United States, 2020 date: 2021-04-02 journal: Am J Infect Control DOI: 10.1016/j.ajic.2021.03.020 sha: 36b179cc821d44db7401df7ea0b512ffe84a492a doc_id: 745364 cord_uid: gv1zf071 BACKGROUND: Correctional and detention facilities are disproportionately affected by COVID-19 due to shared space, contact between staff and detained persons, and movement within facilities. On March 18, 2020, Cook County Jail, one of the United States’ largest, identified its first suspected case of COVID-19 in a detained person. METHODS: This analysis includes SARS-CoV-2 cases confirmed by molecular detection among detained persons and Cook County Sheriff's Office staff. We examined occurrence of symptomatic cases in each building and proportions of asymptomatic detained persons testing positive, and timing of interventions including social distancing, mask use, and expanded testing and show outbreak trajectory in the jail compared to case counts in Chicago. RESULTS: During March 1–April 30, 907 symptomatic and asymptomatic cases of SARS-CoV-2 infection were detected among detained persons (n = 628) and staff (n = 279). Among asymptomatic detained persons in quarantine, 23.6% tested positive. Programmatic activity and visitation stopped March 9, cells were converted into single occupancy beginning March 26, and universal masking was implemented for staff (April 2) and detained persons (April 13). Cases at the jail declined while cases in Chicago increased. DISCUSSION/CONCLUSIONS: Aggressive intervention strategies coupled with widespread diagnostic testing of detained and staff populations can limit introduction and mitigate transmission of SARS-CoV-2 infection in correctional and detention facilities. In correctional and detention facilities, shared physical space and interaction of detained persons and staff facilitate introduction and spread of viruses like SARS-CoV-2 (1). Large COVID-19 outbreaks have been reported in congregate settings (2, 3) , including correctional and detention facilities (4) . Multiple interventions, including physical distancing and reducing introductions from the community via new detained persons, staff, and visitors, are likely needed to effectively interrupt SARS-CoV-2 transmission, but can be difficult to implement (5, 6) . Many individuals incarcerated or detained in U.S. state and federal facilities are at elevated risk for severe COVID-19: they are more likely than the general population to be immunocompromised (7) and approximately 50% have pre-existing medical conditions (8) . Cook County Jail (CCJ) is one of the largest in the United States. On March 18, 2020, a person detained at CCJ reported influenza-like illness, including shortness of breath and fever, but tested negative for influenza. Cermak Health Services (CHS) medical staff suspected COVID-19, isolated the patient, and notified the Chicago Department of Public Health (CDPH). Although the patient did not meet COVID-19 testing criteria (no international travel or known exposure), CHS submitted diagnostic specimens to the Centers for Disease Control and Prevention (CDC). On March 28, a specimen tested positive for SARS-CoV-2 by real-time reverse transcriptase polymerase chain reaction (rRT-PCR). We describe the subsequent outbreak of COVID-19 among detained persons 1 and staff at CCJ and interventions to reduce transmission. CHS, the Cook County Sheriff's Office (CCSO), Cook County Health (CCH), CDPH, and CDC partnered to investigate, identify, and interrupt transmission. In 2019, approximately 59,000 people were admitted into custody at CCJ; the average daily number of detained persons was 5 COVID-19 cases were defined as SARS-CoV-2 infection by molecular detection in persons with an epidemiologic link to CCJ during March 1-April 30, 2020. Any detained person reporting symptoms consistent with COVID-19 was medically isolated in a single-occupancy cell, assessed by medical staff, and tested for SARS-CoV-2 via rRT-PCR performed at Illinois Department of Public Health, QUEST diagnostics (Secaucus, New Jersey), or Stroger Hospital using the m2000 system (Abbott Laboratories, Illinois, USA). In the event a detained person on a unit tested positive or ≥2 suspected cases were detected, they were removed from the unit, and the remaining individuals on the unit were quarantined in place for ≥14 days. Individuals on quarantined units remained on the unit, had meals delivered, medical care provided on the unit, and staff were kept as consistent as possible. Quarantined persons were assessed daily for symptoms; if any became symptomatic, they were medically isolated, and quarantine was extended an additional 14 days for the remainder of the unit. Additionally, once a unit was placed on quarantine, all individuals on that unit were tested. Any individuals found to be positive were removed from the unit and the quarantine was extended 14 days. All individuals on the unit were again tested at Day 10-14, prior to removing the unit from quarantine. Initially, due to resource constraints, only asymptomatic individuals at high-risk for developing severe