by Matthew T. Clarke
A deadly outbreak of drug resistant staph (MRSA) is occurring at prisons throughout the country. It is often misdiagnosed as a spider bite or non-resistant staph, delaying treatment until it is too late. This has already lead to the deaths of two Ohio prisoners.
On May 2, 2003, Clarence Melvin Grubb, 41, gave an interview to WBNS-Channel 10 TV from his Columbus, Ohio jail cell. In it, he criticized the lack of medical treatment he received at the (Franklin County) jail and at Pickaway Correctional Institution in Orient, Ohio, (15 miles south of Columbus) from which he had recently been transferred. Noting that the infection had eaten four large holes in his back and left his shirt soaked with blood, he called the medical treatment he received at Pickaway "a joke." Three weeks later, it became clear that he was the butt of the joke when Grubb became the second prisoner to die of a MRSA infection contracted at Pickaway.
The first Pickaway fatality was Sean Schwamberger, 19, who had been serving 11 months for forgery. He died of an MRSA infection on April 29, 2003. Both Schwamberger's and Grubb's MRSA infections had initially been misdiagnosed as spider bites and then typical staph infections by prison medical staff.
The bacteria that caused the deaths are called methicillin resistant staphylococcus aureus. This is a mutation of the. common staph bacteria which is resistant to most antibiotics. Symptoms of staph infections include: pimples, oozing sores, blood infections and/or pneumonia.
The few remaining antibiotics that are effective against MRSA infections are rare and expensive. Prison and jail medical departments, facing reductions in already strained budgets, are reluctant to purchase such expensive treatment. Thus, MRSA infections are misdiagnosed as spider bites, even when the infection is clearly not a spider bite. An MRSA infection which is left untreated may enter the blood and become septic, causing potentially fatal toxic shock.
Pickaway is not the only prison with MRSA outbreaks. The Ohio prison system confirmed that, during the four months that ended January 31, 2003, it had detected MRSA infections in 142 other prisoners in 12 other state prisons. This included 44 cases at Belmont Correctional Institution and 36 at Mansfield Correctional Institution. Since February 1, 2003, 72 MRSA infections have been detected at Pickaway. Fourteen of those prisoners had fresh tattoos. At least four of the Pickaway prisoners have been hospitalized at Ohio State University Medical Center since April 20,2003, due to MRSA infections. Peter Wray, spokesman for the Pickaway guards' union, suggested that the $5 co-payment prisoners are charged for infirmary visits might have discouraged some prisoners from seeking early treatment, thus exacerbating the outbreak. Prison officials speculated that infected tattoo needles may have contributed to the MRSA outbreaks.
The tale of misdiagnosis, medical indifference, and death in Ohio occurred despite Ohio's top-shelf salaries for prison medical staff. For instance, Maurice Frank, Bart Martelli, and Michael R. Pressley, nurses for the prison system, made $153,476; $142,108; and $98,914, respectively ($81,311; $76,294; and $39,995 of which was overtime). Prison officials said the large amount of overtime was due to nurse shortages in Ohio and the nation. Clearly, for Grubb and Schwamberger, high dollar cost didn't equal high quality medical treatment. This is emphasized by the fact that while Schwamberger was dying, no tests for drug resistance were ordered on the 26 other Pickaway prisoners with oozing wounds. In fact, despite having cases as early as March 4, 2003, no tests were ordered by Pickaway doctors until April 28, 2003, when state health officials ordered them to begin testing. The state health officials might have ordered the testing sooner, but Pickaway doctors delayed reporting the outbreak for over a month, despite state laws requiring the immediate reporting of such outbreaks. State health officials were also concerned by Pickaway prison doctor Adil Yamour's habit of lancing the wounds. This defeats the body's attempt at containing an infection and allows the infection to spread to other parts of the body and other people.
Meanwhile, MRSA outbreaks are being reported in jails and prisons across the nation. A recurring pattern is that prison medical officials first misdiagnose the infection as a bite from the brown recluse, or fiddleback, spider.
