An epidemic of pneumococcal disease in an overcrowded, inadequately ventilated jail

N Engl J Med. 1994 Sep 8;331(10):643-8. doi: 10.1056/NEJM199409083311004.


Background: In the United States many correctional facilities now operate at far over capacity, with the potential for living conditions that permit outbreaks of respiratory infections. We investigated an outbreak that was identified in an overcrowded Houston jail after two inmates died of pneumococcal sepsis on the same day. Outbreaks of pneumococcal disease have been rare in the era of antibiotics.

Methods: We assessed risk factors for pneumococcal disease in both a case-control and a cohort study. Ventilation was evaluated by measuring carbon dioxide levels and air flow to the living areas of the jail. The extent of asymptomatic infection was determined by culturing pharyngeal specimens from a random sample of inmates. Type-specific immunity was determined with an enzyme immunoassay.

Results: Over a four-week period, 46 inmates had either acute pneumonia or invasive pneumococcal disease due to Streptococcus pneumoniae serotype 12F. The jail's capacity had been set at 3500 inmates, but it housed 6700 at the time of the outbreak; the inmates had a median living area of only 34 ft2 (3.2 m2) (interquartile range, 28 to 56 ft2 [2.6 to 5.2 m2]) per person. There were significantly fewer cases of disease among inmates with 80 ft2 (7.4 m2) per person or more (P = 0.030). Carbon dioxide levels ranged from 1100 to 2500 ppm (acceptable, < 1000), and the ventilation system delivered a median of only 6.1 ft3 of outside air per minute per person (interquartile range, 4.4 to 8.5 ft3; recommended, > or = 20 ft3). The attack rate was highest among inmates in cells with the highest carbon dioxide levels and the lowest volume of outside air delivered by the ventilation system (relative risk, 1.94; 95 percent confidence interval, 1.08 to 3.48). Of underlying medical conditions, intravenous drug use was most strongly associated with disease (odds ratio, 4.50). The epidemic strain (serotype 12F) was cultured from 7 percent of the asymptomatic inmates. Of 11 case patients tested with the enzyme immunoassay, 9 (82 percent) lacked preexisting immunity to this strain.

Conclusions: Severe overcrowding, inadequate ventilation, and altered host susceptibility all contributed to this outbreak of pneumococcal disease in a large urban jail.

MeSH terms

  • Adult
  • Air Pollution, Indoor / adverse effects*
  • Carbon Dioxide / analysis
  • Case-Control Studies
  • Cohort Studies
  • Crowding
  • Disease Outbreaks*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Pneumococcal Infections / epidemiology*
  • Pneumococcal Infections / etiology
  • Pneumonia, Pneumococcal / epidemiology
  • Pneumonia, Pneumococcal / etiology
  • Prisons*
  • Prospective Studies
  • Risk Factors
  • Texas / epidemiology
  • Ventilation


  • Carbon Dioxide