disease were tested. As resources became available, all detained persons entering the jail, and all those in quarantine were also tested. Testing was offered to asymptomatic detained persons in units placed under quarantine from March 25 onward. Beginning April 20, testing of newly detained persons was performed with the ID NOW TM COVID-19 assay (Abbott). CCSO employees working on the CCJ campus were provided with a list of testing locations, but testing was optional. Staff were required to report symptoms, positive test results, or COVID-19 clinical diagnoses to CCSO; affected individuals were provided paid time off. Staff cases were cross-referenced with Illinois' National Electronic Disease Surveillance System (I-NEDSS) to validate laboratory results. Epidemiologic curves by division were constructed using date of medical isolation as a proxy for date of symptom onset for detained persons, and by self-reported symptom onset date for staff. First positive specimen collection date was used if medical isolation date was not available. The overall attack rate (AR) among detained persons at CCJ was calculated using the average census population during the study period (N = 4,884) as the denominator; ARs by division are not reported due to fluctuations in daily census and variations in where asymptomatic testing was performed. Age, underlying conditions, temperature closest to specimen collection, and fatal outcome are described for all detained persons testing positive. Descriptive statistics and P values were calculated for each variable to assess association with symptomatic infection. Summaries of categorical variables are expressed as proportions and compared using Pearson χ2 for independence, Fisher's exact test, or Cochran-Armitage test as appropriate. The continuous age variable is expressed as median (interquartile range [IQR]) and compared using Wilcoxon rank sum test. Two-sided statistical tests were considered significant at a P < 0.05. Data for all persons residing in the state of Illinois meeting the case definition for confirmed SARS-CoV-2 infection were extracted from I-NEDSS and included using the specimen collection date. We compared trends in case counts among detained persons, staff, and residents of Chicago during the study period by creating logarithmic-scale graphs of new and total cases; weekly averages were calculated to account for testing variation by day. All analyses were done using SAS v9.4 (Cary, North Carolina). This study was reviewed by CDC, CDPH, CCH, and CCSO institutional review boards or the equivalent entity, and deemed not to be research involving human subjects and public health response. During March 1-April 30, 2020, 907 COVID-9 cases were identified among detained persons and staff epidemiologically linked to CCJ ( Figure 1 ). Of 1,256 detained persons tested for SARS-CoV-2 during this period, 628 (50.0%) were positive, among whom 479 (76.3%) were symptomatic at the time of specimen collection and 149 (23.7%) were identified through asymptomatic testing. The overall AR was 12.9% (Table 1) symptoms upon entry into CCJ. 5 Presence of fever or symptoms required staff to abstain from work for 14 days. A PPE accountability team was assembled April 1, and staff were required to use surgical masks beginning April 2. Universal surgical mask use by detained persons during waking hours began April 13. On April 20, all newly detained persons were tested on intake using ID NOW in addition to undergoing 14-day quarantine (Figure 2 ). All nine housing divisions experienced cases despite variation in housing type, capacity, security, and programmatic involvement (Table 1) . Epidemic curves for certain divisions demonstrated a traditional bell-shape; others experienced sporadic cases (Figure 3 ). In 9/13 buildings, staff cases arose first, with a median 3 days between the first case in a staff member and a detained person. In total, 631 asymptomatic detained persons were tested for SARS-CoV-2; 149 (23.6%) were positive, with percent positive ranging from 8% (2/25, Division 5) to 50% (125/249, RTU; Supplemental Figure 1 ). The unit with the highest percent positive was a dormitory with 37 individuals in the RTU, which housed individuals with comorbidities, including some who used CPAP until use in common areas was stopped. Of the 275 asymptomatic persons tested upon entry into the jail (newly detained persons), 12 (4.8%) were positive. The 149 cases identified through asymptomatic testing represented 23.7% of all cases among detained persons at CCJ. All detained persons testing positive (628) were included, and compared based on whether they reported symptoms (479) or were asymptomatic (149). The median age of all detained persons testing positive was 35 years (IQR 27-48). Obesity (BMI ≥30 kg/m 2 ), hypertension, and asthma or COPD were the most common underlying conditions. Among those with hypertension and diabetes, persons more often reported being symptomatic (62% vs. 39%, and 62% vs. 38%, respectively (p-values: <0.01 for both). Additionally, of all persons testing positive, 