"They constantly blame the brown recluse," said Rick Vetter, senior research associate at University of California Riverside's Department of Entomology and internationally-recognized expert on the brown recluse. "They can never find the damn.spider, but that never seems to matter. The spider bite becomes the default diagnosis for everything that is unexplainable," allowing potentially deadly MRSA infections to go untreated.
Vetter has received calls from prisons in Los Angeles, San Diego, and San Francisco regarding prisoners with spider bites. In all three cases, MRSA was the culprit. In Los Angeles, more than 1,000 prisoners were infected and new cases continue to crop up, including 138 new cases in March 2003, and 105 new cases in April, 2003. About 9% of the infected Los Angeles prisoners are believed to have become infected before arriving at the jail.
The Los Angeles County Department of Health Services investigated the jail outbreak and two other outbreaks in Los Angeles. One of the cases involved two athletes on the same team, the other involved men who have sex with men and was reported by two large infectious disease clinical practices.
A study is being conducted on risk factors for MRSA infection among that population.
Outbreaks of MRSA have occurred in many other states. A late 1999 outbreak in Mississippi infected 59 prisoners. Bucks County Prison in Pennsylvania reported 34 cases in a 2001 outbreak. 200 prisoners were reported infected with MRSA in Texas in 2002. Georgia reported 94 MRSA prisoner infections in 2002. Tennessee had 7 reported MRSA infections among prisoners in 2002.
Six of the Bucks County prisoners filed suit in federal court in Philadelphia alleging Bucks County denied or delayed treatment and seeking over $150,000 per prisoner. Anita Albert and Martha Sperling, the prisoners' attorneys subpoenaed records to show how many prisoners had been tested for staph infectionsthere were 376 confirmed infections. The federal court then ordered those prisoners' infections tested for drug resistance and the outbreak reported to health authorities. Initial results turned up four more MRSA infections. This led to the testing of all 1,100 prisoners and staff at the jail and, the discovery of 34 cases of MRSA infections.
The outlook in 2003 is bleaker. Texas is dealing with a current MRSA outbreak that affects hundreds of prisoners at dozens of prisons. The Los Angeles outbreak is still uncontained. In mid-June, 2003, the Nashville, Tennessee, Metro Detention Facilitywhich is run by Corrections Corporation of Americawas dealing with an MRSA outbreak with "less than fifty" prisoners infected according to Warden Brian Gardner. Gardner instituted a new razor exchange policy which allows prisoners to get new razors instead of sharing them, and a more frequent linen cleaning program to combat the outbreak.
The Centers for Disease Control (CDC) in Atlanta, GA, performed a study of the 2000 outbreak in a Mississippi state prison. All 1,200 female and 1,800 male prisoners were surveyed using nasal cultures. This revealed 59 cases of MRSA infection. Of these MRSA infected prisoners surveyed, 58% had infections on the legs, 16% on the arms, 33% were diagnosed with furuncles, 27% with skin abscesses, and 11%.with open wounds; 47% had cellulitis, and 4% had systemic infections requiring hospitalization. Most disturbing was the high number of asymptomatic carriers and the fact that 58% reported lancing their own boils or other prisoners' boils with fingernails or tweezers and 89% shared potentially contaminated personal items such as linen, pillows, clothing, and tweezers.
To determine the number of carriers of MRSA, swabbing was performed of all female prisoners and one-third of the male prisoners. This revealed that 4.9% of all prisoners were carriers of MRSA. Applied to the 3,000 prisoners, this would mean that one could expect 147 prisoners to be carriers even though only 59 showed active infections.
The CDC recommends immediate culturing of any infection to test for drug resistance. It also notes that daily showers and frequent hand washing reduces the risk of transmission. Prisoners should refrain from touching another prisoner's wound. CDC notes that MRSA can be spread through the sharing of common objects such as athletic equipment, towels, benches, and personal items. MRSA can be effectively killed by using a commercial disinfectant or a solution of 1 tablespoon bleach in one quart of water. However, dressings and other materials that come in contact with pus, blood, nasal discharge or urine should be disposed of.
Sources: Los Angeles County Department of Health Services; CDC; Columbus Dispatch; Philadelphia Inquirer; AP; Springfield (OH) New Sun; Nashville Tennessean; Los Angeles Times.
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