109 (17%) had a temperature ≥37.7°C, and 72 (11%) had a temperature ≥38°C. Most (95%) with a temperature ≥37.7°C also had other symptoms (Table 2) . Seven detained persons and two staff died (case-fatality rate for both = 1.1%). Of fatal cases among detained persons, ages ranged from 42-64 years; all were male and had multiple comorbidities, most commonly hypertension, hyperlipidemia, and obesity (10) . Early in the outbreak, increases in cases among staff and detained persons paralleled that in Chicago, Illinois. After implementation of interventions, cases declined in detained persons and staff, even as cases increased dramatically in Chicago (Figure 4) . Weekly averages demonstrated a decline in cases among detained persons a week after staff cases began declining. Less than 2 months after the first COVID-19 case was identified in CCJ, almost 1,000 detained persons and staff had been infected with SARS-CoV-2. This represents an AR of nearly 13% among detained persons and occurred despite early adoption of containment and mitigation practices. This constitutes one of the largest outbreaks of COVID-19 in a congregate setting described to date, illustrating the difficulties of controlling spread in correctional and detention facilities. Estimates of influenza spread in enclosed populations have found similar ARs (13%) (9) ; experience suggests viral respiratory pathogens like COVID-19 can cause sizeable epidemics in large jails despite implementation of public health interventions (10) . Expanding CCJ's footprint to facilitate physical distancing, limiting movement, and implementing expanded testing were complex and resource-intensive interventions, but effectively slowed spread relative to the surrounding community even as cases there surged. Implementing expanded diagnostic testing at key points, such as intake, helped limit new introductions of the virus. facilities have identified visitors (11) and persons transferred between facilities (12) as possible sources. Restriction of movement within the jail was likely one of the most critical and timely interventions in gaining control of this outbreak; the division with the highest level of movement and most contact with individuals entering from the community experienced the earliest peak. Implementation and enforcement of social distancing of ≥6 feet, surgical mask use, increased access to soap and alcohol-based hand sanitizer, and enhanced cleaning and disinfection practices also likely reduce extent of spread. Later expansion of diagnostic testing, including at intake and of asymptomatic individuals, allowed for medical isolation of cases and reduction in spread. Enhanced measures including PPE accountability, including CCSO establishing a PPE Accountability Team who performed walking rounds on the compound to assess PPE compliance among CCSO staff, were likely also effective. Our data suggest the important role that community-dwelling staff played in COVID-19 introductions into CCJ as cases among staff often preceded cases in detained persons. We also show the effectiveness of employee interventions despite inclusion of <100% of personnel, as vendor and contractors could not be reliably included, nor the same policies enforced; however, temperature and symptoms screening upon entry to CCJ was universal. Implementation of universal screening for symptoms and temperature checks is important, but ensuring access to testing and compliance with illness reporting are vital, as are flexible and non-punitive leave policies to allow sick employees to stay home. As with other outbreaks in correctional and detention facilities (13) , close cooperation between onsite medical service providers, correctional staff, and local and federal public health officials were critical to successful containment of SARS-CoV-2. Efforts to facilitate social distancing and medical isolation through expanding CCJ's footprint likely reduced transmission (14) . Physical distancing to the degree accomplished at CCJ may not be feasible in all facilities, but use of quarantine and cohort housing may be possible even in smaller, more restricted facilities. Of all persons testing positive, the majority (76%) reported symptoms. Whereas asthma or COPD, diabetes, hypertension, and obesity were all common in this population, only those with diabetes and hypertension were found to be significantly associated with being symptomatic when testing positive. A substantial portion (24%) of persons testing positive were asymptomatic, similar to other congregate settings such as homeless shelters (15) . The role of these individuals in SARS-CoV-2 transmission is not well understood (16) . Widespread testing facilitates rapid identification, early medical isolation, and reduction in potential for spread, though and early widespread testing can prevent further cases (17) . Newly detained persons are exposed to the community prior to entering the jail, making expanded testing and cohorting at intake essential to limiting transmission. This investigation has several limitations. First, testing capacity was limited early in the outbreak, potentially underestimating the number of cases; comprehensively employed mitigation methods reduced transmission even in the absence of full testing capacity. Also, since temperature ≥37.7°C prompted testing, results may be biased toward a higher proportion of persons testing positive also exceeding the temperature of 37.7°C. Our case definition required a positive PCR result; this may have excluded staff who were diagnosed clinically, or who had only serology performed. Further, while CCSO staff represented the largest group of staff members entering CCJ, other staff (e.g., healthcare staff) had a wide range of employers with no centralized listing and were not included in the study. Lastly, because interventions were often implemented simultaneously, it was difficult to ascertain relative effectiveness; and this manuscript focuses on a specific period of time, but does not assess whether the interventions were effective long-term. Additionally, we do not comment on interventions put in place in Chicago at the time, and so we cannot attribute causality to the CCJ interventions and difference in cases in the community. The described interventions collectively proved effective in mitigation of the spread of SARS-CoV-2. However, it is important to acknowledge that increased isolation and use of single-celled environments, restricted visitation, and reduced programming may have negative impact outside the context of infection prevention. While not measured in this review, exacerbation of behavioral health issues should be considered. SARS-CoV-2 can spread rapidly in correctional and detention facilities, causing significant morbidity and mortality. Effective response to the COVID-19 outbreak at CCJ demonstrates the need for dynamic and aggressive application of intervention strategies, but also shows how timely response can reduce case counts and prevent morbidity and mortality in correctional or detention facilities. Prisons and custodial settings are part of a comprehensive response to COVID-19 Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington Initial Investigation of Transmission of COVID-19 Among Crew Members During Quarantine of a Cruise Ship -Yokohama COVID-19 in Correctional and Detention Facilities -United States COVID-19) in Correctional and Detention Facilities Preventing major outbreaks of COVID-19 in jails Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees Pandemic Influenza and Jail Facilities and Populations An analysis of influenza outbreaks in institutions and enclosed societies COVID-19 and the Correctional Environment: The American Prison as a Focal Point for Public Health Influenza outbreak in a correctional facility Influenza at San Quentin Prison, California Control of an H1N1 outbreak in a correctional facility in central Taiwan Flattening the Curve for Incarcerated Populations -Covid-19 in Jails and Prisons Prevalence of SARS-CoV-2 Infection in Residents of a Large Homeless Shelter in Boston Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility Facility-wide testing for SARS-CoV-2 in nursing homes-seven U.S. jurisdictions We would like to acknowledge the contributions of Cook County Sheriff Thomas J. Dart, Dr. Andrew Defuniak, Dr. Stamatia Richardson, Michael Miller, Brad Curry, Tarry Williams, and Linda Follenweider for their tireless efforts to implement these interventions. We would also like to acknowledge Jaqueline Tate, Kathryn Curran, Reena Doshi, Patrick Moonan, and the CDC field study team for their support. Mary Ann K. Hall, Sharon Saydah, and Louise K.Francoise Watkins contributed meaningfully to the review of this manuscript. When constructing the epidemiologic curve, the date of medical isolation as a proxy for the date of symptom onset was used for detained persons, and self-reported symptom onset date was used for staff. Screening for influenza-like illness among incoming detained persons occurs on an annual basis, beginning October 1 of each year; in 2019 it was put in place and then expanded on January 21, 2020 to include symptoms of COVID-19 consistent with CDC guidelines. Screening of asymptomatic detained persons (not displayed in epidemic curve) began on March 3, 2020 among high-risk individuals in the Residential Treatment Unit; testing of all incoming detained persons upon intake began on April 20, 2020. Each node represents 1 week of the study period; the highest number of total cases were identified in the jail the week of April 5 th and fell thereafter. The initial doubling times for Chicago, staff, and detained persons were 2.22, 2.15, and 2.1 days, respectively, represented by the increasing slope prior to peak for each population. (13), external operations (9), emergency response team (6), laundry (6), offsite (6), mental health treatment center (3), division 16 (1), electronic monitoring (1), or sanitation (1). b All cases among detained persons (asymptomatic and symptomatic) are included and correspond to the housing division in which they were located at the time of symptom onset or specimen collection.